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Based on review and interview the facility failed to:

1.
review, analyze, and report to the Governing Body (GB) complaints and grievances through the Quality Assessment Performance Improvement (QAPI) process, failed to have a clear understanding of the complaint vs grievance process, failed to ensure the patient's complaint or grievance was effectively handled in a timely manner, and failed to inform the patients of any resolutions to their complaints and grievances.
see Tag A0119

2
A. ensure patients were instructed on their involuntary status, and warrants were filed in a timely manner with results available to the patient and surveyor. Failed to have written documentation that the patient was aware of their rights, court hearing dates, and awareness of the judge's decision on their legal status after the court hearings in 3 of 3 (patient #1, #3, and #29) charts reviewed.
B. patients had the capacity to understand the risk and benefits of treatment with psychotropic medications before signing an informed consent in 1 (Patient #29) of 1 medical record reviewed.
see Tag A0131

3.
A. have a safe process in place to provide care and safely discharge an aggressive psychotic/suicidal patient in 1 (Patient #4) of 1 medical record reviewed.
B. ensure that emergency medical supplies and equipment were immediately available to staff to treat a patient that was experiencing an emergency medical condition.
This deficient practice had the likelihood to cause harm to all patients being admitted and treated for suicidal ideation and psychosis. If the facility is unable to provide care to a mentally ill patient with aggressive psychosis and the patient leaves with the police with no discharge planning is in place, the patient places himself and others at risk of imminent harm or death.
see Tag A0144

4.
A. ensure that chemical restraints administered were identified as a chemical restraint/ emergency behavioral medication (EBM)

B. ensure a process was in place for continuous monitoring after administering a chemical restraint/emergency behavioral medication for side effects, respiratory or cardiac distress, and assessment of medication effectiveness and safety after administration in 3 of 3 (Patients #1,4, and 5) patient charts reviewed.

C. follow their own policy and procedures to ensure the restraint packet was filled out appropriately and completely, a face-to-face was conducted by a trained individual, and patient/ staff debriefing was completed and appropriate in 3 of 3 (Patient #1,4, and 5) charts reviewed.

D. ensure chemical restraints were added to the restraint log and monitored through Risk and Quality in 3 of 3(Patient #1, 4, and 5) charts reviewed.

The deficient practices were identified under the following Condition of Participation, CFR 482.13 Patient Rights, and were determined to pose an Immediate Jeopardy (IJ) to patient health and safety and placed all patients in the facility at risk for the likelihood of harm, serious injury, and possible death.
see Tag A0160

5.
A. ensure a 1-hour Face to Face was completed by the provider or a trained RN within one hour of the administration of a chemical restraint/EBM (emergency behavioral medication) in 5 (Patient #4, #26, #29, #30, and #32) of 5 medical records reviewed.

B. ensure RN's (Registered Nurses) completed training of the 1-hour face to face evaluation before evaluating a patient after a chemical restraint.
see Tag A0178

Based on review and interview the facility failed to review, analyze, and report to the Governing Body (GB) complaints and grievances through the Quality Assessment Performance Improvement (QAPI) process, failed to have a clear understanding of the complaint vs grievance process, failed to ensure the patient's complaint or grievance was effectively handled in a timely manner, and failed to inform the patients of any resolutions to their complaints and grievances.

During the survey process, the administrative staff was asked 4 different times to provide the surveyor with GB bylaws and GB meeting minutes. The administrative staff could not provide the information requested.

A review of the policy and procedure "Patient and Family Grievance Guidelines" stated, "Oversight and Reporting The patient grievance process is approved by the governing board. The governing board is responsible for the effective operation of the grievance process. The governing board - by approval of this policy - officially has delegated the oversight and responsibility for implementing this grievance process to Quality Assessment/Performance Improvement Committee (QA/PI) .Complaints or grievances involving the members of the medical staff are forwarded to the DON for review, investigation and follow-up.
The data collected regarding patient grievances, as well as other complaints that are not defined as grievances will be reported through the Quality Assessment/Performance Improvement Committee (QA/PI)."

An interview was conducted with staff #2 on 5/8/23. Staff #2 stated that she just started at the facility. Staff #2 stated she was aware that QAPI information and meeting minutes were conducted monthly but were not able to speak to any previous meeting minutes and was not able to provide the surveyor with any previous meeting minutes. Staff #2 stated that she would be having a meeting sometime in June 2023.

Staff #2 provided the surveyor with a Complaint Tracking Log, only three complaints were documented. The dates were 4/13/23 and 4/15/23. There were no other logs provided. Staff #2 stated that was all she had. The complaints on 4-15-23 were requests to have a label on the complaint box. The complaint was not resolved until 4/18/23. The complaint was not handled in a timely manner. The next complaint on 4/15/23 was patient(s) not having any "outside time". There was no resolution documented. The final complaint written on 4/13/23 revealed an outcry of abuse and staff retaliation. The complainant stated the staff refused to give patient #1 snacks when there was extra left over. When the patient (patient #1) got upset a tech gave him a snack, the second tech took it away from the patient with no explanation. Patient #1 received chemical restraints for emergency behavior on 4/10/23 prior to this incident.

The complainant stated, "The night shifts attitude are horrible. I have to get a nurse to go with me just to ask a question because the tech's dispositions are horrible. I'm here to get my meds adjusted. I am a human being and completely coherent. They roll their eyes when we ask questions but smile if someone higher up is near. A kindness training or something needs to happen. I will be following up with higher ups myself thank you. ... I'm writing on a blank piece of paper because the nurse stated there were no complaint forms. Ms. ____ (RN) and ___ (RN) are amazing they are welcoming if they weren't here I would be afraid to go to sleep because the techs ____ (tech)and ___(tech) are so nasty. The sad part is that Ms. ___ (RN) agrees that they have horrible attitudes she could barely write down crayon names for me because when they came back there she stopped writing and just franticly said, "Here take this" (politely). No one including myself asks (the techs) for them to do anything because of their horrible attitudes. They don't hand things to you, they avoid eye contact, and say here!..."

A review of the complaint log revealed a comment that stated, "Will forward to ____ ( Staff #1) to have an in-service training with ____ (tech) and ___ (tech) over patient care. There was no other documentation of interviews with staff or the patient. The complaint was not addressed as a grievance and possible staff abuse was not addressed. Staff #2 could not provide the surveyor with any grievances or outcomes. Staff #2 stated that she did not have anything else to provide. Staff #2 was not aware that patient #1, who was refused a snack, was patient #1 and had been given chemical restraints on 4/10/23. The facility failed to ensure this patient was not being singled out or any retaliation was placed upon the patient due to prior behaviors.

Based on record review and interview the hospital failed to ensure,
A. the patients were instructed on their involuntary status, and warrants were filed in a timely manner with results available to the patient and surveyor. Failed to have written documentation that the patient was aware of their rights, court hearing dates, and awareness of the judge's decision on their legal status after the court hearings in 3 of 3 (patient #1, #3, and #29) charts reviewed.
B. patients had the capacity to understand the risk and benefits of treatment with psychotropic medications before signing an informed consent in 1 (Patient #29) of 1 medical record reviewed.

A.
A review of patient #1's chart revealed he was admitted on 4/8/23 as an involuntary patient. The facility had applied for an Order of Protective Custody (OPC) on 4/10/23.

An OPC is an order issued by a Texas county judge that allows the psychiatric facility to hold the patient and provide treatment and that the judge has determined that the proposed patient presents a substantial risk of serious harm may be demonstrated by the proposed patient's behavior or by evidence that the proposed patient cannot remain at liberty.

A review of the patient rights information given to the patients at admission revealed the following,
"Order of Protective Custody (OPC) -- Special Rights
1. You have the right to call a lawyer or to have a lawyer appointed to represent you in a hearing to determine whether you must remain in custody until a hearing on court-ordered mental health services is held.

2. Before a probable cause hearing is held, you have the right to be told in writing: a. that you have been placed under an order of protective custody; b. why the order was issued; and c. The time and place of a hearing to determine whether you must remain in custody until a hearing on court-ordered mental health services can be held. This notice must also be given to your attorney.

3. You have the right to a hearing within 72 hours of your detention, except that on weekends or legal holidays, the hearing may be delayed until 4:00 in the afternoon on the first regular workday. The hearing may also be delayed in the event of an extreme weather emergency or disaster.

4. You have the right to be released from custody if a. 72 hours have passed and a hearing has not taken place (excepting weather emergencies and extensions for weekends and legal holidays); b. an order for court-ordered mental health services has not been issued within 14 days of the filing of an application (30 days if a delay was granted); or c. Your doctor finds that you no longer need court-ordered mental health services.

Involuntary Patients - Special Rights Under most circumstances, you or a person who has your permission may, at any time during your commitment, ask the court to ask a physician to re-examine you to determine whether you still meet the criteria for commitment. If the physician determines you no longer meet the criteria for commitment, you must be discharged. If the physician determines you continue to meet the criteria for commitment, the physician must file a Certificate of Medical Examination with the court within 10 days of the filing of your request. If a certificate is filed, or if a certificate has not been filed within 10 days and you have not been discharged, the judge may set a time and place for a hearing on your request."

A review of patient #1's chart revealed he had a probable cause hearing on 4/14/23 at 1:30 PM. The judge signed the warrant to hold the patient for his hearing on 4/26/23. There was no judgment or written information if the patient had a hearing, an order of commitment, or any time frame that the patient was committed for. There was no documentation that the patient was made aware of the judge's decision or was aware of his rights.

A review of patient #3 was admitted to the facility as involuntary on 2/15/23. Patient #3 had a date set for the probable cause hearing on 2/23/23 and the hearing on 3/6/23. There was no evidence in the patient's chart that she was ever made aware of her rights. The patient did not sign any consent on admission. There was no evidence that the patient was told at any other later time of her rights. There was no order found from the judge of commitment for any time frame.

An interview with Staff #2 was conducted on 5/9/23. Staff #2 stated that the court liaison was on vacation, and he handled all the court proceedings. Staff #2 stated that the court liaison kept a log of warrants and would share the information. The log revealed patient #1 was not on it. There were only 4 patients on the log. Patient #29 was on the log, but her court date had been extended to 5/8/23. Staff #2 was unable to tell me if the patient was involved in the court process on 5/8/23, if the patient had been committed, and for how long. Staff #2 stated when the court liaison is out the therapist that is responsible for the patients are supposed to turn the paperwork in to the courts however, there was no log and no process to show the surveyor what patients had current warrants and when they were due to go to court.


40989


B.

Findings


Patient #29 was a 62-year-old female admitted involuntary to the facility 4/14/2023 with a diagnosis of Schizophrenia. As of survey exit date on 5/10/2023 Patient #29 was still an inpatient at the facility. Review of the Psychiatric Evaluation by Physician #9 revealed the patient was delusional, had visual and auditory hallucinations, oriented to person only, and had impaired insight and judgement. There was no documentation by Physician #9 that the patient had the capacity to consent. There was no evidence found that the patient was able to understand where she was, her patient rights, or was mentally competent to understand she was in the facility to receive treatment for mental health care or receive psychotropic medications.
Further review revealed the Order of Protective Custody (OPC) did not have a court order for forced medications.

A review of the nurses note dated 4/14/2023 was as follows:

"...Patient came from Facility #6 unvoluntary (sic). Patient was screaming, yelling, and stating that she belong (sic) to her commanders. Patient has internal stimuli. Physician #9 ordered Geodon 20mg IM (intramuscular) and Ativan 2mg IM. Given as ordered. Patient is in bed sleeping now..."

A review of the medical record revealed informed consents for treatment with psychoactive medications were as follows:

" ...Trazadone-signed by patient on 4/14/2023 and witnessed by the nurse. Patient #29 did not receive this medication. Patient #29 did not receive this medication prior to the survey exit date of 5/10/2023.

Geodon (antipsychotic)-no patient signature. The patient signature line read, took medication-verbal consent on 4/14/2023 and witnessed by two nurses. This medication was administered as an EBM (Emergency Behavioral Medication. Patient #29 received 2 doses of Geodon 20mg IM (intamuscular) between 4/14/2023 and survey exit date of 5/10/2023.

Haldol (antipsychotic)-signed by Patient #29 on 4/15/2023 and witnessed by two nurses. Patient #29 received 6 doses of Haldol 1mg by mouth between 4/14/2023 and survey exit date of 5/10/2023.


Zyprexa (antipsychotic)-initialed by Patient #29 on 4/16/2023 and witnessed by one nurse. Patient #29 received 30 doses of Zyprexa 10mg by mouth between 4/14/2023 and survey exit date of 5/10/2023.

Geodon-no patient signature. The patient signature line read Psychosis, Emergency Meds, patient willingly took meds on 4/28/2023. Witnessed by two nurses. This medication was administered as an EBM.

Thorazine (antipsychotic)-signature on patient line states psychotic, yelling, growling dated 4/17/2023 and witnessed by two nurses. This medication was administered as an EBM. Patient #29 received 2 doses of Thorazine 50mg IM between 4/14/2023 and survey exit date of 5/10/2023.

Thioridazine (Thorazine-antipsychotic)-signed by the patient on 5/02/2023 and witnessed by two nurses . Patient #29 received approximately 9 doses of Thorazine 50mg by mouth and approximately 29 doses of Thorazine 100mg by mouth between 4/14/2023 and survey exit date of 5/10/2023. .."


A review of Physician #9's progress note dated 5/04/2023 was as follows:
" ...Patient does not have moments of clarity while here, no waxing and waning of symptoms making delirium unlikely ..."


During an interview on 5/10/2023 after 9:00 AM Staff #22 confirmed Patient #29 received multiple doses of Zyprexa, Geodon, Haldol, and Thorazine prior to the survey exit date of 5/10/2023.

An interview was conducted with Staff #1 on 5/10/2023 after 9:00 AM. Staff #1 confirmed there was no route of administration or medication dose listed on any of the informed consents for psychotropic medications. Staff #1 was asked if the staff got informed consent from the patient for EBM's. Staff #1 stated, "If the patient takes the medications willingly, the staff will get the patient to sign the informed consent or take a verbal consent". Staff #1 was asked if the medications were administered as a behavioral emergency how was there time to get informed consent. Staff #1 replied, "She most likely agreed to take the shot."

An interview was conducted with Staff #22 on 5/10/2023 after 9:00 AM. Staff #22 was asked if Patient #29 had the capacity to understand the risks and benefits of the psychoactive medications that she was taking. Staff #22 stated, "Well when I am with her, I can talk to her and I think she understands them." Staff #22 was asked when the physician increases the dose of the antipsychotic medication did the nursing staff and physician sign a new consent and explain the possible risks and benefits to the patient. Staff #22 stated, "No, I was told we did not have to do that if it was the same medication. When we do the first consent, we write the name of the medication on the consent and go over the medication with the patient."



A review of the facility policy titled, "Informed Consent for Psychoactive Medications RI.014", with a review date of 12/08/2020 was as follows:

"...POLICY

It is the policy of Aspire Hospital to obtain consent for treatment with psychoactive medication. An exception would be a emergency situation. Each patient has a right to clear information about his/her behavioral healthcare and possible treatment options. An interpreter will be provided whenever necessary.

The physician is to inform the patient's to their right to the extent permitted by law to refuse treatment interventions, including medications. The physician will discuss benefits, risks, side effects of medications and alternative treatments. The discussion will be documented in the medical record. Informed consent shall be obtained by the physician or treatment provider.

DEFINITIONS

Capacity-A persons ability to:

Understand the nature and consequences of a proposed treatment, including benefits, risks and alternatives to the proposed treatment and

Make an informed decision whether to undergo the proposed treatment..."



Staff #23 was asked if Patient #29 had the capacity to understand the risks and benefits of the medications. Staff #23 confirmed Patient #29 did not have the capacity to understand anything since her admission on 4/14/2023.

Based on document review and interview the facility failed to:

A. have a safe process in place to provide care and safely discharge an aggressive psychotic/suicidal patient in 1 (Patient #4) of 1 medical record reviewed.

B. ensure emergency medical supplies and equipment was immediately available to staff to treat a patient that was experiencing an emergency medical condition.


The facility was unable to provide adequate staff to safely care for a mentally ill patient with aggressive psychosis. Patient #4 was discharged to the police without appropriate community referrals and follow up appointments. This deficient practice had the likelihood to cause harm to all patients admitted and treated for suicidal ideation and psychosis.

Findings


A.

Patient #4
Patient #4 was a 21-year-old male admitted voluntary to the hospital on 2/14/2023 at 6:25 AM with a diagnosis of Psychosis and severe substance abuse-Methamphetamine, Cocaine, Adderall, alcohol, and Benzodiazepines. He had a past medical history of Cerebral Palsy and Seizures.
A review of the Psychiatric Evaluation dated 2/14/2023 at 3:29 PM by Physician #9 revealed the patient was only oriented to person and place, not time or situation. He had poor memory and recall, impaired insight, and impaired judgement. The psychiatrist documented the patient was highly anxious, easily agitated, and had a difficult time answering questions. The discharge plan documented by Psychiatrist #9 was to discharge the patient when he was no longer a danger to himself and others, his level of depression was decreased, had reduced anxiety and psychosis, and when he was compliant with treatment and medication management.
Staff #1 confirmed he had not met the criteria when he left the facility with the police.

A review of the medical record revealed Patient #4 received a chemical restraint/EBM (emergency behavioral medication) on 2/15/2023 at 8:30 AM because he became agitated, aggressive towards staff, irritable, and yelling uncontrollably.

A review of the nurse's note dated 2/15/2023 at 3:00 PM was as follows:
" ...0900-Patient agitated and aggressive towards staff. Patient was uncontrollably yelling and screaming. Patient stating that he hates everyone because they are looking at him. Patient believes that everyone is a cop. Staff engaged in 1:1 communication and verbal redirection. Patient refused to be redirected. Attending psychiatrist notified of the situation and ordered emergency medication as follows: Ativan 4mg IM, Haldol 10mg IM, and Benadryl 100mg IM The Emergency medication administered on bilateral deltoid. Patient tolerated medication well. Staff will continue to monitor Q15 minutes for safety ..."


Review of the nurses notes dated 2/16/2023 was as follows:
"Patient started getting agitated and aggressive and went to his room at around 0800. Patient was throwing hygiene products all over his room. Staff started to verbally redirected (sic) and deescalate patient. Patient observed to escalate, angry, aggressive, and agitated. Patient refused to be verbally redirected and started to approach the nurses station and pulled out and broke the glass windows. Patient asking staff to give his freedom. Patient continued to state verbal threats that he will destroy more property if he gets pissed off one more time. Staff called 911 at around 0803. DON and attending psychiatrist notified of the incident. Cops came at around 0810. Cops picked up patient and left facility at 0845."

A review of the discharge summary by Physician #9 dated 2/16/2023 at 3:57 PM was as follows:
" ...Course of Treatment-Patient admitted in acute psychotic state. He had multiple episodes of anger and mood swings, lashing out at staff and other patients. This morning, he became irate and ripped down the partition on the nurse's station. Cops were called and patient was escorted out. Mom came to pick him up from hospital. Condition at discharge-Not improved (labile, aggressive, cops called and discharged to mom) Discharge to-Home with family ..."

An interview was conducted with Staff #22 and #25 on 5/10/2023 after 11:00 AM. Staff #22 was asked if she remembered calling the police on Patient #4. Staff #22 stated, "Yes, he was tearing the place apart. He busted the window at the nurses' station and was trying to bend the metal frame." The nurses were asked if the facility had a process in place to ensure that the patients and staff were safe when an event like this occurred. The nurses confirmed there was no policy on how to handle this type of situation, so they just call the police. Staff #22 stated, "I'm going to call the cops because I am not going to risk my life when a patient strung out on drugs becomes that aggressive. We had to do this before because a patient became aggressive. Patient #4 was mad and aggressive when he got here." Staff #22 was asked if any of the staff tried to de-escalate the patient? Staff #22 replied, "There was no de-escalating him. We had to just shut the door in the hallway after we moved the other patients until the police got here. We do not have very many men that work here and it's mostly just us women and we could not control him." Staff #22 was asked if the police left with the patient or did his family come and pick him up. She confirmed that she did not see anyone come and get him and that the police left the building with the patient.

An interview was conducted with Staff #1 on 5/10/2023 after 11:00 AM. Staff #1 was asked if the family picked the patient up after the police left the building with the patient. She stated, "I cannot say for sure." She also confirmed Physician #9 was not there at the time of discharge and there was no documentation by Physician #9 that the family was contacted to pick the patient up at the facility. Physician #9 documented the patient was discharged home with his mom and Staff stated during interviews he left with the police.

Staff #1 confirmed there was no discharge order completed by Physician #9 and that Patient #4 was discharged from the facility without a safe discharge in place. Again, Staff #1 stated there was no follow up on the incident and they were unsure of the patients safety and the safety of others at time of discharge.

Staff #2 confirmed no follow up documentation was found in the medical record by the nursing team, physicians, or risk management team regarding the incident after the patient left the facility. She also confirmed the physician was not present at the time of discharge and there was no staff debriefing or education following the incident.


B.

A tour of the locked Psychiatric Unit was conducted on 5/08/2023 at 10:00 AM with Staff #1 and Staff #3.

Staff #1 was asked where the emergency treatment room was located on the locked unit. Staff #1 replied, "We do not have a treatment room on the unit. We can take the patient to the Emergency Department for exam if we need to." Staff #1 was asked if the Emergency Room was opened and staffed for emergencies. She replied, "No, the emergency room is closed." Staff #1 was asked if the Unit had an emergency cart with emergency medications, supplies, and equipment. Staff #1 confirmed there was no emergency crash cart located on the locked unit.

An interview was conducted on 5/8/2023 at 10:15 AM with Staff #11 and Staff #24. Staff #11 and #24 were asked if a patient had a medical emergency, where was the emergency medical equipment located. Staff #24 stated, "We have oxygen stored in the equipment room, but we would normally call 911 if it was a life-threatening emergency." Staff #11 and Staff #24 were asked if the facility had an automated external defibrillator (AED) and suction equipment available. The staff responded saying there was no AED on the unit but they did have suction equipment in the equipment supply room but they were unsure if the suction equipment was working.


Staff #24 was asked if a patient required treatment for a minor incident, where could the patient be examined privately. The nurse confirmed there was no emergency treatment room on the unit where a patient could be examined privately other than in the patients assigned room.


An interview was conducted with Staff #20 on 5/9/2023 after 9:00 AM. Staff #20 confirmed the locked unit did have an AED. Staff #20 went into the medical record room within the nurses station and pulled out a dark colored duffle bag stored in a lower cabinet. The duffel bag contained an AED, an ambu bag (bag valve mask that can be connected to oxygen to provide respiratory support to a patient) and oral airways.

Staff #20 confirmed the AED was not checked daily for operational use. The equipment and supplies were not checked on a routine basis and he could not confirm when the last time the supplies had been replaced.


Staff #7, #21, #22, #23, and #25 confirmed they were not aware that the AED and airway supplies were stored in the medical record room.

Based on review and interview the facility failed to:

A. ensure that chemical restraints administered were identified as a chemical restraint/ emergency behavioral medication (EBM)

B. ensure a process was in place for continuous monitoring after administering a chemical restraint/emergency behavioral medication for side effects, respiratory or cardiac distress, and assessment of medication effectiveness and safety after administration in 3 of 3(Patients #1,4, and 5) patient charts reviewed.

C. follow their own policy and procedures to ensure the restraint packet was filled out appropriately and completely, a face-to-face was conducted by a trained individual, and patient/ staff debriefing was completed and appropriate in 3 of 3(Patient #1,4, and 5) charts reviewed.

D. ensure chemical restraints were added to the restraint log and monitored through Risk and Quality in 3 of 3(Patient #1, 4, and 5) charts reviewed.

The deficient practices were identified under the following Condition of Participation, CFR 482.13 Patient Rights, and were determined to pose an Immediate Jeopardy (IJ) to patient health and safety and placed all patients in the facility at risk for the likelihood of harm, serious injury, and possible death.

A review of patient #1's chart revealed he was admitted to the facility on 4/8/23 for depression without psychotic features. Patient #1 was placed on suicidal precautions.

A review of the 12-hour nursing assessment revealed Staff #1 documented that patient #1 was "agitated and angry." Patient #1 wanted to smoke, and the facility was a non-smoking facility. There was no documentation that the patient was offered any other alternatives for smoking. Patient #1 started to bang on the nurse's station window and made threats toward staff. The nurse documented, "Pt encouraged to follow the treatment plan and medication regimen, pt. redirected many times to stay calm and not to make threats and recited the policy on smoking in the hospital."
The psychiatrist was notified by phone and a verbal order was given for Haldol 10 mg IM "take now" and Ativan 4 mg IM "take now". A review of the Medication Administration Record (MAR) revealed Staff #24 Licensed Vocational Nurse (LVN) administered the restraint medication on 4/10/23 at 9:45 AM and 9:50 AM.

There was no found evidence that the patient was removed from the situation, placed on a 1:1, placed in seclusion, or had therapy services intervene. There was no other documented evidence that any other restraint process was used before administering a chemical restraint.

A review of Staff #1's nursing note documentation revealed on 4/10/23 at 10:12 AM, "Pt became calm and willing to receive emergent medication by staff at 0945 (9:45 AM)." There was no evidence that the patient was offered po meds. There was no documented justification of why patient #1 received an emergent IM chemical restraint if he was calm and willing to take medications.

A review of the q15 min observation sheet revealed the mental health technician (MHT) had pre-charted the q15 min observations. The MHT had charted from 8:00 AM thru 9:45 AM that the patient was in his bedroom and hallway with no abnormal verbal behavior. The MHT then wrote over the top of the previous documentation from 8:15 AM thru 9:30 AM that the patient was repetitive, making noises, complaining, and constant requests for attention.

A review of patient #1's chart revealed a restraint/seclusion packet dated 4/10/23 at 9:45 AM. The packet included the following forms:

A. Physician order for restraint.
The packet was filled out by staff #19 RN. Staff #19 signed the order stating she took the verbal order for the restraint medication on 4/10/23 at 9:25 AM. Staff #19 failed to fill out the section for clinical justification for the use of restraint. The order was never signed or authenticated by the physician.

B. face-to-face.
A review of the face-to-face form dated 4/10/23 at 10:45 AM revealed no vital signs were documented. The vital signs were left blank with no reason documented. Staff #39 RN assessed the patient for a face-to-face. It was confirmed by Staff #1 on 5/9/23 that Staff #39 did not have face-to-face training.

C. Staff debriefing.
A review of the staff debriefing form revealed the form was dated 4/10/23 at 9:35 AM 10 minutes before the patient was given a chemical restraint. There was no information on what staff was in attendance. Staff #39 left the questions on the form blank on "triggers or early signs of agitation and what could the staff do to minimize those triggers to avoid a chemical restraint." The only de-escalation technique documented was "communication."

A review of the restraint and seclusion policy and procedure stated, "A post-restraint or post-seclusion staff debriefing occurs as soon as possible, but no longer than 24 hours. The content of the staff debriefing includes the following: Assessment of the effectiveness of less restrictive alternatives or methods to prevent further episodes, Identification of patient triggers, Effectiveness of de-escalation techniques, approaches and/or staff communication, Compliance with restraint and seclusion policies, Evaluation and prevention of staff or patient injuries, The results of the debriefing will be documented and reviewed for performance improvement initiatives."

Patient debriefing.
The patient did not participate in the patient debriefing due to "sleeping." There was no found documentation of any debriefing performed with patient #1 after he awakened.

A review of the restraint and seclusion policy and procedure stated, " 4.4.4 Post restraint or Post-seclusion Patient and Staff Debriefing. A post-restraint or post-seclusion patient debriefing will occur as soon as possible, but no longer than 24 hours, after the restraint or seclusion episode. The content of the patient debriefing after each episode of restraint or seclusion includes the following: Identification of what led to the use of restraint or seclusion and what could have been done differently. Ascertainment that the patient's well-being, psychological comfort, and right to privacy were maintained Counseling of the patient for any physical or psychological trauma that may have resulted from the use of restraint or seclusion. Modification of the patient's plan of care, if indicated. The results of patient debriefing will be documented in the patient's medical record."

A review of patient #1's nurse note dated 4/10/23 at 2:00 PM stated, "up from bed, screaming, yelling, hitting the windows. Geodon/Ativan 20/2 given IM at left buttocks. Patient sleeping."

A review of the physician orders revealed patient #1 was ordered: "Geodon 20mg INJ NOW, and Ativan 2 mg IM NOW." There was no reason documented on the order for the chemical restraint/EBM. A review of the MAR revealed the nurse administered the medications IM on 4/10/23 at 2:00 PM.

A review of the restraint packet revealed the medications administered were not administered IM but by mouth. The physician failed to sign the seclusion order form. There was no debriefing with the patient documented or with any staff.

There was no documentation on the effects of the medication, the patient's disposition, or vital signs until 4:30 PM. A review of the nurse's notes dated 4/10/23 at 4:30 PM stated, "Up again, Dr ____ and /____(physician) notified, pt on 1:1. Fall precautions."

A review of patient #1's chart revealed there was no found order for a 1:1 on 4/10/23. A review of the observation sheet revealed the patient was not on a 1:1 and was documented as in the hallway and dining room with no behavioral issues. The MHT documented no abnormal verbal behavior from 4:00 PM until 5:00 PM.

A review of patient #1's vital sign sheet in the chart revealed he had no vital signs taken until 5:00 PM on 4/10/23, 7 hours after his first injection and 3 hours after his second.

A review of the restraint and seclusion policy and procedure revealed there was no process for patient nursing assessment or reassessment after the administration of a chemical restraint/EBM. There was no process for how frequently the nurse was to reassess the patient and for how long. There was no found education to staff on how to assess and reassess a patient after a chemical restraint was administered.

According to the manufacturer insert Haldol (Haloperidol) is an antipsychotic medicine that is used to treat schizophrenia and psychosis. It can also be used for psychiatric emergency behavioral situations. Any patient receiving these medications should be monitored by a trained medical professional due to the side effects of Anemia, Headache, Increased or Decreased respiratory rate, Orthostatic hypotension, Prolonged QT interval, and Visual disturbances.

Geodon (Ziprasidone) belongs to a class of drugs called atypical antipsychotics used to treat schizophrenia. It is also known as a second-generation antipsychotic (SGA) or atypical antipsychotic. Ziprasidone rebalances dopamine and serotonin to improve thinking, mood, and behavior. All antipsychotics have been associated with the risk of sudden cardiac death due to an arrhythmia (irregular heartbeat). To minimize this risk, antipsychotic medications should be used in the smallest effective dose when the benefits outweigh the risks. All antipsychotics can cause sedation, dizziness, or orthostatic hypotension (a drop in blood pressure when standing up from sitting or lying down). These side effects may lead to falls which could cause bone fractures or other injuries. This risk is higher for people with conditions or other medications that could worsen these effects. Summary Of FDA Black Box Warnings Increased Mortality in elderly patients with dementia-related psychosis. Both first-generation (typical) and second-generation (atypical) antipsychotics are associated with an increased risk of mortality in elderly patients when used for dementia-related psychosis.
Although there were multiple causes of death in studies, most deaths appeared to be due to cardiovascular causes (e.g., sudden cardiac death) or infection (e.g., pneumonia).
Antipsychotics are not indicated for the treatment of dementia-related psychosis
https://www.nami.org/About-Mental-Illness/Treatments/Mental-Health-Medications/Types-of-Medication/Ziprasidone-(Geodon).

An interview was conducted with Staff #1, Staff #16, Staff #11, and Staff #22 in the afternoon of 5/9/23. Staff #1 confirmed there was no written nursing process for assessment and reassessment of a patient that had received a chemical restraint. Staff #11 stated that he assessed patients that received a chemical restraint very regularly. Staff #11 stated that he tried to check on them every 15 minutes but did not know for how long. Staff #11 stated, "I would be very interested in knowing what the rule is on reassessment." Staff #22 stated as an LVN (licensed vocational nurse) she had been administering chemical restraints/EBM but was unaware of any process in how often to assess the patient. Staff #11 and staff #12 were unaware that there was no antidote to psychotropic medications and were not aware of the black box warnings on Haldol or Geodon. Staff #16 stated that he was not aware that there was no direction from Medical Staff on how to assess the patient after a chemical restraint was administered. Staff #16 stated that he would call an ad-hoc meeting with medical staff to discuss and resolve the issue. The nursing staff interviewed was unable to voice their complete understanding of a chemical restraint/ emergency behavioral medication administration and how to assess for any emergencies or adverse effects.

An interview was conducted on the morning of 5/9/23 with Staff # 1 and Staff #2. Staff #1 confirmed that there was no restraint log. Staff #1 was unable to confirm who had received a restraint or what type. Staff #2 was asked how Quality assessed restraints and restraints use if the facility had no log. Staff #2 stated that when a patient is restrained the nurse was to fill out a restraint packet and Staff #2 would pick those up every day. Staff #2 stated that she would do a quality assessment on the restraints to see if there were any problems. Staff #2 was shown the pharmacy log that revealed multiple patients receiving IM psychotropic medications as "now" orders for behavioral emergencies that had no restraint packets. Staff #2 stated that she had just started in this position, and she was told that the previous QAPI director was monitoring the restraints but that she had not been able to compile the information and was not monitoring the restraint process in QAPI at this time.

The following patient charts revealed there were incomplete restraint and seclusion forms, failure to assess the patient after the administration of a chemical restraint/ EBM, and failure to log the restraint and follow through with QAPI to ensure the safe administration of a chemical restraint/EBM.

Patient #4
A review of patient #4's chart revealed he was administered a chemical restraint/EBM on 2/15/23 at 9:00 AM. The nurse documented he was "Agitated and aggressive towards staff ... Yelling and screaming ...believes everyone is a cop." The staff attempted to redirect the patient but did not document what that consisted of. The physician was called and a telephone order for Ativan 1 mg IM, Haldol 10mg IM, and Benadryl 100mg IM was ordered and administered. There was no further information on the effectiveness of the medication. There were no documented vital signs until 5:45 PM, 8 ½ hours after the medication was administered.

A review of the restraint packet on the face-to-face dated 2/15/23 at 9:30 AM stated, "Patient was agitated, aggressive, uncontrollable, and refused direction ... voluntarily took emergency medication and tolerated well." Patient #1 was documented as "willing" to take medication however, there was no documentation on why medications were not offered by mouth. The nurse documented she was unable to assess the patient due to sedation. The nurse checked the box that stated, "The patient was assessed, verbalized understanding of the release criteria at this time, and restraint or seclusion should be discontinued." The nurse stated no vital signs due to sedation, but the patient was able to verbalize understanding of the restraint and release criteria. There were no documented release criteria for a chemical restraint/ EBM. There was no documented patient debriefing or names of staff involved with the staff debriefing.

Patient #5
Review of patient #5's nursing note, staff #21 RN documented that on 2/9/23 at 11:50 AM, "Patient started screaming and yelling expletive at another patient. Patient was very agitated. 12:00 PM Haldol 10mg IM, Ativan 4mg IM, and Benadryl 100mg IM given with the patient's consent and patient tolerated well." 12:30 PM Patient is ambulating in the unit, calm, and quiet, interacting with staff and patients. Denies any side effects. Went to group." There was no explanation documented why the patient was not offered medications in pill form if he was willing to take medications.

A review of the face-to-face dated 2/9/23 at 12:30 PM stated the patient was sedated and refused vital signs. However, the nurse documented on the face to face that patient #5 was alert, and oriented to person and place. There was no time or date on when the patient debriefing took place. Upon the patient signature line, it stated, "refused". There was no time or names for any staff debriefing. A review of the seclusion/restraint progress note revealed the note had no date or time.


40989

An interview was conducted on 5/09/2023 at 9:00 AM with Staff #20 and #21.

Staff #20 was asked how long the patient was monitored after a chemical restraint/EBM (emergency behavioral medication) was administered. Staff #20 stated, "After they get a shot, we try and keep them in their room for the first 30 minutes. You know, just so they don't fall. Then we will go back and check on them in an hour or so. The techs will watch them and tell us if there is a problem." Staff #20 was asked if an assessment and vital signs (blood pressure, temperature, heart rate, respiratory rate, and oxygen level) were taken and documented. Staff #20 stated, "Not all the time because the patient will refuse, or they may be sleeping." Staff #20 was asked if he documented a respiratory rate if the patient was sleeping or if the patient refused the vital sign assessment. Staff #20 stated, "If I tell you the patient refused, then that should be good enough. If the patient is talking and refuses, then you know the patient is alive. There is no reason for me to document a respiratory rate."

Staff #21 was asked if a restraint packet was always completed when a patient received an IM (intramuscular) injection of an EBM. Staff #21 replied, "No, not all the time, but I do most of the time. If a patient takes the medications willingly, sometimes we don't do a restraint packet. Like Patient #26 would come and ask for a shot of Haldol and Ativan because he was very anxious and agitated. We would call the doctor and get an order. Then, most of the time he would just go and sleep. Since he asked for the shot, we didn't do a restraint packet because he took it willingly."

Based on record review and interview the facility failed to:

A. ensure a 1-hour Face to Face was completed by the provider or a trained RN within one hour of the administration of a chemical restraint/EBM (emergency behavioral medication) in 5 (Patient #4, #26, #29, #30, and #32) of 5 medical records reviewed.

B. ensure RN's (Registered Nurses) completed training of the 1-hour face to face evaluation before evaluating a patient after a chemical restraint.


Findings:

A.

Patient #4
Patient #4 was a 21-year-old male admitted to the facility voluntary on 2/14/2023 at 6:25 AM with a diagnosis of Psychosis and severe substance abuse-Methamphetamine, Cocaine, Adderall, alcohol, and Benzodiazepines. He had a past medical history of Cerebral Palsy and Seizures. A review of the Psychiatric Evaluation by Physician #9 revealed he was only oriented to person and place, not time or situation. He had poor memory and recall, impaired insight, and impaired judgement. The psychiatrist documented the patient was highly anxious, easily agitated, and had a difficult time answering questions.

A review of the document titled, "Restraint/Seclusion/Emergency Medication" packet dated 2/15/2023 at 8:30 AM by Staff #30 revealed Patient #4 was agitated, irritable, and yelling uncontrollably. A telephone order was received from Physician #9 at 8:30 AM for Ativan (sedative) 4mg IM, Haldol (antipsychotic) 10mg IM, and Benadryl (antihistamine) 100mg IM and administered to the patient by Staff #30 at 8:50 AM.

Review of the 1-hour face to face was as follows:
" ...Patient agitated, aggressive, and yelling uncontrollably and refused to be verbally redirected. Patient voluntarily took emergency medication, and he tolerated them well. Patient eventually calmed down and sleep (sic). No vital signs taken due to patient being sedated. The review of systems revealed all systems (skin assessment, circulatory status, genitourinary, reproductive, respiratory status, neurological, and musculoskeletal) were documented as within normal limits. Pain assessment was documented as Yes, but no description as to where or how severe the pain was. The Mental Status exam was only documented as unable to assess due to sedation ..."

Staff #1 confirmed the 1-hour face to face was documented and signed by Staff #29 on 2/15/2023 at 8:00 AM. Staff #29 signed the 1-hour face-to-face evaluation 50 minutes prior to the chemical restraint being administered.


Patient #26
Patient #26 was a 25-year-old male admitted to the hospital voluntary on 4/26/2023 with a diagnosis of Major Depressive Disorder with suicidal ideation.

A review of the medical record revealed Patient #26 was administered a chemical restraint/EBM on 4/30/2023, 5/2/2023 and 5/03/2023.

Physician #9 gave a telephone order dated 4/30/2023 at 2:53 PM for Geodon (antipsychotic) 20mg IM NOW x1 and Ativan 2mg IM NOW x1. There was no rationale or specific behaviors justifying the restraint on the physician order. The nurse administered the medication at 2:54 PM.

A review of nursing documentation on 4/30/2023 by Staff #19 was as follows:
" ...3:00 PM - patient went after another patient to attack and hits his head at the right side. MD notified, Geodon 20 mg Ativan 2mg IM given and tolerated well. Patient sleeping at this time..."

Physician #9 gave a telephone order dated 5/02/2023 at 2:27 PM for Ativan 2mg IM NOW x1 and Haldol 10mg IM NOW x1. There was no rationale or specific behaviors justifying the restraint on the physician order. The nurse administered the medication at 2:27 PM. There was no documentation regarding a behavioral emergency at the time the medication was administered.

Physician #9 gave a telephone order dated 5/03/2023 at 11:09 AM for Ativan 2mg IM NOW x1 and Haldol 10mg IM NOW x1. There was no rationale or specific behaviors justifying the restraint on the physician order. The nurse administered the medication at 11:19 AM. There was no documentation regarding a behavioral emergency that would require a chemical restraint/EBM at the time the medication was administered.

RN Staff #19 documented at 11:00 AM, "Patient received Ativan 2mg and Haldol 10mg IM at right and left deltoid, per patient request, patient tolerated well, noted patient breathing pattern is normal, and sleeping after 30 minutes. Will continue to monitor."

Staff #1 confirmed the medications administered IM to Patient #26 on 4/30/2023, 5/02/2023, and 5/03/2023 were administered as a chemical restraint/EBM and there should have been a restraint packet completed. Staff #1 also confirmed there was no 1-hour face to face evaluation completed.


Patient #29
Patient #29 was a 62-year-old female admitted to the facility 4/14/2023 involuntary with a diagnosis of Schizophrenia. A review of the Physician orders dated 5/02/2023 noted Physician #9 gave a verbal order for Ativan 2mg IM NOW and Geodon 20mg IM NOW at 4:50 PM. The medication was administered by the nurse at 5:04 PM.

A review of the nurse's notes dated 5/02/2023 at 10:44 PM was as follows;
"Patient #29 was observed asleep in bed, due to pt received emergency medication of Ativan 2mg and Geodon 20mg IM for agitation, pt is hard to awaken, will continue to monitor pt."

Staff #1 confirmed there was no restraint packet or 1 hour face to face completed for the chemical restraint/EBM.


Patient #30
A review of the document titled, "Restraint/Seclusion/Emergency Medication" dated 4/02/2023 at 3:30 was as follows:

A verbal order was given for Ativan 2mg IM, Haldol 5mg IM, and Benadryl 50mg IM by Physician #9. Patient #30 received an IM injection at 3:30 PM because she was exhibiting "combative behavior".

A review of the 1-hour face to face was incomplete. There were no vital signs or refusal by patient. No release criteria was documented as met or not met. No date or time was documented of when the physician was notified.

The 1-hour face to face was signed by LVN Staff #32 at 3:30 PM. This was the same time as the medication was administered.


During an interview on 5/09/2023 after 1:00 PM, Staff #1 confirmed the 1 hour face to face evaluation was not complete and was signed at the same time the medication was administered. Staff #1 also confirmed LVN's (Licensed Vocational Nurses) were not allowed to complete a 1-hour face to face evaluation.

Patient #32
Patient #32 was a 44-year-old male admitted to the hospital on 3/05/2023.

A review of the incident report dated 3/5/2023 at 4:00 PM by Staff #19 was as follows:
" ...The patient was agitated, irritable, taking clothes off aggressive and yell uncontrollably, and threatening staff.MD notified. Geodon 20mg, Ativan 2mg, Benadryl 50mg ..." There was no time documented on the incident report when the medication was administered.

Staff #1 confirmed there was no restraint packet or 1 hour face to face evaluation completed by the Physician or a trained RN.




A review of the facility policy titled, "PC.027 Behavioral Health Restraint and Seclusion" with a revision date of 12/12/2022 was as follows:

" ...4.0 Restraint and Seclusion for Violent or Self-Destructive Behavior
The following standards apply to patients who are demonstrating violent or self-destructive behavior, regardless of their hospital setting. These behaviors jeopardize the immediate physical safety of the patient, staff or others.
4.1 Physician Orders and Physician Assessment
4.1.1 Use of restraint or seclusion is based upon the time limited order with rationale of a physician, clinical psychologist or other authorized licensed independent practitioner in accordance with hospital policy and state law. In addition, the physician order will include:
Date, time and signature
Rationale and specific behaviors justifying use of restraint or seclusion
Type of restraint or seclusion
4.1.2 In the absence of a physician, an authorized RN who has successfully completed restraint and seclusion competency may initiate restraint or seclusion.
4.1.3 When an RN initiates restraint or seclusion, an order will be obtained from a physician as soon as possible after the restraint is initiated.
4.1.4 The original order is based on a face-to-face assessment of the patient by a physician or authorized RN. The face-to-face assessment which is mandatory within 1 hour of the initiation of the restraint or seclusion must be done by a physician or RN other than the RN whenever possible. The results of the assessment will be documented in patient's medical record and will include following:
Patient's immediate situation
Patient's reaction to the intervention
Patient's medical and behavioral condition
Need to continue or discontinue restraint or seclusion
4.1.5 The face to face assessment is completed for all episodes of restraint or seclusion regardless of patient being released within the first hour.
4.1.6 If the order or face to face assessment is not completed by the patient's attending physician, the attending physician will be consulted as soon as possible ..."


An interview was conducted on 5/09/2023 at 9:00 AM with Staff #20 and #21. Staff #20 was asked when a chemical restraint/EBM was administered, who completes the 1-hour face to face evaluation and how is it documented. Staff #20 stated, "I know a different nurse has to do the face to face. It's not supposed to be the same nurse that gives the medicine. We try and go back and get that done." Staff #20 was then asked if vital signs (blood pressure, temperature, heart rate, respiratory rate, and oxygen level) are taken and documented on the face-to-face form. Staff #20 stated, "Not all the time because the patient will refuse, or they may be sleeping." Staff #20 was asked if he documented a respiratory rate if the patient was sleeping or refused the vital sign assessment. Staff #20 stated, "If I tell you the patient refused, then that should be good enough. If the patient is talking and refuses, then you know the patient is alive. There is no reason for me to document a respiratory rate."
Staff #21 was asked if a 1-hour face to face evaluation was always completed when a patient received an IM injection of an EBM. Staff #21 replied, "No, not all the time, but I do most of the time. If a patient takes the medications willingly, sometimes we don't do a restraint packet. Like Patient #26 would come and ask for a shot of Haldol and Ativan because he was very anxious and agitated. We would call the doctor and get an order. Then most of the time he would just go and sleep. Since he asked for the shot, we didn't do a restraint packet on him and that's where the 1-hour face to face is documented."



B.

A review of the personnel files for 3 (Staff #11, #18, and #19) of 3 RN's was conducted on 5/09/2023 with Staff #1 and #2. Employee files did not reveal training and staff competency to complete a 1-hour face to face evaluation after a chemical restraint/EBM was administered IM to a patient.

Employee #11
A review of Employee #11's file revealed acknowledgement documents was signed on 11/14/2022 for the education of:
1. Restraint and Seclusion Process
2. Restraint/Seclusion/Emergency Medication Packet

Staff #2 confirmed there was no documentation of the 1-hour face to face training.


Employee #18
A review of Employee #18's file revealed acknowledgement documents were signed on 4/26/2022 for the education of:
1. Restraint and Seclusion Process
2. Restraint/Seclusion/Emergency Medication Packet
3. Provision of care-Restraints and Seclusion

Further review revealed a Post Test titled, "Conducting the One Hour Face to Face Evaluation for Restraint/Seclusion" was signed by Employee #18 but there was no date when the post test was taken. The post test consisted of 7 questions and there was no pass or fail documented on the test.


Employee #19
A review of Employee #19's file revealed an acknowledgement document was signed on 6/1/2022 for the education of Restraint/Seclusion/Emergency Medication Packet and on 10/20/2022 for Restraint and Seclusion Packet. A post test for Restraint and Seclusion was taken with a grade of 80. There was no date on the test. No further education was found in the file.

Further review revealed a Post Test titled, "Conducting the One Hour Face to Face Evaluation for Restraint/Seclusion" was signed by Employee #19 but there was no date when the post test was taken. The employee scored a 58 out of a possible 100. An additional test was taken for the one-hour face to face but there was no grade, no signature, or date by the employee. This surveyor was unable to determine when the test was taken. The posttest consisted of 6 questions and there was no pass or fail documented on the test.


An interview was conducted on 5/09/2023 at 9:00 AM with Staff #20. Staff #20 was asked if the 1-hour face to face was an annual training. Staff #20 replied, "We do it at orientation. They give us the policy and we sign the paper saying that we got it." Staff #20 was asked to explain the process for the 1-hour face to face. Staff #20 replied, "We try and keep the patients in their rooms for the first 30 minutes after they had a shot just so they don't fall. Then we will go back and see them in an hour or so. The techs can monitor the patients and come and tell us if there is a problem."


An interview was conducted with Staff #4 on 5/09/2023 after 1:00 PM. Staff #4 was asked if the RN's had specific training for the 1-hour face to face evaluations. Staff #4 stated they are given the policy on restraints to go over and the training comes from the policy. Staff #4 was asked if there was a policy on the 1-hour face to face evaluation. He replied, "No, all the information was in the restraint policy."
During an interview on 5/09/2023 after 1:00 PM, Staff #1 stated, "I know we did a power point on that training."
After multiple requests for the 1-hour face to face training, none was received or provided for review.
Staff #1 confirmed there was no competencies for the 1-hour face to face evaluation training in 3 (Staff #11, #18, and #19) of 3 personnel files reviewed.

Based on review and interview the facility failed:

1.
to provide credentialing, privileges, and a current list of telemedicine physicians.
Refer to Tag A0343

2.
to provide medical staff bylaws.
Refer to Tag A0353

Based on review and interview the facility failed to provide credentialing, privileges, and a current list of telemedicine physicians.

The facility presented a practitioner list by specialty. The list did not identify by name or specialty any of the telehealth physicians performing current psychiatric evaluations and care.

The facility was not able to provide the surveyor with Governing Board bylaws after 5 requests. The surveyor was unable to determine if the GB allowed the contracted service to credential its staff or if the facility chose to credential all physicians through the hospital process.

A review of the contract for Physician Credentialing and Privileging Agreement dated 2/28/2014 stated, " Each such credentialed Redi answer physician providing telemedicine physician services to the hospital has been appropriately credentialed and privileged by Redi answer...The hospital may accept Redi answer and comply as necessary with the standards set forth in that regulation."

The distant-site telemedicine entity failed to provide a list to the hospital of all physicians and practitioners covered by the agreement, including their privileges at the distant-site telemedicine entity, current privileges, and pertinent licensure information.

There was no evidence that the hospital reviews the services provided by the telemedicine physicians and practitioners, including any adverse events and complaints, and provides written feedback to the distant-site telemedicine entity.

An interview was conducted with staff #16 on 5/9/23. Staff #16 confirmed that the provider list given to the surveyor had no telemedicine physicians listed and confirmed the physicians had not been credentialed for the facility. Staff #16 confirmed that he was unsure who was credentialed and stated many of the providers on the list were no longer with the organization.

Based on interview the facility failed to provide medical staff bylaws.

An interview was conducted with staff #4 on 5/9/23. Staff #4 was asked 2 times on 5/8/23 to provide the surveyor with medical staff bylaws. On 5/9/23 staff #4 stated he did have medical staff by laws and would provide them for the surveyor. Staff #4 was unable to provide the bylaws. On 5/10/23 staff #4 was asked if the facility had medical staff bylaws and why would he not provide the bylaws. Staff #4 reassured the surveyor he would provide the bylaws. The facility failed to provide any medical staff bylaws after 5 requests.

Based on review and interview the facility failed to ensure:

1.
adequate staffing levels to ensure patient and staff safety.
see Tag A0392

2.
to provide a interdisciplinary treatment plan for 2 (Patient #26 and 29) out of 3 (patient #1, #26 and #29) charts reviewed.
See Tag A0396

Based on review and interview the facility failed to ensure adequate staffing levels to ensure patient and staff safety.

Findings:
During a tour of the facility on 5/8/23 in the afternoon the surveyor observed one large patient care area with a nurse's station in the middle. At the front of the nurse's station were two double doors and also at the back. This allowed one side of the unit to be closed off from the other creating two separate units. The nurses could observe both sides from the nurse's station. There was an ER unit and a medical unit that were not open or functioning.

An interview was conducted with Staff #1 on 5/9/23 concerning staffing. Staff #1 stated that she does the nurse and mental health technician staffing. Staff #1 was asked how she determines how to staff the unit. Staff #1 stated that she staffs 3 nurses (2 RN's and 1 LVN) and 3 techs at all times. Staff #1 was asked if she had a grid or matrix that showed her minimum staffing grid. Staff #1 stated, "We did have a matrix, but I don't have one anymore." Staff #1 stated that she just puts people in when she needs extra people, but she sticks with the 3 techs, and 3 nurses for 1-21 patients. Staff #1 was unable to provide an acuity scale to show when she needed to increase staff. There was no information on the staffing sheets for a patient who was being admitted or discharged, patient required a line of sight, the patient was ordered a 1:1, or requiring more staff if the milieu was changing or disruptive. Staff #1 stated that she makes those decisions on what she is being told by the staff. Staff #1 confirmed that if she was not available there was no one else making those determinations and there was no documented process.

A review of the policy and procedure " Nursing Staffing and Assignments" stated, " 3. Core staffing requirements have been established for each unit based upon the types of patients admitted to the unit, acuity needs, unit geography, and availability, of support staff and methods of patient care delivery. The hospital will schedule a minimum of two (2) licensed nurses on every shift for the behavioral unit and a minimum of (1) licensed nurse for the medical psych unit. A licensed nurse will be on each unit at all times. A charge nurse on each shift provides relief and backup for the assigned nurses."

The policy and procedure were not accurate to the types of units available nor were there "core staffing requirements" available. There were no acuity levels. The surveyor was unable to determine safe staffing levels.

Based on review the facility failed to provide a interdisciplinary treatment plan for 2 (Patient #26 and 29) out of 3(patient #1, #26 and #29) charts reviewed.

A review of patient #29's chart revealed the patient was admitted to the facility on 4/14/23 and was still in the facility as of 5/10/23. Patient #29 had no treatment plan on the chart. The facility was unable to provide a treatment plan after 3 requests.

A review of patient #26's chart revealed the patient was admitted to the facility on 4/26/23. Patient #26 had no treatment plan on the chart. The facility was unable to provide a treatment plan after 2 requests.


A review of the policy and procedure Interdisciplinary Treatment Plan stated:

"POLICY
Each patient admitted to Aspire Hospital shall have a written, individualized, comprehensive, outcome-oriented interdisciplinary treatment plan of care. Based on assessments of clinical needs (as well as reassessments and results of diagnostic testing) and the patient's goals (and the time frames, settings, and services required to meet those goals), the plan for the patient's care, treatment, and services shall describe patient strengths and limitations; short and long term goals of treatment; clinical interventions prescribed; patient progress in meeting treatment goals; criteria for discharge from treatment; and provisions for aftercare. Treatment shall be planned, reviewed, and evaluated at regular intervals by the Interdisciplinary Treatment Team. This team shall consist of the physician and representatives of each clinical discipline involved in the treatment as appropriate .

Based on document review and interview the hospital failed to ensure that telephone/verbal orders were authenticated promptly by 3 (Physician #9, Physician #27, and Provider #28) of 3 providers in 2 (Patient #26 and Patient #29) of 2 medical records reviewed. Also, the hospital failed to follow their own policy and ensure that only a Registered Nurse was accepting verbal and/or telephone orders from the Medical Staff Providers.


A review of medical records was conducted on 5/10/2023 after 10:00 AM with Staff #23.

Findings:


Patient #26

Patient #26 was a 25-year-old male admitted voluntary to the facility on 4/26/2023 with a diagnosis of Major Depressive Disorder and Psychosis with Suicidal Ideation.

All telephone orders dated 4/26/2023 at 4:12 AM were accepted by LVN (Licensed Vocational Nurse) Staff #31.

A review of the orders revealed Physician #9 gave telephone orders for admission, medications, ancillary (lab and x ray), and nursing on 4/26/2023. Physician #9 failed to authenticate the telephone orders until 5/08/2023 at 1:10 PM. This was 12 days after the telephone orders were accepted by the hospital staff.

Further review of the physician orders revealed Physician #9 gave telephone orders for the following medications:
" ...4/26/2023 at 8:38 AM Zyprexa (antipsychotic) 10 mg tab by mouth. Now order for a new patient
4/29/2023 2:41 PM Valium (sedative) 5 mg tab by mouth NOW
4/28/2023 10:18 AM Ativan (sedative) 2mg IM NOW
4/30/2023 2:54 PM Ativan 2mg IM NOW
4/30/2023 2:53 PM Geodon (antipsychotic) 20mg IM NOW
5/03/2023 11:10 PM Haldol (antipsychotic) 10mg IM NOW
5/03/2023 11:09 PM Ativan 2mg IM NOW
5/02/2023 2:27 PM Ativan 2mg IM NOW
5/02/2023 2:27 PM Haldol 10mg IM NOW ..."

Physician #9 failed to authenticate the telephone orders until 5/08/2023 at 1:10 PM.


A review of the telephone orders dated 4/30/2023 by Physician #27 was as follows:
" ...9:49 AM Valium 10mg tablet by mouth twice a day
12:57 PM Zyprexa 15mg tablet by mouth NOW
12:58 PM Valium 10mg tablet by mouth NOW ..."

As of survey exit date on 5/10/2023, the telephone orders given by Physician #27 had not been authenticated. This was 10 days after the telephone orders were accepted by the hospital staff.




Patient #29

Patient #29 was a 62-year-old female admitted to the facility Involuntary on 4/13/2023 with a diagnosis of schizoaffective disorder and Psychosis. The Psychiatric Evaluation revealed the patient was delusional, had visual and auditory hallucinations, oriented to person only, had impaired insight, and impaired judgement.

A review of the medical record for Patient #29 revealed Physician #9 gave telephone orders on 4/14/2023 at 10:07 AM for admission, medications, ancillary (lab and x ray), and nursing orders. Physician #9 failed to authenticate the telephone orders until 5/08/2023 at 1:10 PM. This was 24 days after the telephone orders were accepted by the hospital staff.

A review of the physician orders dated 4/14/2023 at 2:46 PM revealed Provider #28 gave telephone orders for medications. The orders were as follows:
" ...Synthroid (hormone) 88mcg daily by mouth and Lipitor (medication used to lower your cholesterol) 40 mg at bedtime ..."

As of survey exit date 5/10/2023, Provider #28 failed to authenticate the telephone orders.




Further review revealed telephone orders were accepted by LVN Staff #22. The orders were as follows:
" ...4/23/2023 10:18 AM Ativan 2mg by mouth. Telephone order given by Physician #27 ...
4/27/2023 at 2:06 PM Dulcolax 10 mg by mouth now. Telephone Order given by Provider #28 ..."

As of survey exit date 5/10/2023, Physician #27 and Provider #28 failed to authenticate the telephone orders.



A review of the facility policy titled, "Verbal/Telephone Orders, Policy #IM.003" with a review date of 12/11/2020 was as follows:

" ...POLICY
It is the policy of Aspire Hospital that only a licensed registered nurse may accept telephone or verbal orders from the physicians. Verbal orders will be accepted in emergency situations only when immediate written or electronic communication is not feasible and will be documented with the date and time that the verbal order is received. The physician or covering physician will be responsible for authenticating the order with his/her signature, as soon as possible, but within 48 hours of the verbal/telephone order unless state law is more restrictive ..."

During an interview with Staff #22 on 5/10/2023 after 11:00 AM she confirmed she was not aware that the facility policy did not allow LVN's to take verbal orders.

An interview was conducted with Staff #23 on 5/10/2023 after 11:00 AM. Staff #23 was asked if the facility uses telephone orders on a regular basis. Staff #23 replied, "Sometimes we have no other option. We do not have doctors in the hospital all the time. If one of us nurses do the intake, we call the doctor for orders and some of the orders are just routine that we use for every patient but if the patient needs specific orders, then we get them from the physician as well. We put the orders in the system and then the doctor signs them. Sometimes the doctor is not here until the next day, so we have to make sure that we have orders to care for the patient."

Staff #1 confirmed that verbal and telephone orders were not routinely signed within 48 hours. She also confirmed LVN's were taking telephone/verbal orders.

Based on observation the hospital failed to ensure 5 of 5 patient rooms including shower areas (rooms 151, 120, 106, 102, and 101)were maintained in a manner to ensure cleanability and prevent contamination.

During initial tour of the patient care areas on 05/08/23/in the presence of facility Staff #7 and 3 , the following was observed:
Room 151 "Patient Shower Room" was being used to bathe multiple patients rather than showers in patient rooms. The following was observed:

The surface of the interior wall of the shower was chipped, having multiple round holes and indentations throughout the shower enclosure and a section of the lower molding, approximately 3' in length, appeared to have broken off and was missing. A build up of a black substance having the appearance of mold or mildew was observed along the bottom edges of the shower entrance and along the lower molding and interior of the shower enclosure. There was a horizontal silver grab bar mounted to the interior of the shower wall that had a used, wet wash cloth wadded up and tucked in between the railing and the wall, and white plastic cup was sitting on the railing.

Room 120 "Patient Shower" was observed to have chipped, multiple round holes and indentations throughout the shower enclosure. The interior drain and interior of the shower had a build up of a black substance with the appearance of mold or mildew. The exterior of the shower entrance had a build up of a black substance throughout the grout/seal located along the floor edge that had the appearance of mold or mildew. The horizontal silver grab bar had areas of rust.

The following was observed in Patient Room 106's bath and shower area: the interior of the shower had a build up of a black substance along the grout that had the appearance of mold or mildew. There was grafitti writing in various places on the of the bathroom area that included "M.O.B", "KILLZ", "Brooke was here XOXO", and "So was (illegible)". The round, silver plates located on the wall under the patient sink had a build up of red substance with the appearance of rust. To the right of the sink, connecting the sink to the wall, was a small counter surface area that had chipped edges exposing what appeared to be particle board that could not be sanitized. There was also a build up of a black substance and dirt/debris along the corners of the counter surface. There were personal toiletries including a comb, toothbrush, small tube of toothpaste, two small bottles of liquid personal hygiene materials that included mouthwash.

The following was observed in Patient Room 102, the mattress had several rips and tears along its surface preventing the mattress from being able to be sanitized. The baseboard molding had been removed from the base of each wall, leaving chipped paint and exposed sheetrock that could not be sanitized. The ceiling vents had a build up of a reddish material with the appearance of rust and an accumulation of dust.

The bathroom of Patient Room 101 was observed the ceiling vents had a build up of a reddish material with the appearance of rust and an accumulation of dust. The commode, behind the seat at the base of the tank, along the seam, had a build up of a reddish material with the appearance of rust.

Each of these observations of environmental issues posed issues of potential contamination.

Based on record review and interview the facility failed to:
A. ensure emergency medical supplies and equipment was immediately available to staff to treat a patient that was experiencing an emergency medical condition. REFER to 144

B. provide emergency medical treatment to patients experiencing a medical emergency in 10 (patients #10, 11, 12, 14, 15, 18, 21 (x2), 22, 23, and 24) of 13 patient records reviewed.

A review of the incident reports dated January 2023-March 2023 was completed on 5/09/2023. The review revealed 11 (Patients # 11, 12, 14, 15, 17, 18, 20, 21 (x2), 22, 23, and 24) of 11 patients experienced an emergency medical condition while admitted to the behavioral health unit. Two (Patient #10 and #13) of 2 patients receiving outpatient services experienced an emergency medical condition. Hospital staff called 911 and transferred 10 (patients #10, 11, 12, 14, 15, 18, 21 (x2), 22, 23, and 24) of the 13 patients reviewed to other hospitals for a higher level of care.


Findings:


On 05/09/23, observations made of the hospital's exterior noted signage above an entrance for "Ambulance", there was no signage reflecting "Emergency". During a tour of the hospital the morning of 05/09/23 with Staff #4, an emergency suite was observed as well as two emergency treatment rooms. The emergency suite and treatment rooms appeared to be set up and ready for patients with patient beds made up, crash carts and other supplies however there was no staff noted in the department.

In an interview conducted while touring the hospital with Staff #4 on the morning of 05/09/23, Staff #4 noted the emergency department was not open. Staff #4 stated there was no staffing for this department, and patients were not received or accepted through the emergency department, nor were current in-patients provided treatment through the emergency suite or emergency treatment rooms. Staff #4 affirmed that the hospital did not staff the emergency department with nurses, or physicians or have a designated emergency department medical director. Staff #4 stated that the emergency department had not been open since sometime before COVID.

During a tour of the hospital 05/08-05/09/23, the only unit observed to be utilized and staffed by the hospital was the locked, behavioral unit. The hospital was not utilizing the licensed medical/surgical beds and was only providing behavioral/psychiatric care. Staff # 1 confirmed in an interview on 05/09/23 that the hospital did not utilize the emergency room or the emergency treatment rooms. When Staff #1 was asked what they would do if a patient on the locked, inpatient behavioral unit had an emergent condition, responded an incident report would be completed and the patient would be assessed by the floor nurse and if necessary, they would call 911 and the patient would be transferred to another hospital for further assessment, stabilization, or treatment. In interviews on 05/08 and 05/09/23, Staff #1 confirmed the emergency department was closed and had been since before 2022.

A review of incident reports from January 2023-March 2023 found that 11 patients complaining of medical conditions while admitted to the behavioral unit (Patients # 11, 12, 14, 15, 17, 18, 20, 21 (x2), 22, 23, and 24) were assessed on the behavioral unit and not provided emergency services by the hospital, and two patients receiving outpatient services (Patients #10 and 13) with complaints of medical conditions were not provided emergency services by the hospital. Hospital staff called 911 and transferred 10 (patients #10, 11, 12, 14, 15, 18, 21 (x2), 22, 23, and 24) of the 13 patients to other hospitals for additional assessment, observation, and care.

01/30/23 Patient #24, under the section titled "Summary of incident" the patient complained of "sickle cell crisis Pt asked to call her MD for instruction. Dr called back & she recommended to send to ER", under the section titled "Interventions/Resolutions made during and after the incident" documented " VS 184/102 HR 153, R22, T 97.9" Under the section "Summary of license healthcare professional's findings" documented "EMS picked up patient at 1930 & report given to (Facility 3) and (Facility 4)..."

01/30/23 Patient #23, under the section titled "Summary of incident" documented "Pt had an abnormal EKG... ". Under the section titled Interventions/Resolutions made during and after the incident, "NP (Staff #34) notified and ordered to have pt sent to ER". Under section titled "Summary of license healthcare professional's findings" documented, "Pt was sent to ER"

01/28/23 Patient #22, under the section titled Summary of incident documented, "Patient presents with AMS and unstable blood sugar levels. Patient new admit, referral from Facility #1 (community behavioral center). Came in without medical clearance from ED." Under the section titled Interventions/Resolutions made during and after the incident "Patient sent out to (Facility #2) ED @ 13:45 via city ambulance. Patient sent out for medical clearance." Under the section titled" Summary of treatment given bv the licensed healthcare professional" documented, "Patient sent out to (Facility #2) ED for medical clearance @1345"

01/23/23 Patient #21, under the section titled "Summary of incident" documented "Dr. (Physician #33) ordered to send pt due to change in mental status. Pt left through EMS @2055 with all pertinent paperwork and requested all his belongings."

01/10/23 Patient #18, under the section titled "Summary of incident" documented, "No witnesses of any incident, or injury to this Pt. 1900 PT c/o pain to day shift nurses, at which time LLE foot was said to be swollen and bruised. When asked by (Staff #21) RN Pt stated he fell before coming here but pain started today." Under the section titled "Interventions/Resolutions made during and after the incident" documented, "Provider notified @ 1900, Elevated LLE and Tylenol was given. Pt remained non-wt bearing c LLE elevated until 2100 when EMS took him Provider (Staff #34) NP gave order to send to (Facility #2) to rule out FX and DVT". Under the section titled "Summary of treatment given by the licensed healthcare provider" documented "Monitored pt to stay off feet and resting. Called EMS and (Facility #2) ED."

02/17/23 Patient #15, under the section titled "Summary of incident" documented, "Pt as seen by doctor c/o wrist pain, x-ray ordered and found to be broken (small Fx)." Under the section titled "Interventions/Resolution made during and after incident" documented "Sent to hospital". Under the section titled "Summary of treatment given by the licensed healthcare professional" documented "notified MD, Assess situation/ROM, Sendf to E.R".

02/20/23 Patient #14, under the section titled "Summary of incident" documented, "Pt has been refusing to eat or drink since before admission", under the section titled "Interventions/Resolution made during and after the incident" documented "Dr (Staff #33) ordered to send pt to ER", under the section titled "Summary of treatment given by the licensed healthcare professional" documented "Pt transferred to ER"


03/03/23 Patient #13, who was receiving outpatient services and exhibited stroke-like symptoms including signs of tunnel vision, dizziness, headache, dysphasia, and right-sided facial droop, was assessed by a PTA (physical therapist assistant) and an employee of the outpatient imaging department who was also a paramedic. EMS was called, and the patient was transported to another hospital. Aspire Hospital did not provide emergency services and there was no documentation that the patient was stabilized prior to transfer to another hospital.

Patient #13 under the section titled "Summary of incident" documented "Approximately 9:10am- Patient completed physical therapy session and cleaned up and changed clothes in preparation to leave the facility. Patient requested water to drink and then began reporting dizziness and headache, PTA assessment BP 168/98. Patient reported he didn't feel he would be around for his next birthday in June then informed he was having tunnel vision and began showing signs of dysphasia with difficulty word-finding. PTA requested Paramedic assistance and obtained the the patient wallet for ID. Patient reported he wanted paramedic to be aware of religious beliefs. Paramedic from Aspire Hospital Imaging Center entered and began assessment of Mr. (Patient #34). PT was contacted. After ~3-minute assessment 911 was called and emergency services were dispatched. Paramedic and PTA continued assessment and patient care until emergency services arrived. Information provided to EMTs including vitals, assessment details, and face sheet for patient information. PTA informed EMT of patient's recent mental health statements; he reported he is self-medicating with alcohol daily dealing with spouse and adult children, and stated this date that he may be better if he were no longer here". Under the section titled "Interventions/Resolution made during and after the incident" documented "Vitals 160/98 (manual), HR 67, RR16, SPO2 97% RA, No Glucose (no glucometer) Cincinnati stroke scale score @ 5 min (2)m 10m min (4), 20 min (2) Pt never had LOC but did display right sided facial droop & complained of headache on left side posterior of head. PTA assessed BP and contacted Paramedic. Paramedic performed assessments while awaiting EMS.". Under the section titled "The treating licensed health care professional(s) name(s) documented the Paramedic (Staff #35) and PTA (Staff #36).
Under the section titled "The treating licensed health care professional(s) name(s)" documented "Staff #35 Paramedic on staff & (Facility #5) County EMS" Under section titled "Summary of treatment given by the licensed healthcare professional" documented "See vitals & Assessment for stroke scales, 911 was called & pt was transported". The incident report documents the "patient was transported by EMS to hospital". There was no documentation the patient was assessed by a physician or stabilized prior to transport by EMS.

03/12/23 Patient #21, "Summary of incident" documented "Patient #21 transferred to Facility #2 ED due to symptoms of Delirium. Patient left facility @1020 via city Ambulance" Under the section titled "Interventions/Resolution made during and after incident" documented "Patient transferred to ED for a level of care the facility cannot provide." Under the section titled "Summary of licensed healthcare professional's findings" documented "Patient is increasingly confused and hallucinating even after antipsychotics prescribed." Under the section titled "Summary of treatment given by the licensed healthcare professional" documented " Dr (Staff #27) gave phone orders to transfer patient to ED"

In incident dated 03/29/23, Patient #12, who was complaining of chest pain on scale of 10/10 and with a history of CAD (coronary artery disease) , HTN (hypertension), and recent heart attacks was transferred to Facility #2 via ambulance. There was no indication the patient had been assessed by a physician before transfer. Aspire Hospital did not provide emergency services and there was no documentation the patient was stabilized prior to transfer to another hospital.
03/29/23 Patient #12, under the section titled "Summary of incident" documented, "Patient c/o pain 10/10. Patient has history of CAD, HTN, Recent heart attacks per patient." The section titled "Summary of license healthcare professional's findings" documented, "Patient complaining of chest pain 10/10. Patient vitals taken BP 141/94 P-65 02-99% R-16". Under the section titled "Summary of treatment given by the licensed healthcare professional" documented "MD notified. Patient transferred to Facility #2 via ambulance." Under the section titled "Summary of treatment given by the licensed healthcare professional" documented "Patient sent via ambulance to Facility #2". In the section titled "Follow-Up Notes" documented "1400 As per RN Staff #37 still running tests" "1630 No Answer" "1746 Pt admitted to room 237". Under the section titled "The treating licensed health care professional(s) name(s)" documented RN Staff #38 and Nurse Practitioner Staff #28, there was no documentation the patient was assessed by a physician or stabilized prior to transfer by EMS to Facility #2.

03/29/23 Patient #11, under the section titled "Summary of incident" documented "Patient complained of chest pain to medical doctor. Patient C/o neck & head pain unresolved." The section titled "Interventions/Resolution made during and after incident" documented "Received order from MD to transfer via ambulance to ER." Under the section titled "The treating licensed health care professional(s) name(s) documented NP Staff #28. Under the section titled "Follow-Up Notes" documented "1720 Pt's CT scan & labs WNL (within normal limits). Pt will be sent back via ambulance"

03/30/23 Patient #10, "Summary of incident" documented "Patient was sitting in the IV room while the (SIC) attempted to start an IV on him. Patient's speech started slurring and he became unresponsive. His eyes rolled back and CT tech attempted to arouse him CT Tech shouted for staff to call 911. When 911 staff arrived on (?) patient was already awake. Blood pressure was taken before the arrival of the 911 personnel and reading was low (87/59) When 911 personnel repeated BP, it was within normal limits. Patient refused to go with EMT personnel. CT scan was complete" Under the section titled "The treating licensed health care professional(s) name(s)" documented "None- no treatment given."

In interview held in the conference room, the afternoon of 05/10/23, Staff #16 confirmed the emergency department was closed and no emergency services were being provided.