HospitalInspections.org

Based on record review and interviews, the hospital failed to meet the requirements of the Condition of Participation for Governing Body as evidenced by:

1) Failing to meet its responsibility for the conduct of the hospital and the responsibilities as stated in the governing body bylaws as evidenced by: a) Failing to conduct governing body meetings at the frequency required by the governing body bylaws:
Review of the governing body meeting minutes presented, when asked for the governing body meeting minutes for the year thus far, revealed a governing body meeting was held on 09/15/10.

In a face-to-face interview on 11/09/10 at 11:15am, Chairman of the Board S32 indicated he had never participated in performance improvement committee meetings and could offer no explanation for the governing body meetings not being conducted quarterly as required by the governing body bylaws.

In a face-to-face interview on 11/09/10 at 4:15pm, Performance Improvement/Risk Management Director S3 indicated the only governing body meeting held this year was on 09/15/10.

Review of the Governing Body Bylaws, effective 01/11/03 and presented by Administrator S1 as their current Governing Body Bylaws, revealed, in part, "...The Governing Body, by resolution, may provide for the holding of regular meetings, with or without notice, and may fix the times and places (within or outside of the State of Louisiana) at which such meetings shall be held provided that such regular meetings shall be held at least quarterly ...".

b) failing to ensure the hospital complied with state licensing laws by not reporting allegations of abuse to DHH (Department of Health and Hospitals) in 24 hours; c) failing to ensure all clinical staff were certified in aggressive behavior training/non-crisis prevention intervention as required by hospital policy; d) failing to implement and/or maintain a quality assurance performance improvement program; e) failing to ensure adequate staffing according to hospital policy to meet the needs of the patients; f) failing to ensure the Hospital Administrator performed her duty of working with health care professionals to ensure high-quality care was rendered to patients as evidenced by the ordered level of patient observation and unit restrictions not being maintained which resulted in injuries of unknown origin on two separate occasions for a patient who was on unit restriction and assigned continuous visual observation (#2); and g) failing to provide resources for training employees in administrative positions on the investigation of and reporting of abuse and neglect (see findings in Tag A0057) and

2) Failing to ensure all contracted services were provided in a safe and effective manner by failing to have contracted agency nurses who had first worked on 10/17/10 (S20) and 10/20/10 (S30) oriented, assessed for competency, and their performance evaluated according to hospital policy for 2 of 2 contract Agency A Registered Nurses' (RN) personnel files reviewed from a total of 39 contract nurses' from Agency A (the list did not indicate whether the nurse was a RN or a Licensed Practical Nurse) (S20, S30) (see findings in Tag A0084).

Based on record review and interview, the governing body failed to ensure the administrator of the hospital was responsible for managing the hospital as evidenced by: 1) failing to ensure the hospital complied with state licensing laws by not reporting allegations of abuse to DHH (Department of Health and Hospitals) in 24 hours; 2) failing to implement and/or maintain a quality assurance performance improvement program; 3) failing to ensure adequate staffing according to hospital policy to meet the needs of the patients; 4) failing to provide resources for training employees in administrative positions on the investigation of and reporting of abuse and neglect; 5) failing to ensure all clinical staff were certified in aggressive behavior training/non-crisis prevention intervention as required by hospital policy; and 6) failing to ensure the Hospital Administrator performed her duty of ensuring adequate staffing was available in order to provide the ordered level of patient observation and unit restrictions which resulted in injuries of unknown origin on two separate occasions for a patient who was on unit restriction and assigned continuous visual observation (#2). Findings:

1) Failing to ensure the hospital complied with state licensing laws by not reporting allegations of abuse to DHH (Department of Health and Hospitals) in 24 hours:

Review of the Governing Body Bylaws, effective 01/11/03 and presented by Administrator S1 as their current Governing Body Bylaws, revealed, in part, "...Article V: Board of Directors A. General Responsibilities and Qualifications. 1. Responsibilities ...j) To take reasonable steps to insure the Hospital conforms with all applicable federal, state and local laws and regulations...".

Review of the Quality/Risk Management Report of Event (Occurrence Report) dated 10/24/10, no time documented, revealed Patient #11's father called the hospital on 10/24/10 at 11:35am about a telephone conversation he had earlier in the morning with his son concerning an incident which happened on 10/23/10 whereby a Mental Health Tech had slammed him against the wall.

Review of the e-mail sent to DHH Health Standards dated Monday, October 25, 2010 at 2:43pm with the subject of "New Report of Complaint" revealed an incident had occurred on 10/23/10 involving a Mental Health Tech assigned to the male adolescent/children's unit pushing a child into a corner and keeping him there for 3 hours. The email notification was greater than the required 24 hours to submit a written report to the Department of Health and Hospitals, Health Standards Section (27 hours and 7 minutes). See also findings in Tag A145.

2) Failing to implement and/or maintain a quality assurance performance improvement program:

Review of the Governing Body Bylaws, effective 01/11/03 and presented by Administrator S1 as their current Governing Body Bylaws, revealed, in part, "...Article V: Board of Directors A. General Responsibilities and Qualifications. 1. Responsibilities ...c) To ensure continuous quality improvement through monitoring of professional services provided by the Medical Staff supporting staffs...".

3) Failing to ensure adequate staffing according to hospital policy to meet the needs of the patients:
See findings in Tag A0385.

Review of the Governing Body Bylaws, effective 01/11/03 and presented by Administrator S1 as their current Governing Body Bylaws, revealed, in part, "...Article V: Board of Directors A. General Responsibilities and Qualifications. 1. Responsibilities ...k) To participate in the development of the Hospital's mission, strategic plan, budgets, resource allocations, operational plans and policies...".

4) Failing to provide resources for training employees in administrative positions on the investigation of and reporting of abuse and neglect:
In a face-to-face interview on 11/05/10 AT 2:45PM, Director of Regulatory Compliance/Staff Development S4 indicated she had requested to attended a workshop on patient rights and investigation of abuse and neglect that was presented in July or August 2010. She further indicated she her request was denied by Chairman of the Board S32.

Review of the Governing Body Bylaws, effective 01/11/03 and presented by Administrator S1 as their current Governing Body Bylaws, revealed, in part, "...Article V: Board of Directors A. General Responsibilities and Qualifications. 1. Responsibilities ...i) To make recommendations to the Administrator/CEO (chief executive officer) and Corporation on support systems for quality assessment/improvement and risk management ...".

5) Failing to ensure all clinical staff were certified in aggressive behavior training/non-crisis prevention intervention as required by hospital policy:
In a face-to-face interview on 11/04/10 at 2:40pm, Administrator S1 indicated she was not currently certified as a STEPS (Supportive Therapeutic Encounters for Positive Success) instructor, and STEPS was the only training being conducted for non-crisis prevention intervention.

In a face-to-face interview on 11/05/10 at 12:30pm, Administrator S1 confirmed no clinical staff at the hospital was certified in non-crisis prevention intervention or STEPS as required by job descriptions and hospital policy.

In a face-to-face interview on 11/09/10 at 11:15am, Chairman of the Board S32, when informed of new employees and contract agency staff not being oriented and certified in non-crisis prevention intervention, indicated he was not aware that no current clinical staff was trained in non-crisis prevention intervention.

Review of the hospital policy titled "Staff Development - Inservice", revised 07/03/00 and submitted by Administrator S1 as their current policy for orientation, revealed, in part, "...All hospital employees will receive mandatory orientation at the beginning of their employment. Mandatory orientation includes education on the following CRH (Crossroads Regional Hospital) policy and procedures: ...5. Non-Violent Crisis Intervention Techniques (Clinical Staff) ... All clinical staff members will be re-certified annually in non-violent crisis intervention techniques (S.T.E.P.S., CPI [crisis prevention intervention], PMAB [Prevention and Management of Aggressive Behavior] and CPR. The re-certification process will consist of cognitive and behavioral education and will include written tests as well as skills checklists ...".

Review of the Governing Body Bylaws, effective 01/11/03 and presented by Administrator S1 as their current Governing Body Bylaws, revealed, in part, "...Article V: Board of Directors A. General Responsibilities and Qualifications. 1. Responsibilities ...h) To advise and recommend to Corporation observed ... personnel needs, and on control and use of physical and financial resources of the Hospital ...".

6) Failing to ensure the Hospital Administrator performed her duty of working with health care professionals to ensure high-quality care was rendered to patients as evidenced by the ordered level of patient observation and unit restrictions not being maintained which resulted in injuries of unknown origin on two separate occasions for a patient who was on unit restriction and assigned continuous visual observation (#2):
See findings in Tag A0395.

In a face-to-face interview on 11/09/10 at 11:15am, Chairman of the Board S32, when informed of the two occurrences with injuries for Patient #2, indicated "this is beyond my imagination that this is happening at all".

Review of the Governing Body Bylaws, effective 01/11/03 and presented by Administrator S1 as their current Governing Body Bylaws, revealed, in part, "...Article VIII. Administration of Hospital ... B. Authority and Duties. The authority and responsibility of the Administrator/CEO shall include: ...14. Working continually with other health care professionals to the end that high-quality care may be rendered to patients of the Hospital at all times ...".

Based on record review and interviews, the governing body failed to ensure all contracted services were provided in a safe and effective manner by failing to have contracted agency nurses oriented, assessed for competency, and their performance evaluated according to hospital policy for 2 of 2 contract Agency A Registered Nurses' (RN) personnel files reviewed from a total of 39 contract nurses' from Agency A (the list did not indicate whether the nurse was a RN or a Licensed Practical Nurse) (S20, S30). Findings:

Review of Agency A RN S20's personnel file revealed a packet titled "Orientation Of Nursing Agency Personnel" that included the following topics: confidentiality; ethical issues; maintaining a professional relationship; fire safety and security; fire safety/rules for the prevention of fires; safety; emergency codes; infection control; reporting of unusual occurrences; patient rights; documentation charting checklist; documentation don'ts; EMTALA (emergency medical treatment and active labor act); patient abuse and neglect; seclusion and restraint. The packet was signed by RN S20 and Administrator S1, who was not qualified to orient a RN, on 10/17/10. Further review of the personnel file revealed no documented evidence of a job description, certification in aggressive behavior training as required by hospital policy and evaluation to assess the effectiveness of job performance as required by hospital policy.

Review of Agency A RN S30's personnel file revealed a packet titled "Orientation Of Nursing Agency Personnel" that included the following topics: confidentiality; ethical issues; maintaining a professional relationship; fire safety and security; fire safety/rules for the prevention of fires; safety; emergency codes; infection control; reporting of unusual occurrences; patient rights; documentation charting checklist; documentation don'ts; EMTALA (emergency medical treatment and active labor act); patient abuse and neglect; seclusion and restraint. The packet was signed by RN S30 on 10/20/10 and Staff Development Coordinator S4 on 10/20/10. Further review of the personnel file revealed no documented evidence of a job description, certification in aggressive behavior training as required by hospital policy and evaluation to assess the effectiveness of job performance as required by hospital policy.

In a face-to-face interview on 11/09/10 at 8:30am, RN S30 with Agency A indicated she had been a RN for 10 years, and her experience was in ICU (intensive care unit). She further indicated she had no experience in caring for psychiatric patients. S30 indicated when she arrived for her first shift, she was given a thick packet of orientation material to sign, she was not asked to see her nursing license, and then she was "thrown to the wolves". She further indicated she had to call for assistance, because she had 2 admits and had no knowledge of the paperwork. She confirmed she was the only RN assigned to the unit. S30 indicated when she worked the day-shift, she received assistance from the LPN (licensed practical nurse) when she had 6 to 7 discharges to complete and one admit towards the end of the shift. S30 indicated she has had no interaction in her nursing role with the DON since beginning as an agency nurse at the hospital, and she had never seen or signed an evaluation of her performance.

Review of the hospital policy titled "Temporary Agency Personnel", revised 02/04/03 and submitted by Administrator S1 as their current policy for use of agency personnel, revealed, in part, "...Purpose: To describe a system for ensuring appropriate licensure, orientation and evaluation of the performance of agency personnel. ... Procedure: A. When a facility utilizes outside registry personnel the following items must be immediately available for verification: 1. Current licensure 2. Current CPR (cardiopulmonary resuscitation)/first aide training B. The facility will provide facility specific orientation or information which is to include but not be limited to the following: 1. Map of campus 2. Phone lists for emergency purposes 3. Where to access policy and procedure manuals 4. Location/use of emergency equipment 5. Aggressive behavior techniques/documentation 6. Safety Procedures A. Codes - types B. Fire Safety C. Extinguisher locations D. Infection Control 7. Incident Reporting This training can be done either through general orientation or prior to start of shift. C. An evaluation tool will be completed by Crossroads Regional Hospital personnel within 24 hours of assigned shift to assess the effectiveness of job performance by the agency personnel ... E. Personnel data/information is to be sent to Human Resources for record keeping purposes prior to assigned shift ...".

Based on observations, record review and interview the hospital failed to meet the requirements for the Condition of Participation for Patient Rights as evidenced by:

1) The hospital failed to maintain a safe environment in which to provide patient care as evidenced by:
a) Failure to ensure all patients were free from dangerous items and/or contraband resulting in a razor blade being found in the pocket of a pair of pants given, to wear after showering, to a 16 year old male (Patient #8) with a diagnosis of suicidal ideation. The patient was searched for contraband upon admission to the boys' unit of the hospital.
b) Failure to ensure that areas used for treatment of high risk children ages 6-12 years were free of dangerous items including three sets of electrical sockets without safety plugs posing a potential electrocution hazard, two feet of electrical cords extending from the TV and DVD and dangling from the back of the TV posing potential strangulation hazard, and one three-foot computer cord lying on the window ledge posing a potential strangulation hazard; of the children diagnosed with IED (Intermittent Explosive Disorder) and 2 were identified with suicidal ideations;
c) Failure to ensure that the MHT (Mental Health Technician) monitored the four children identified above, in accordance with physician's orders for continuous visual contact, as evidenced by two observations of the MHT turning his back to the children and walking to the doorway in the hall;
d) Failure to implement interventions regarding the six foot chain link fence surrounding the South Wing Courtyard (Adult Unit) once it was identified by the hospital as an elopement risk, which contributed to the elopement of 6 patients in a 12 month period; and
e) Failure to maintain two trees located in the Boy's Unit outdoor area resulting in two large trees with thick limbs protruding over the ten foot chain link fence which could enable a child to climb the tree over the fence as a means of elopement (See findings at Tag A0144).

An immediate jeopardy situation was identified on 11/09/10 at 4:30pm and reported to Administrator S1 and Chairman of the Board S32. The immediate jeopardy situation was a result of failing to ensure thorough patient searches were performed upon admit resulting in a patient (#8) with the diagnosis of suicidal ideations found with a razor blade in his pocket; failing to ensure the Boys' TV area, utilized by males aged 6-12, was free of safety hazards such as electrical sockets without safety plugs, loose computer cords laying on a window ledge, and TV and DVD cords dangling from the back of the equipment posing potentials for electrocution and/or strangulation hazards; failing to ensure children ages 6-12 utilizing the Boys' TV Room, having diagnoses of IED and/or Suicidal Ideations and ordered to be on continuous visual contact were monitored by the MHT assigned to their care as evidenced by observations on 11/09/10 at 8:35am and 8:55am of the MHT walking to the door leading to the hallway and turning his back to the children; failing to implement corrective action to raise the height of the fence surrounding the Adult Recreation Areas from six to twelve feet, after an adult patient eloped in January 2010, which resulted 5 more elopement attempts; and failure to maintain the trees in the Boys' Recreational Area resulting in the limbs hanging over the fence and a potential for the boys to climb the branches and elope over the fence.

A corrective action plan was submitted by the hospital on 11/10/10 at 10:10 am to address the immediate jeopardy situations. The corrective action plan included the following:
a) Revision of Policy # RI-00-020 "Search/Inventory of Patient Valuables and Other Personal Effects" and Policy # RI-00-015 "Patient Searches-Contraband/Personal" were revised to reflect that all admission searches would be conducted in one of the Assessment Rooms in the Intake/Admissions area. The room would be stocked with all necessary equipment to perform a search. The policy included that, "the patient would be asked to remove shoes and socks and any items in pockets and turn all pockets inside out. All areas of the clothing, inseams, waistbands, hems, innersoles of sneakers, bras (have patient flip bottom of bra to expose any contraband), etc ... will be thoroughly searched for contraband". The policies were presented to the Medical Director and the Chairman of the Governing Board for approval on 11/09/10. Immediate staff - in-services concerning the new policies were scheduled for 11/09/10 at 2030 (8:30pm) by the RN Staff Development Coordinator S4 with completion of training scheduled for 11/12/10. A performance improvement monitor was developed to be utilized in monitoring appropriate documentation/observation of patient searches and search inventory of patient valuables and other personal effects. The PI (Performance Improvement) monitor will include supervisory monitoring of the search procedure and utilized by the nursing department. A report of the data collected would be submitted to the PI Committee, MEC (Medical Executive Committee) and the Governing Body on November 23, 2010.
b) The administrator was notified of the identified hazards in the Little Boys' Group (TV) room on 11/08/10 by the Director of Nursing and the room was closed. The Director of Maintenance will ensure daily environment of care safety rounds include identification of potential hazards such as uncovered electrical sockets, unsecured cords, holes in walls, etc.. (Start date 11/10/10)
c) Bids for replacing the six foot chain link fence have been obtained and submitted to the Governing Board for approval. The Director of Maintenance will be notified of the bid that is chosen and schedule completion of installation of a ten foot chain link fence within the next two weeks. (Estimated installation date 11/30/10).
d) The Director of Maintenance will obtain a bid on having the trees in the courtyard area of the 16 bed south west wing (Boys' Unit) trimmed to ensure they do not provide a means of elopement. (Estimated installation date 11/30/10).

Review of the hospital action plan for the immediate jeopardy situations submitted 11/10/10 at 10:10am identified the following issues:
a) The hospital policies (# RI-00-020 "Search/Inventory of Patient Valuables and Other Personal Effects" and # RI-00-015 "Patient Searches-Contraband/Personal") failed to include who would perform the searches, what actions would be taken if contraband was found, who would be notified, how the contraband would be disposed of, and documentation of the incident. The hospital failed to include how the in-services would be conducted to ensure those staff members assigned the duty of patient searches would be assessed for competency after completing the inservice training. Further review of performance improvement actions to be taken revealed no inclusion in the plan of who would be responsible for collecting the data, what shifts would be included in the monitor, how many patient searches would be monitored or for how long, or possible corrective action to be taken for identified problems.
b) The hospital closed the little boys' TV room and placed them with the adolescents ages 13-17 in the main TV/Group area. Administration offered no other plan to ensure the safety of the males, ages 6-12. The hospital failed to address in their action plan the Mental Health Technician assigned to the care of the four boys in the little boys' TV room on 11/08/10 and his failure to monitor the boys as ordered by the physician for continuous visual observation.
c) The hospital had identified the problem of the 6 foot chain link fence in January of 2010. The statement submitted as the plan of action to lift the immediate jeopardy situation came from the Performance Improvement Committee Meeting Minutes, dated January 25, 2010 which indicated bids had been obtained and were awaiting approval from the Governing Body. The Administrator could not submit any evidence of any bids obtained on the fence or that the issue had been addressed at any subsequent meeting of the Governing Body due to the fact there was no meeting of the Governing Body held until September 2010. Further, the hospital failed to submit any corrective action that would be taken to correct the immediacy of the situation and avoid any potential elopement of adult patients until the fence work was completed.
d) The hospital could not submit any documented evidence any bids had been obtained for the trees to be trimmed in the boys' recreational area. Further, the hospital failed to submit any corrective action that would be taken to correct the immediacy of the situation and avoid any potential elopement of adult patients until the tree work was completed.

As a result of the hospital's failure to submit an acceptable action plan, the immediate jeopardy situation was not removed and the survey team exited the hospital on 11/10/10 at 5:00 pm. The hospital's non-compliance for Patient Safety remains at the immediate jeopardy level.



2) The hospital failed to ensure a patient was free from neglect as evidenced by Patient #2 sustaining two injuries of unknown origin on 11/07/10 of a 3x5 cm abrasion to the left lateral thigh and 11/08/10 of a laceration to the lower left lip while having physician's orders for continuous visual observation (See findings in Tag A0145).

An immediate jeopardy situation was identified on 11/09/10 at 4:30 pm and reported to Administrator S1 and Chairman of the Board S32. The immediate jeopardy situation was a result of the hospital failing to ensure Patient #2, who had Physician's Orders for continuous visual contact, was monitored by the assigned Mental Health Technician.

Review of the hospital action plan for the immediate jeopardy situations submitted 11/10/10 at 10:30am revealed the following:
The Mental Health Technician Notes/Observation Sheet was revised to reflect a note:
"You must document behaviors on page two of this form". The statement was printed in all capital letters and bolded. A note was added to the Narrative Summary to state that, "When patient exhibits acting act behaviors such as kicking, screaming, banging head, fighting, yelling, crying uncontrollably, throwing objects, attempting to destroy property, attempting harm to self, or is isolative, sulking, not wanting to interact with others, refusing groups, etc ...., a narrative note must be charted by the assigned MHT. Include in the narrative note that the charge nurse has been notified (signature of RN/LPN and time). Also chart patient behaviors during quiet time, seclusion and/or restraint procedures".
In-services to present the revisions to the Observation forms were started by Staff Development on 11/09/10 with a completion date of 11/12/10.
Monitoring for performance improvement would be accomplished through a data collection tool referred to as "Carrying Out Patient Observation" to ensure the Observation Status categories are maintained. Report of the findings would be submitted to the Performance Improvement Committee at the schedule 11/23/10 meeting.
The Quality/Risk Management Coordinator, Director of Nursing and Staff Development Coordinator will conduct a morning meeting to review all incident reports that are received from the previous 24-hour period.

Review of the hospital action plan for the immediate jeopardy situations submitted 11/10/10 at 10:10am revealed the following:
The hospital failed to include the responsibility(ies) of the Registered Nurse in the care of the patient identified to have a change in condition as evidenced by changes in behaviors. Documentation of the behaviors in the notes (which is a permanent record in the patient's chart) is the responsibility of the RN and not of the MHT.
The hospital failed to include how the in-services would be conducted to ensure the MHTs assigned to perform patient observations would be assessed for competency after completing the inservice training. Further review of performance improvement actions to be taken revealed no inclusion in the plan of who would be responsible for collecting the data, what shifts would be included in the monitor, how many patients would be monitored or for how long.

As a result of the hospital's failure to submit an acceptable action plan, the immediate jeopardy situation was not removed and the survey team exited the hospital on 11/10/10 at 5:00pm. The hospital's non-compliance for the Patient's Right to be Free from Neglect remains at the immediate jeopardy level.

Based on observations, record reviews and interviews the hospital failed to maintain a safe environment in which to provide patient care as evidenced by: 1) failing to ensure all patients were free from dangerous items and/or contraband resulting in a 16 year old male (Patient #8), with a diagnosis of suicidal ideation, who was searched for contraband upon admission to the boy's unit of the hospital findings a razor blade in the pocket of the pants he was given to wear after showering, a 30 year old male (R1) on the adult unit found with a box of medication in his possession six days after admit containing narcotics, a 15 year old male found with a lighter in his room hidden behind the toilet 5 weeks after admit and a 42 year old female found with her suit case in her room ; 2) failing to ensure potentially dangerous items (three sets of electrical sockets without safety plugs posing a potential electrocution hazard, two feet of electrical cords extending from the TV and DVD and dangling from the back of the TV posing potential strangulation hazard, and one three foot computer cord lying on the window ledge posing a potential strangulation hazard) were not allowed in the treatment areas utilized by children ages 6-12, 4 of whom were identified with IED (Intermittent Explosive Disorder) and 2 of whom were identified with suicidal ideations (Patient #2, #4, #5, #6); 3) failing to implement interventions regarding the six foot chain link fence surrounding the South Wing Courtyard (Adult Unit) once it was identified by the hospital as an elopement risk, which contributed to the elopement of 6 patients in a 12 month period; 4) failing to maintain two trees located in the Boy's Unit outdoor area resulting in two large trees with thick limbs protruding over the ten foot chain link fence which could enable a child to climb the tree over the fence as a means of elopement; and 5) failing to ensure plastic bags were not used in waste receptacles in patient care areas; 6) failing to ensure a classroom door containing electrical cords and located on a patient care unit was kept locked; 7) failing to ensure all children were observed for safety while in the swimming pool as evidenced by Random Patient R12 finding his way to the deep end of the pool and having to be rescued by the MHT/Lifeguard; and 8) failing to ensure a 16 year female admitted to the hospital for suicidal/homicidal ideations with an order for constant visual observation on 09/29/10 was not given the opportunity to attempt suicide by hanging 21 hours after admit (Patient #13). Findings:

1) failing to ensure all patients were free from dangerous items and/or contraband
Patient #8
Review of the medical record for Patient #8 revealed he was admitted to the hospital on 11/03/10 for depression, suicidal ideation, and cutting himself on the right forearm with a knife and the right shoulder with a razor blade. Physician's Orders dated 11/03/10 at 2345 (11:45pm) revealed an order for Status B (Constant Visual Observation, Unit Restriction) for safety.

Review of the Quality/Risk Management Report of Event for Patient #8 dated 11/04/10 at 0040 (12:40am) revealed ..... "While patient showered, MHT S8 was observed inspecting patient's belongings and cutting drawstring of sleep pants. However, after shower completed and patient given sleep (fleece) pants he put his hands in his pocket and pulls out a razor blade. Patient immediately reports his find and gives the razor blade to MHT S8 .... " . Further review of the report revealed no documented evidence an investigation was performed nor was the incident reviewed by the Director of Nursing or the Risk Manager.

Random Patient R1
Review of the Quality/Risk Management Report of Event revealed Random Patient R1 was admitted to the hospital on 09/21/10. Further review revealed on 09/27/10 at 10:25 (AM/PM not documented),. "Pt (Patient) being Dc'd (Discharged) - Tech went to closet, got pt's bag, box of meds found in bag, had not been checked in - Box contained the following meds: Alprozalam 0.25mg (8 tabs), Hydrocodone APAP 10/650mg (34 1/2 tabs), Rhentermine37.5mg (19 tabs) and Alprozalam 2mg (86 1/2 tabs)". Review of the Inventory of Personal Effects form for R1 revealed no documented evidence a box with medications had been found on the patient or among his personal effects at the time of admit. Further review revealed no documented evidence an investigation had been conducted.

Random Patient R2
Review of the Quality/Risk Management Report of Event revealed Random Patient R2 was admitted to Adolescent Unit of the hospital on 08/13/10. Further review revealed on 09/20/10 1645 (2:45pm) R2 reported to the nurses' station and told the staff that, "He had brought in 5 lighters when he was admitted and gave them all away. Now those people are threatening to start a fire in here. Further review revealed the DON initiated an individual and unit searched; however no evidence of an investigation could be submitted by the hospital

Random Patient R2
Review of the Quality/Risk Management Report of Event revealed Random Patient R2 was admitted to the Unit Adolescent of the hospital on 08/13/10. Further review revealed on 09/21/10 AM (no specific time documented) the RN on the boy's unit approached R2 concerning an incident which happened the previous day when R2 threatened to set fire to the building. The patient went to his room and retrieved a lighter which he showed staff that he had hidden behind the toilet. Further review revealed no documented evidence an investigation of the incident had been performed.

Random Patient R3
Review of the Quality/Risk Management Report of Event revealed R3 was admitted to the Adult Unit of the hospital on 09/16/10. Further review revealed on 09/17/10 at 0930 (9:30am) she was found to have her suitcase still in her room, a room search was performed and a bottle of cleaning solution found in the patient's drawer. In addition, there was no documented evidence an investigation of the incident had been performed.

Review of Policy # RI-00-015 titled "Patient Searches-Contraband/Personal" last reviewed 05/19/05and submitted as the one currently in use revealed patient searches were to be conducted upon admit and at any time during the hospital stay if behaviors indicate the necessity for a search. "Searches would be conducted as follows: 1. At the time of admission (Admissions and Unit Staff); 2. Routinely on a daily basis; 3. Any time contraband is suspected on the unit; and 4. Anytime a patient returns from an outside appointment. Definition of contraband includes nut is not limited to any sharp objects such as razors, knives, scissors ... .... Flammable materials such as matches and lighters ... " .

In a face to face interview on 11/08/10 at 12:05pm Risk Manager S 3 revealed as Risk Manager she has limited investigation abilities. Further the Director of Nursing should get the Occurrence Reports first, investigate the incident and then forward them to me so I can enter the information into the database and trend for the performance improvement meetings. S3 indicated this used to be the process; however the Administrator decided to change the order on who receives them first.

In a face to face interview on 11/08/10 at 2:30pm Director of Nursing RN S2 revealed the Occurrence reports used to be put in her box daily and she would review them first and then send them to Risk Management. S2 indicated the administrator decided to send the information first to Risk Management and then that department would forward them to her. Further she indicated she has talked to the nurses individually and sent them to inservices to re-educate them on the important of completing the investigations when an incident has taken place. DON S2 indicated there is no excuse for patients not to be thoroughly searched.

2) failing to ensure potentially dangerous items were not allowed in the treatment areas utilized by children ages 6-12
Observation on 11/08/10 at 8:35am of the little boy's day room revealed three sets of electrical sockets without safety plugs, two feet of electrical cords extending from the TV and DVD and dangling from the back of the TV, and one three foot computer cord lying on the window ledge. At the time of the observation Patient #2, #4, #5 and #6 were sitting in the room watching television and monitored by one MHT (Mental Health Tech).

Review of the medical records for the children observed to be in the little boy's day room revealed the following: Patient #2 was admitted on 11/06/10 at 8:50pm with the provisional diagnosis of Intermittent Explosive Disorder (IED); Patient #4's was admitted on 11/03/10 with diagnoses of suicidal ideation, intermittent explosive disorder, and oppositional deviant disorder; Patient #5 was admitted on 11/05/10 with the diagnoses of suicidal ideation and depression; and Patient #6 was admitted on 11/04/10 with diagnoses of Intermittent Explosive Disorder, Oppositional Defiant Disorder, and Attention Deficit/ Hyperactive Disorder.

Observation of the Little Boy's Dayroom on 11/08/10 at 8:30am revealed Patients #2, #4, #5, and #6 were sitting in the room watching television. Further observation revealed the only MHT turned his back to the children and walked to the doorway to call the housekeeper to come into the room to clean it.

Observation on 11/08/10 at 8:55am of the little boy's day room revealed Patient #2, #4, #5 and #6 were sitting in the room watching television when the only MHT assigned to monitor the children turned his back to them and walked to the door and attempted to signal the attention of one of the staff members.

3) failing to implement interventions regarding the six foot chain link fence surrounding the South Wing Courtyard (Adult Unit)
Observation on 11/01/10 at 9:20am in the presence of Administrator S1 revealed an outdoor area off the patio area surrounded by a six foot chain link fence.

In a face to face interview on 11/04/10 at 9:30am Director of Nursing RN S2 confirmed the height of the fence could be a means of elopement after being brought to her attention by the surveyor.

Review of the Performance Improvement (PI) Statistical data for 08/10 through 07/10 revealed 6 documented elopements in a10 month period all occurring in the outdoor area of the adult unit. Review of the PI Meeting minutes dated 01/25/10 revealed the information had been sent to the Governing Body for correction action.

Review of the Governing Body Meeting Minutes revealed no documented evidence a meeting had been held before September 15, 2010.

In a face to face interview on 11/10/10 at 9:35am Quality/Risk Manager S3 indicated the quarterly meeting were scheduled for 03/11/10 and 06/10/10; however no members of the Governing Body showed up for the meetings.

4) failing to maintain two trees located in the Boy's Unit outdoor area
Observation on 11/09/10 at 10:05am of the outdoor area of the male adolescent/children's unit revealed 2 large trees with thick limbs protruding beyond the top of the fence. Further the tree limbs were at a height accessible to some male patients and could be used as a means of elopement.

In a face to face interview on 11/09/10 at 10:10am Administrator S1 and Risk Manager S3 both confirmed the tree could be used as a means of elopement and need to be cut.

5) failing to ensure plastic bags were not used in waste receptacles in patient care areas
Observation on 11/04/10 at 9:20am of the Adult Unit revealed a garbage can with a plastic liner in the waste receptacles located in the open hall leading to the dayroom.

Observation on 11/04/10 at 10:00am of the Male Adolescent/Children's Unit Adult Unit revealed a garbage can with a plastic liner in the open hallway between the nurses' station and in the adolescent day room.

Observation on 11/04/10 at 10:05am of the Female Adolescent /Children's Unit revealed a garbage can with plastic liner located in the dayroom where group was in session.

In a face to face interview on 11/04/10 at 9:30am Administrator S1 indicated the plastic bags should not be used and instructed the housekeeper to put the garbage container in the seclusion room.

Observation on 11/08/10 at 8:40am of the Male Adolescent/Children's Unit revealed a garbage can with a plastic liner located in the open hallway leading to the seclusion room which was kept unlocked.

Observation on 11/09/10 at 5:30pm of the Gymnasium used by all patients in the hospital revealed a garbage can with a plastic liner in the corner of the large open area space.

6) failing to ensure a classroom door containing electrical cords and located on a patient care unit was kept locked
Observation on 11/04/10 at 9:20am on the Adult Unit revealed a classroom door unlocked which contained a microwave, coffeemaker, tape recorder with a long cord, and a refrigerator with a long cord.

In a face to face interview on 11/04/10 at 9:30 Administrator S1 indicated the door should be locked at all times.

7) failing to ensure all children were observed for safety while in the swimming pool as evidenced by Random Patient R12 finding his way to the deep end of the pool and having to be rescued by the MHT/Lifeguard
Review of the Quality/Risk Management Report of Event revealed 11 year old Random Patient R12 was admitted to the Male Adolescent/Children's Unit of the hospital on 09/11/10. Further review of the report revealed he was swimming in the facility pool on 09/13/10 at 3:43pm when after being warned once to stay in the shallow end of the pool, he managed to make his way to the deep end and had to be rescued by the MHT/Lifeguard.

8) failing to ensure a 16 year female admitted to the hospital for suicidal/homicidal ideations with an order for constant visual observation on 09/29/10 was not given the opportunity to attempted suicide by hanging 21 hours after admit
Review of the medical record for Patient #13 revealed she was admitted to the Female Adolescent/Children's Unit of the hospital on 09/29/10 at 0215 (2:15am) with the diagnosis of suicidal/homicidal ideation. Review of the Physician's Admit Orders dated/timed 09/29/10 at 0215 (2:15am) revealed an order for Status B (Constant Visual Observation, Unit Restriction) until seen by the MD.

Review of the Nurses' Notes dated/timed 09/29/10 at 2320 (11:20pm) revealed Patient#13 had put a sheet through a curtain rod, pulling curtains down in an attempt to hang herself.

Review of the Quality/Risk Management Report of Event dated 09/29/10 at 2335 (11:35pm) revealed while the RN assigned to the care of the patients on the unit was in intake admitting a patient, Patient #13 was reported to have hung a sheet through the curtain at the top with a knot and attempted to hang herself and the MD was called. Further review revealed no documented evidence the Administrator on call had been notified or an investigation had been performed.

In a face to face interview on 11/08/10 at 12:05pm the QA/Risk Manager S3 indicated she is limited in the ability to perform her job duties and has to be careful not to "over-step her bounds". Further she indicated many times she is not allowed to ask the nursing staff questions when attempting to perform an investigation of an incident.

Nursing personnel (Nurses and Mental Health Techs) involved in this incident were no longer employed by the facility and could not be reached for interview.

Based on record review and interview the hospital failed to ensure a patient was free from abuse and/or neglect as evidenced by Patient #2 sustaining two injuries of unknown origin on 11/07/10 of a 3x5 cm abrasion to the left lateral thigh and 11/08/10 of a laceration to the lower left lip while having physician's orders for continuous visual observation. The hospital also failed to ensure that reporting requirements of allegations of abuse as defined in state law were followed. Findings:

1. Patient #2
Review of Patient #2's "Physician's Admit Order" on 11/06/10 at 8:50pm revealed the provisional diagnosis of Intermittent Explosive Disorder (IED). Further review revealed an order for Status B (constant visual observation, unit restriction) observation until seen by the physician.

Review of the "Physician's Orders" dated 11/07/10 at 7:20pm for Patient #2 revealed an order for Status B with OUP (off unit privileges).

Review of the "Tech Notes/Observation Sheet Page 1" for Patient #2 revealed he was in the gym on 11/07/10 from 3:30pm until 4:30pm with observation by MHT (mental health technician) S33, while his physician orders were for unit restriction. Further review of the "Narrative Summary" revealed no documented evidence of behaviors such as "kicking, screaming, banging head, fighting, yelling, yelling uncontrollably, throwing things, attempting to destroy property, attempting to harm self ... " .

Review of the "Multi-Disciplinary Progress Note" documented by RN S30 from Agency A on 11/07/10 at 7:30pm revealed "3 x 5 cm (3 by 5 centimeter) abrasion noted on left lateral thigh; no bleeding or drainage; patient denies pain. "It happened in the gym today" patient reported. Pt (patient) unsure of time injury occurred or if others were involved. Pt denies that he was intentionally injured ... " .

In a face-to-face interview on 11/09/10 at 8:10am, MHT S8 indicated he arrived at the hospital on 11/07/10 about 4:00pm. He further indicated he was asked by the nurse to go to the gym to get Patient #2 to return to the unit. He indicated he was assigned to observe Patient #2 for the remainder of the 3:00 - 11:00pm shift on 11/07/10. S8 indicated there was no "horse-playing accidents, kids are hyper and sometimes they jump up and run into somebody ... things like that happen all the time". He further indicated he was not aware of an injury to Patient #2 until RN S30 informed him of the abrasion.

In a face-to-face interview on 11/09/10 at 8:30am, RN S30 from Agency A indicated when MHT S33prepared Patient #2 for his shower, S33 called her to notify her of the abrasion to the left lateral thigh. She indicated that she notified the patient's parent, the physician, and the oncoming RN who replaced her, but she was not aware if the hospital policy required her to notify the administrator on-call of the injury of unknown origin. RN S30 indicated she replaced a contract agency RN when she arrived for her shift. S30 further indicated the agency day RN had not taped a report as required by policy, so she gave S30 a verbal report. RN 30 indicated she asked the agency RN she was replacing if there were any patients on unit restriction, and she was told there were none. S30 indicated when she looked at the board, she noticed that Patient #2 and Patient #5 were on unit restriction and should not have been in the gym. S30 indicated that since there were no patients on the unit, she went to the gym to take Patients #2 and #5 back to the unit and met MHT S8 who returned to observe the 2 patients. RN S30 indicated she asked MHT S33 if he had witnessed anyone push Patient #2 while in the gym, and MHT S8 indicated that they played rough in the gym, but no one was aggressive toward him. S30 indicated she was able to speak privately with Patient #2, and he denied that anyone hurt him.

In a telephone interview on 11/09/10 at 2:55pm, MHT S33 indicated he had worked the evening and night shifts on 11/07/10. He further indicated Patient #2 was in the gym from 3:30pm until 4:15pm on constant visual observation. S33 indicated he observed Patient #2 slip on the carpet in the gym, but Patient #2 didn't come to S33 to complain about being hurt. He further indicated he didn't report the fall to the RN, because Patient #2 didn't complain of an injury. He could offer no explanation for not documenting Patient #2's fall on a "Quality/Risk Management Report of Event" form or on the observation narrative report.

Review of the "Multi-Disciplinary Progress Note" documented by RN S29 on 11/08/10 at 6:50am revealed " heard pt crying while in the day area with other peers sitting on the benches. Pt stated that another peer kicked him & (and) staff noted that his lower lip is bleeding. The other peers who were present stated that pt was running around & he accidentally fell ... " . There was no documented evidence that RN S29 asked MHT S33, who was assigned constant visual observation of Patient #2, what had occurred to cause the bleeding to the lip.

Review of the "Tech Notes/Observation Sheet Page 1 "for Patient #2 revealed he was on continuous visual observation by MHT S33 in the dayroom on 11/08/10 from 6:45am until 7:00am.

In a face-to-face interview on 11/09/10 at 7:45am, RN S29 indicated she heard Patient #2 crying. She further indicated he came to the nursing station and said that someone kicked him. S29 indicated she went to the dayroom and asked the other patients what had happened. S29 further indicated Patient # s peers said he just fell. S29 indicated Patient #2 was alone when he came from the day area to the nursing station. S29 further indicated when she asked MHT S33, who was assigned constant visual observation of Patient #2, what had happened, S33 told her " no one touched him". S29 confirmed that she should have documented her conversation with MHT S33. S29 indicated she did not notify the physician of the injury, but she did report it to the oncoming RN and asked him to inform the physician.

In a telephone interview on 11/09/10 at 2:55pm, MHT S33 indicated one patient stuck his foot out, and Patient #2 tripped over his own foot. He further indicated this happened during shift change. He further indicated Patient #2 was in the big dayroom and fell on the floor by the table located toward the front left of the dayroom, but he didn't hit anything when he fell. S33 further indicated Patient #2 had no injury. MHT S33 confirmed he did not see Patient #2 bleeding from the lip. He could offer no explanation regarding how Patient #2 could be on continuous visual observation, receive a laceration to the lower lip resulting in bleeding, and S33 not know the lip was bleeding and what caused the injury.

2. Review of the Governing Body Bylaws, effective 01/11/03 and presented by Administrator S1 as their current Governing Body Bylaws, revealed, in part, "...Article V: Board of Directors A. General Responsibilities and Qualifications. 1. Responsibilities ...j) To take reasonable steps to insure the Hospital conforms with all applicable federal, state and local laws and regulations...".

Review of the Quality/Risk Management Report of Event (Occurrence Report) dated 10/24/10, no time documented, revealed Patient #11's father called the hospital on 10/24/10 at 11:35am about a telephone conversation he had earlier in the morning with his son concerning an incident which happened on 10/23/10 whereby a Mental Health Tech had slammed him against the wall.

Review of the e-mail sent to DHH Health Standards Office dated Monday, October 25, 2010 at 2:43pm with the subject of "New Report of Complaint" revealed an incident had occurred involving a Mental Health Tech assigned to the male adolescent/children's unit pushing a child into a corner and keeping him there for 3 hours. The email notification was greater than the required 24 hours to submit a written report to the Department of Health and Hospitals, Health Standards Section (27 hours and 7 minutes).

In a face to face interview on 11/09/2010 at 3:10pm Administrator S1 verified she did not come to the hospital to initiate the investigation on 10/24/10 when notified of the incident. Further she indicated she delegated the duty to begin the investigation to the charge nurse of the unit RN S6, a PRN (as needed) nurse. The Administrator could offer no explanation as to why no one on the administrative team came to the hospital on 10/24/10 to begin the investigation process.
Further the Administrator confirmed she had a meeting with DHH officials on the morning of 10/25/10 and failed to report the incident at that time.

Review of the State law R. S. 40:2009.20 revealed "Any person who is engaged in the practice of medicine, social service, facility administration, psychological or psychological services, or any RN, LPN, nurses ' aide, personal care attendant, respite worker, physician's assistant, physical therapist, or any other health caregiver having the knowledge that a consumer's physical or mental health or welfare has been or may be further adversely affected by abuse neglect, or exploitation shall, within 24 hours submit a report to the department or inform the unit or local law enforcement agency of such abuse or neglect".

In a face to face interview on 11/05/10 at 2:45pm Staff Development/Director of Regulatory RN S4 revealed she began her investigation as instructed by the administrator on Monday morning (10/25/10) because everyone else (Administrator S1, Risk Manager S3 and DON S2) had all gone to a meeting in Baton Rouge. Further S4 verified her e-mail was sent to State Office on 10/25/10 at 2:43pm 27 hours after the event had been reported to hospital staff.

Based on record review and interview the hospital failed to meet the requirements for the Condition of Participation for Quality Assurance as evidenced by:

1) failing to ensure indicators were developed for all department in the hospital to include aspects of patient care for dietary services, laboratory services, radiology services, and Infection Control; develop indicators for the performance of chart audits to monitor the quality of care patients were receiving; and complete investigation for adverse patient events in order to analyze their cause and implement corrective action (see findings at Tag A0267);

2) failing to have a system in place to set priorities and monitor high-risk, problem prone and high volume areas as evidenced by no documented evidence priorities had been included in the Performance Improvement Plan and failing to monitor possible incidents of abuse and neglect, suicides, incidents of patient to patient aggression with injury/without injury, elopements, injuries of unknown origin and injuries resulting from activities in the gym (See findings at Tag A0285)

3) failing to ensure the data collected on patient falls, patient to patient aggression with/without injury, elopement attempts, contraband found in patient's possession had been used to make improvements in patients care as evidenced by no documented evidence of any corrective action taken when the above issues occurred in order to prevent continued incidents of identified patient care issues (See findings at Tag A0287); and

4) failing to ensure the hospital had an ongoing program for Quality Assurance/Performance Improvement (QA/PI) as evidenced by for documented evidence quarterly meetings were conducted as per the hospital's QA/PI plan for both the Governing Body and the Performance Improvement Committee (See findings at Tag A0310).

Based on record review and interview the hospital failed to ensure indicators were developed for all aspects of patient care as evidenced by: 1) failing to develop indicators for dietary services, laboratory services, radiology services, Infection Control, or the Human Resource Department; 2) failing to develop indicators for the performance of chart audits to monitor the quality of care patients were receiving; and 3) failing to complete investigation for adverse patient events in order to analyze their cause and implement corrective action. Findings:

1) failing to develop indicators for dietary services, laboratory services, radiology services, Infection Control, or the Human Resource Department;
Review of the Performance Improvement data collected by the Quality/Risk management Director for 08/01/10 through 10/30/10 revealed no documented evidence of participation of the following departments via measurable indicators: dietary services, laboratory services, radiology services, Infection Control, or the Human Resource Department.

In a face to face interview on 11/09/10 at 12:05pm Quality Risk Management S3 indicated all of the departments did not send data on a regular basis. Further she indicated administration did not back her up in assisting her in making it mandatory that all departments report on time.

2) failing to develop indicators for the performance of chart audits to monitor the quality of care patients were receiving;
In a face to face interview on 11/09/10 at 12:05pm Quality Risk Management Director S3 indicated chart audits were not being performed at the present time and could offer no explanation as to why.

3) failing to complete investigation for adverse patient events in order to analyze their cause and implement corrective action.
Review of the Hospital Occurrence/Risk Management Summary 2010, a hospital wide report, revealed a breakdown of the occurrences which had been reported via the use of the Occurrence form for the time period of January through August of 2010. Further review revealed patient care issues documented were as follows: falls, accidents with/without injury; patient to patient aggression with/without injury, restraints, seclusion, self inflicted injury, suicide, contraband, abuse and neglect. Further review of the findings and recommendation revealed no documented evidence of any trends identified and therefore no corrective action implemented.

Review of 54 Patient Occurrence Reports submitted by the hospital for review by the survey team for the time period of 08/01/10 through 11/04/10 revealed no documented investigation any of the incidents reported.

In a face to face interview on 11/09/10 at 12:05pm Quality/Risk Management Director S3 indicated she was limited in the type of investigation she could perform. Further S3 indicated she felt it was the responsibility of the person discovering the occurrence to complete the form, the Director of Nursing (DON) to perform the investigation and then for her to review the information and to put it in report form; however the reports were sent to her to do.
S3 said that sometimes depending on the occurrence, she is limited on what questions she is allowed to ask the nursing staff. When asked why the DON did not perform the investigations S3 responded it was because sometimes the Occurrence Reports sat too long on her desk, so the change was made by the Administrator.

Based on record review and interview the hospital failed to ensure the data collected on patient falls, patient to patient aggression with/without injury, elopement attempts, contraband found in patient's possession had been used to make improvements in patients care as evidenced by no documented evidence of any corrective action taken and the continuing incidents of the identified patient care issues. Findings:

Review of the Hospital Occurrence/Risk Management Summary 2010, a hospital wide report, revealed a breakdown of the occurrences which had been reported via the use of the Occurrence form for the time period of January through August of 2010. Further review revealed patient care issues documented were as follows: falls, accidents with/without injury; patient to patient aggression with/without injury, restraints, seclusion, self inflicted injury, suicide, contraband, abuse and neglect. Further review of the findings and recommendation revealed no documented evidence of any trends identified and therefore no corrective action implemented.

Review of 54 Patient Occurrence Reports submitted by the hospital for review by the survey team for the time period of 08/01/10 through 11/04/10 revealed no documented investigation any of the incidents reported.

In a face to face interview on 11/09/10 at 12:05am Quality/Risk Management Director S3 indicated she was limited in the type of investigation she could perform. Further S3 indicated she felt it was the responsibility of the person discovering the occurrence to complete the form, the Director of Nursing (DON) to perform the investigation and then for her to review the information and to put it in report form; however the reports were sent to her to do.
S3 said that sometimes depending on the occurrence, she is limited on what questions she is allowed to ask the nursing staff. When asked why the DON did not perform the investigations S3 responded it was because sometimes the Occurrence Reports sat too long on her desk, so the change was made by the Administrator.

Based on record review and interview the hospital failed to include the frequency and detail of the data collection for the Quality Assurance Program as evidenced by the failure of all departments to participate and submit data for identified problems and selected indicators. Findings:

Review of Policy No. PI-00-001 titled "Performance Improvement", last revised 1/22/09 and submitted as the one currently in use by the hospital revealed no documented evidence the frequency and detail of the data collection for the QA/PI program had been included.

In a face to face interview on 11/05/10 at 8:50am Quality/Risk Manager indicated not all departments submit data which you can see in the blank pages of the PI data collection manual.

Based on record review and interview the hospital failed to have a system in place to set priorities and monitor high-risk, problem prone and high volume areas as evidenced by: 1) failing to include the setting of priorities in the Performance Improvement Plan; 2) failing to monitor possible incidents of abuse and neglect, suicides, incidents of patient to patient aggression with injury/without injury, elopements, injuries of unknown origin and injuries resulting from activities in the gym. Findings:

1) failing to include the setting of priorities in the Performance Improvement Plan
Review of the Policy No. Policy #PI-00-001 titled "Performance Improvement Plan", last revised 1/22/09 and submitted as the one currently in use, revealed no documented evidence the setting of priorities for high-risk, problem prone and high volume problems which affect patient care and outcomes had been included in the plan.

2) failing to monitor possible incidents of abuse and neglect, high incident of patient to patient aggression with injury, elopements, injuries of unknown origin and injuries resulting from activities in the gym
Record review of clinical records and incident reports for the time period of 08/01/10 through 11/04/10 revealed the following areas of concern documented by the hospital:
Possible incidents of abuse/neglect - 2; suicide - 2 (one resulted in death); patient to patient aggression with injury/without injury- 31; elopements - 1 (5 had already occurred 01/10 through 08/10 with no trending or corrective action taken); injuries of unknown origin - 1; and injuries in the gym- 14.

In a face to face interview on 11/08/10 at 12:10pm Quality/Risk Management Director S3 indicated the PI plan did not include setting priorities. Further she indicated her main duty is to collect and compile the data sent from the departments and that since the hospital does not have PI meetings, she does not know who decides what is to be monitored.

Based on record review and interview the hospital failed to ensure the data collected on patient falls, patient to patient aggression with/without injury, elopement attempts, contraband found in patient's possession had been used to make improvements in patients care as evidenced by no documented evidence of any corrective action taken and the continuing incidents of the identified patient care issues. Findings:

Review of the Hospital Occurrence/Risk Management Summary 2010, a hospital wide report, revealed a breakdown of the occurrences which had been reported via the use of the Occurrence form for the time period of January through August of 2010. Further review revealed patient care issues documented were as follows: falls, accidents with/without injury; patient to patient aggression with/without injury, restraints, seclusion, self inflicted injury, suicide, contraband, abuse and neglect. Further review of the findings and recommendation revealed no documented evidence of any trends identified and therefore no corrective action implemented.

Review of 54 Patient Occurrence Reports submitted by the hospital for review by the survey team for the time period of 08/01/10 through 11/04/10 revealed no documented investigation any of the incidents reported.

In a face to face interview on 11/09/10 at 12:05am Quality/Risk Management Director S3 indicated she was limited in the type of investigation she could perform. Further S3 indicated she felt it was the responsibility of the person discovering the occurrence to complete the form, the Director of Nursing (DON) to perform the investigation and then for her to review the information and to put it in report form; however the reports were sent to her to do. S3 said that sometimes depending on the occurrence, she is limited on what questions she is allowed to ask the nursing staff. When asked why the DON did not perform the investigations S3 responded it was because sometimes the Occurrence Reports sat too long on her desk, so the change was made by the Administrator.

Based on record review and interview the Governing Body failed to ensure the hospital had an ongoing program for Quality Assurance/Performance Improvement (QA/PI) as evidenced by failing to conduct quarterly meetings as per the hospital's QA/PI plan for both the Governing Body and the Performance Improvement Committee. Findings:

1) failing to conduct quarterly meetings as per the hospital's QA/PI plan
Review of the Memorandum dated March 11, 2010 to the members of the Governing Board revealed the meeting for the first quarter of 2010 was scheduled for Saturday, March 27, 2010. The hospital could submit no documented evidence the meeting had taken place.

Review of the Memorandum dated June 10, 2010 to the members of the Governing Board revealed the meeting for the first quarter of 2010 was scheduled for Saturday, June 26, 2010. The hospital could submit no documented evidence the meeting had taken place.

In a face to face interview on 11/10/10 at 9:35am Quality/Risk Management Director S3 indicated she would send the meeting notice memorandum to all of the listed Governing Body Board Members, prepare the agenda and all of the reports. Further S3 indicated that on 03/27/10 and 06/26/10 she and the Director of Regulatory Compliance/Staff Development would show up for the meeting and be the only two at the hospital. Further she verified neither the Present/Chairman of the Board, Administrator or Medical Director showed up, so the meetings had to be cancelled.

In a telephone interview on 11/08/10 at 1:45pm Human Resource Director S5, named as a member of the QA/PI Committee by the Administrator, indicated she had not attended any QA/PI meetings.

In a telephone interview on 11/08/10 at 1:50pm Pharmacist S16, named as a member of the QA/PI Committee by the Administrator, indicated she has not attended any QA/PI meetings. Further she indicated the only meeting she remembered attended was the Medical Executive Committee meeting.

In a face to face interview on 11/08/10 at 2:35pm Director of Nursing S2, named as a member by the Administrator, indicated the hospital does not have QA/PI meetings.

In a face to face interview on 11/08/10 at 3:30pm Administrator S1 indicated the Performance Improvement (PI) Committee meetings are held monthly. When the surveyor indicated that some of the members of the committee had denied ever attending a PI meeting, S1 responded that they had attended the PI meeting they just did not know it because it was during the Medical Executive Committee Meeting.

The hospital could submit one set of meeting minutes for the Medical Executive Committee dated October 14, 2010 at 0900 (9:00am).

In a face to face interview on 11/10/10 at 9:35am Quality/Risk Management Director S3 indicated she would send the meeting notice memorandum to the physicians and they would not show up for the meetings.

In a face-to-face interview on 11/09/10 at 11:15am, Chairman of the Board S32 indicated he had not participated in performance improvement committee meetings and could offer no explanation for the governing body meetings not being conducted quarterly as required by the governing body bylaws.

Based on record review and interviews, the hospital failed to meet the Condition of Participation for Nursing Services as evidenced by:

1) Failing to ensure the registered nurse (RN) supervised and evaluated the care of each patient as evidenced by: 1) failure to maintain the ordered level of observation and unit restrictions for 4 of 13 sampled patients (#2, 4, 5, 6); this resulted in injuries of unknown origin on two separate occasions for a patient who was on unit restriction and assigned continuous visual observation (#2); 2) failure to ensure the MHT followed policy and procedure by applying non-approved methods of disciplining a patient with no documentation of behavior and direction by the RN for 1 of 13 sampled patients (#11); 3) failure to monitor staff to ensure duties were performed as assigned by having no documented evidence of patient behaviors on the observation sheets as required by hospital policy for 13 of 13 sampled patients (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13); and 4) failure of the RN to perform a daily physical assessment for 13 of 13 sampled patients (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13) (see findings in tag A0395);

Two immediate jeopardy situations were identified on 11/09/10/10 at 4:30pm and reported to Administrator S1. The immediate jeopardy situation was a result of:

Immediate Jeopardy #1
The hospital failed to maintain adherence to the ordered level of observation and unit restrictions, which resulted in injuries of unknown origin on two separate occasions for a patient who was assigned continuous visual observation. On 11/07/10, Patient #2, who was on unit restriction and continuous visual observation, sustained a 3x5 centimeter abrasion to the left lateral thigh with no documented evidence of the origin of the injury. On 11/08/10, Patient #2, who was on continuous visual observation, sustained a laceration to the lower lip with no documented evidence of the origin of the injury. On both of these occasions, the staff assigned to monitor this patient on constant visual observation did not observe and could not account for the injury; and

Immediate Jeopardy #2
The hospital failed to ensure the registered nurses supervised and monitored staff to ensure that duties were performed as assigned. See findings in number 1 regarding staff not following the orders for continuous visual observation and unit restriction.

A corrective action plan was submitted by Administrator S1 and Chairman of the Board S32 on 11/10/10 at 10:10am to address the immediate jeopardy situation. The corrective action plan included the following:

Immediate Jeopardy #1:

"The Tech Notes/Observation Sheet was revised to reflect a note that "You must document behaviors on page two of this form". A note was added to Page 2, Narrative Summary, to state that "When patient exhibits acting out behaviors such as kicking, screaming, banging head, fighting, yelling, crying uncontrollably, throwing objects, attempting to destroy property, attempting to harm self, or is isolative, sulking, not wanting to interact with others, refusing groups, etc. (and so on), a narrative note must be charted by the assigned MHT (mental health technician). Include in the narrative note that the charge nurse has been notified ... Also chart patient behaviors during quiet time, seclusion and or restraint procedures". This was completed 11/09/10.

All clinical staff will have additional education in-services on the observation status categories policy and procedure, the required documentation on the tech notes/observation sheet and narrative summary, the requirements for maintaining the ordered status, and identifying and documenting patient behaviors with a report of behaviors and/or any occurrences to the RN charge nurse. This education began at 8:30pm on 11/09/10 by Staff Development Coordinator S4 and will be completed by 11/12/10. The plan did not include a schedule of in-service dates, times, and personnel scheduled to attend (81 full-time direct care staff; 56 PRN [as needed] direct care staff; 100 contract agency direct care staff). There also was no plan that addressed how personnel who had not attended the in-service but were scheduled to work would be handled.

The Director of Nursing will ensure that performance improvement monitoring of the "Appropriateness of Carrying Out Patient Observation" will be accomplished to ensure that observation status categories are being maintained. Corrective action in the form of counseling with staff, in-service education, and disciplinary action will be accomplished if indicated. Reports of findings will be submitted to the performance improvement committee on 11/23/10. This was to be completed by 11/09/10. The plan did not identify who would be performing the chart audits, the frequency at which the chart audits would be done, the percentage of compliance expected, and the length of time the audits would be performed.

Quality/Risk Management Coordinator S3, Director of Nursing S2, and Staff Development Coordinator S4 will conduct a morning meeting to review all incident reports that have been received in the past 24 hours to ensure that appropriate investigation of events is monitored and appropriate corrective action delineated. This was to be completed by 11/20/10. The plan as stated did not allow for incidents required to be reported within 24 hours to have that expectation met. The plan did not indicate how long the administration would continue to conduct these meetings.

The policy and procedure on "Reporting and Analysis of Events" was revised to ensure that all occurrences involving patients will be reviewed by the Director of Nursing/designee with appropriate investigation and corrective action as indicated. The policy reflects that the Quality/Risk Management Coordinator will summarize all occurrences and submit a trending report by department and shift with noted trends forwarded to the performance improvement committee, the Medical Staff, and the Governing Board. This was to be completed by 11/10/10. Review of the policy revealed no documented evidence that allegations of or witnessed abuse and/or neglect were expected to be reported immediately, so the necessary information could be completed to meet the 24-hour reporting requirements.

The Quality/Risk Management Coordinator and the Staff Development Coordinator will present in-service education on reporting, documenting, and investigating of unusual occurrences. This was to be completed by 11/10/10. The plan did not include a schedule of in-service dates, times, and personnel scheduled to attend (81 full-time direct care staff; 56 PRN direct care staff; 100 contract agency direct care staff). There also was no plan that addressed how personnel who had not attended the in-service but were scheduled to work would be handled.

Immediate Jeopardy #2:

The Director of Nursing (DON) and Staff Development Coordinator will ensure that all licensed nursing staff have received in-service education regarding requirements for supervision and monitoring of staff to ensure that duties are performed as assigned. The DON will conduct counseling and disciplinary action as indicated on all identified cases of failure of licensed nursing staff to supervise other nursing personnel to ensure that duties are performed as assigned. This will be completed on 11/10/10. The plan did not include a schedule of in-service dates, times, and personnel scheduled to attend (16 full-time RNs and LPNs; 26 PRN RNs and LPNs; 100 contract agency RNs and LPNs). There also was no plan that addressed how personnel who had not attended the in-service but were scheduled to work would be handled. The plan did not identify the method to be used to monitor that all nursing staff were performing their duties as assigned, the person responsible for monitoring, the frequency at which this monitoring would take place, and the length of time that the monitoring would occur.

The Quality/Risk Management Coordinator, DON, and Staff Development Coordinator will conduct a morning meeting to review all incident reports that have been received in the past 24 hours to ensure that appropriate investigation of events is monitored and appropriate corrective action delineated. This was to be completed by 11/10/10. The plan as stated did not allow for incidents required to be reported within 24 hours to have that expectation met. The plan did not indicate how long the administration would continue to conduct these meetings.

As a result of the hospital's failure to submit an acceptable action plan, the immediate jeopardy situation was not removed, and the survey team exited the hospital on 11/10/10 at 5:00pm. The hospital's non-compliance for Nursing Services remains at the immediate jeopardy level.

2) Failing to ensure the Director of Nursing (DON) monitored and supervised nursing services to determine the number of nursing personnel needed to meet the needs of the patient as evidenced by 24 of 180 eight hour shifts (3 shifts per day for 3 separate nursing units) without a licensed practical nurse present on the unit as required by hospital policy (see findings in tag A0386);

3) Failing to ensure the DON provided adequate supervision of the clinical activities of non-hospital-employed nursing staff by having contract RNs from Agency A or Agency B who had not been oriented and evaluated for competency according to hospital policy assigned as the charge nurse for 43 of 180 eight hour shifts (3 shifts per day for 3 separate nursing units) reviewed (see findings in tag A0398); and

4) Failing to ensure the RN assigned the nursing care of each patient according to the needs of the patient and the specialized qualifications, experience, and competence of the nursing staff by having: a) 5 of 5 RN personnel files reviewed from a total of 25 RNs on staff (either full-time or PRN - as needed) with no documented evidence of orientation, training, and/or assessment for determination of competency (S4, S6, S22, S29); b) 3 of 3 licensed practical nurses' (LPN) files reviewed from a total of 17 LPNs on staff (either full-time or PRN) with no documented evidence of orientation, training, and/or assessment for determination of competency (S19, S23, S27) and 2 of the 3 with no documented evidence of psychiatric experience when hired (S23, S27); c)9 of 9 mental health technicians' (MHT) personnel files reviewed from a total of 74 MHTs (either full-time or PRN) with no documented evidence of orientation, training, and/or assessment for competency (S7, S8, S9, S13, S17, S18, S25, S26, S28) and 5 of the 10 with no documented evidence of psychiatric experience when hired (S8, S17, S18, S25, S28); and d) 2 of 2 contract Agency A RNs' personnel files reviewed from a total of 39 nurses' from Agency A (the list did not indicate whether the nurse was a RN or a LPN) with no documented evidence of orientation, training, assessment for determination of competency (S20, S30) and 1 of the 2 RNs had no documented evidence of psychiatric experience (S30) (see findings in tag A0397).

Based on record review and interview the hospital failed to follow their policy and procedure for staffing as evidenced by failing to staff an LPN for 21 of 180 shifts. Findings:

Review of the "Patient/Charting Assignment" sheets submitted by the Director of Nursing (DON) RN S2 revealed the following shifts which did not have an LPN (Licensed Practical Nurse) assigned according to the policy and procedure for staffing:
Adult Unit
10/19/10 (11p-7a shift) with a census of 13 patients; 10/20/10 (11p-7a shift) with a census of 14 patients;
10/21/10 (7a-3p shift) with a census of 12 patients; 10/22/10 (3p-11p shift) with a census of 14 patients and the (11p-7a shift) with a census of 11 patients; 10/23/10 (11p-7a shift) with a census of 15 patients;
10/24/10 (11p-7a shift) with a census of 15 patients; 10/25/10 (11p-7a shift) with a census of 14 patients; 10/27/10 (11p-7a shift) with a census of 10 patients; 10/28/10 (3p-11p shift) with a census of 9 patients and the (11p-7a shift) with a census of 12 patients; 10/29/10 (11p-7a shift) with a census of 9 patients; 10/30/10 (7a-3p shift) with a census of 11 patients and the (3p-11p shift) with a census of patients; 11/03/10 (11p-7a shift) with a census of 12 patients; 11/04/10 (11p-7a shift) with a census of 16 patients; 11/05/10 (11p-7a shift) with a census of 14 patients; 11/06/10 (11p/7a shift) with a census of 14 patients; and 11/07/10 (11p-7a shift) with a census of 13 patients
Female Adolescent/Children's Unit
10/31/10 (11p-7a shift) with census of 16 patients
Male Adolescent/Children's Unit
10/31/10 (7a-3p shift) with a census of 16 patients

Review of Policy No. TX.00.022 titled "Nursing Staffing and Patient Classification Acuity System" last revised 10/14/10 and submitted by the hospital as the one currently in use revealed an LPN would be assigned to the units with a census of 1-9 patients.

Review of the Position Control Report (List of Employees) submitted by the hospital as current and the one being used for scheduling of staff revealed 8 LPNs employed full time by the hospital to provide coverage for approximately 270 shifts per month. Also listed on the roster are 9 PRN (as needed) LPNs.

In a face to face interview on 11/05/10 at 10:00am DON RN S2 indicated the hospital has an LPN staffing coordinator who makes out the schedules and is responsible for calling the PRN and agency staff for filling in the staffing needs. The charge nurses are responsible for assessing the patient acuity, making the assignments and contacting the staffing coordinator if additional staff is required. Further S2 indicated it is her responsibility to review the acuity data daily.

Based on record review and interviews, the hospital failed to ensure the registered nurse (RN) supervised and evaluated the care of each patient as evidenced by: 1) failure to maintain the ordered level of observation and unit restrictions for 4 of 13 sampled patients (#2, #4, #5, #6); this resulted in injuries of unknown origin on two separate occasions for a patient who was on unit restriction and assigned continuous visual observation (#2); 2) failure to ensure the MHT followed policy and procedure by disciplining a patient with no documentation of behavior and direction by the RN for 1 of 13 sampled patients (#11); 3) failure to monitor staff to ensure duties were performed as assigned by having no documented evidence of patient behaviors on the observation sheets as required by hospital policy for 13 of 13 sampled patients (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13); and 4) failure of the RN to perform a daily physical assessment for 13 of 13 sampled patients (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13). Findings:

1) Failure to maintain the ordered level of observation and unit restrictions:
Patient #2
Review of Patient #2's "Physician's Admit Order" on 11/06/10 at 8:50pm revealed the provisional diagnosis of Intermittent Explosive Disorder (IED). Further review revealed an order for Status B (constant visual observation, unit restriction) observation until seen by the physician.

Review of Patient #2's "Physician's Orders" dated 11/07/10 at 7:20pm revealed an order for Status B with OUP (off unit privileges).

Review of the "Tech Notes / Observation Sheet Page 1" for Patient #2 revealed he was in the gym on 11/07/10 from 3:30pm until 4:30pm with observation by MHT (mental health technician) S33, while his physician orders were for unit restriction. Further review of the "Narrative Summary" revealed no documented evidence of behaviors such as "kicking, screaming, banging head, fighting, yelling, yelling uncontrollably, throwing things, attempting to destroy property, attempting to harm self ...".

Review of the "Multi-Disciplinary Progress Note" documented by RN S30 from Agency A on 11/07/10 at 7:30pm revealed "3 x 5 cm (3 by 5 centimeter) abrasion noted on left lateral thigh; no bleeding or drainage; patient denies pain. "It happened in the gym today" patient reported. Pt (patient) unsure of time injury occurred or if others were involved. Pt denies that he was intentionally injured .. ".

In a face-to-face interview on 11/09/10 at 8:10am, MHT S8 indicated he arrived at the hospital on 11/07/10 about 4:00pm. He further indicated he was asked by the nurse to go to the gym to get Patient #2 to return to the unit. He indicated he was assigned to observe Patient #2 for the remainder of the 3:00 - 11:00pm shift on 11/07/10. S8 indicated there was no "horse playing accidents, kids are hyper and sometimes they jump up and run into somebody ... things like that happen all the time". He further indicated he was not aware of an injury to Patient #2 until RN S30 informed him of the abrasion.

In a face-to-face interview on 11/09/10 at 8:30am, RN S30 from Agency A indicated when MHT S 33 prepared Patient #2 for his shower, S33 called her to notify her of the abrasion to the left lateral thigh. She indicated that she notified the patient ' s parent, the physician, and the oncoming RN who replaced her, but she was not aware if the hospital policy required her to notify the administrator on-call of the injury of unknown origin. RN S30 indicated she replaced a contract agency RN when she arrived for her shift. S30 further indicated the agency day RN had not taped a report as required by policy, so she gave S30 a verbal report. RN 30 indicated she asked the agency RN she was replacing if there were any patients on unit restriction, and she was told there were none. S30 indicated when she looked at the board, she noticed that Patient #2 and Patient #5 were on unit restriction and should not have been in the gym. S30 indicated that since there were no patients on the unit, she went to the gym to take Patients #2 and #5 back to the unit and met MHT S8 who returned to observe the 2 patients. RN S30 indicated she asked MHT S33 if he had witnessed anyone push Patient #2 while in the gym, and MHT S8 indicated that they played rough in the gym, but no one was aggressive toward him. S30 indicated she was able to speak privately with Patient #2, and he denied that anyone hurt him.

In a telephone interview on 11/09/10 at 2:55pm, MHT S33 indicated he had worked the evening and night shifts on 11/07/10. He further indicated Patient #2 was in the gym from 3:30pm until 4:15pm on constant visual observation. S33 indicated he observed Patient #2 slip on the carpet in the gym, but Patient #2 didn't come to S33 to complain about being hurt. He further indicated he didn't report the fall to the RN, because Patient #2 didn't complain of an injury. He could offer no explanation for not documenting Patient #2's fall on a "Quality/Risk Management Report of Event" form or on the observation narrative report.

Review of the "Multi-Disciplinary Progress Note" documented by RN S29 on 11/08/10 at 6:50am revealed "heard pt crying while in the day area with other peers sitting on the benches. Pt stated that another peer kicked him & (and) staff noted that his lower lip is bleeding. The other peers who were present stated that pt was running around & he accidentally fell ...". There was no documented evidence that RN S29 asked MHT S33, who was assigned constant visual observation of Patient #2, what had occurred to cause the bleeding to the lip.

Review of the "Tech Notes / Observation Sheet Page 1" for Patient #2 revealed he was on continuous visual observation by MHT S33 in the dayroom on 11/08/10 from 6:45am until 7:00am.

In a face-to-face interview on 11/09/10 at 7:45am, RN S29 indicated she heard Patient #2 crying. She further indicated he came to the nursing station and said that someone kicked him. S29 indicated she went to the dayroom and asked the other patients what had happened. S29 further indicated Patient #2's peers said he just fell. S29 indicated Patient #2 was alone when he came from the day area to the nursing station. S29 further indicated when she asked MHT S33, who was assigned constant visual observation of Patient #2, what had happened, S33 told her "no one touched him". S29 confirmed that she should have documented her conversation with MHT S33. S29 indicated she did not notify the physician of the injury, but she did report it to the oncoming RN and asked him to inform the physician.

In a telephone interview on 11/09/10 at 2:55pm, MHT S33 indicated one patient stuck his foot out, and Patient #2 tripped over his own foot. He further indicated this happened during shift change. He further indicated Patient #2 was in the big dayroom and fell on the floor by the table located toward the front left of the dayroom, but he didn't hit anything when he fell. S33 further indicated Patient #2 had no injury. MHT S33 confirmed he did not see Patient #2 bleeding from the lip. He could offer no explanation regarding how Patient #2 could be on continuous visual observation, receive a laceration to the lower lip resulting in bleeding, and S33 not know the lip was bleeding and what caused the injury.

Patient #4
Review of Patient #4's medical record revealed he was admitted on 11/03/10 with diagnoses of suicidal ideation, intermittent explosive disorder, and oppositional deviant disorder.
Patient #5
Review of Patient #5's medical record revealed he was admitted on 11/05/10 with the diagnoses of suicidal ideation and depression.
Patient #6
Review of Patient #6's medical record revealed he was admitted on 11/04/10 with diagnoses of Intermittent Explosive Disorder, Oppositional Defiant Disorder, and Attention Deficit/ Hyperactive Disorder.

Observation of the Little Boy's Dayroom on 11/08/10 at 8:30am revealed Patients #2, #4, #5, and #6 were sitting in the room watching television. Further observation revealed the only MHT turned his back to the children and walked to the doorway to call the housekeeper to come into the room to clean it.
Observation on 11/08/10 at 8:55am of the little boy's day room revealed Patient #2, #4, #5 and #6 were sitting in the room watching television when the only MHT assigned to monitor the children turned his back to them and walked to the door and attempted to signal the attention of one of the staff members.
Review of the hospital policy titled "Observation Status Categories", revised 10/22/10 and submitted by Administrator S1 as their current policy for observation levels, revealed, in part, "... It is the policy of Crossroads Regional Hospital that each patient will be monitored throughout his or her hospitalization according to an assigned observation status. The patient's status is assigned at the time of admission, re-evaluated and changed as clinically indicated. ... Procedure: At the time of admission, the physician will give an order for required Observation Status. Any time the patient's observation status changes; there must be an accompanying physician's order. ... The Charge R.N. is responsible for assigning the staff members to perform designated special observation status for each patient on his/her assigned unit. The Patient Care Assignment Cannot Be Delegated. ... B. "Constant Visual Observation During Waking Hours" (Line of Site Visual Contact during waking hours) (for purposes of confidentiality the code for this status on identification badges and unit bed availability boards is "B-UR or B-OUP") 1. Definition: This status consists of line of site visual observation by staff during waking hours. A staff member may observe more than one patient at a time but the patient must remain in the assigned staff member's eyesight at all times. ... Physicians may give an order for status B patients to be unit restricted (B-UR) or have off unit privileges (B-OUP) ... If patients require "Constant Visual Observation During Waking Hours" but the clinician writes an order for off unit privileges (B-OUP), the reason for the order must be included in the written order. During hours of sleep, staff members will be strategically placed down hallways to ensure that patients are monitored at least every five minutes and a one (1) to six (6) staff to patient ratio is maintained at all times. Each patient care unit will have an additional staff member assigned to accomplish observation of each patient in their bed area every five minutes by making continuous walking rounds of the unit during sleeping hours. ...Documentation: ... Documentation for "1:1", "Constant Visual Observation During Waking Hours" (B-UR and B-OUP)" and "Special Observation During Waking Hours" statuses will have an entry made, every 15 minutes, on the Tech Notes/Observation Sheet. Documentation on the Tech Note/Observation Sheet must be done at 15-minute intervals by gender to gender staff member ... When patient exhibits acting out behaviors such as kicking, screaming, banging head, fighting, yelling crying uncontrollably, throwing objects, attempting to destroy property, attempting to harm self, etc. ... a narrative note must be charted by the assigned MHT on page 2, Narrative Summary. Notes on the Tech Sheet Narrative Summary should reflect notification of behaviors to the RN/LPN and be signed off by the RN/LPN Signature ...".

2) Failure to ensure the MHT followed policy and procedure by disciplining a patient with no documentation of behavior and direction by the RN:
Patient #11
Review of the medical record for Patient #11 revealed he was admitted to the hospital on 10/22/10 with the diagnosis of anxiety and depression with suicidal thoughts. Review of the Physician's Admit Orders dated 10/22/10 revealed an order for "Status B" (Constant Visual Observation, Unit Restriction with no documentation of the reason for the unit restriction).

Review of the Quality/Risk Management Report of Event dated 10/24/10 1235 (AM or PM not documented) revealed the father of Patient #11 called the hospital to report his son had been pushed up against the wall by Mental Health Tech S7.

Review of the Tech Notes/Observation Sheet 10/23/10 for Patient #11 revealed the following:
0715 - 1230 (7:15am-12:30pm) QD - (Dayroom, Continuous Visual Observation) no documented evidence behaviors had been observed.
1230- 1300(12:30pm-1:00pm) E - Visit with the Physician
1300-1315 (1:00pm-1:15pm) QD - (Dayroom, Continuous Visual Observation) no documented evidence behaviors had been observed.
1315-1515 (1:15pm-3:15pm) Y - Visitation with family
1515-2100 (3:15pm-9:00pm) QD - (Dayroom, Continuous Visual Observation) no documented evidence behaviors had been observed.
2100-2115 (9:00pm-9:15pm) I 10 D - Room asleep, lying on mattress, continuous visual observation.

Review of the Nursing Progress Notes revealed an entry made on 10/23/10 at 0430 (4:30am) revealed the patient was in bed with no signs of distress and even respirations and another at 1430 (2:30pm) revealing the patient went to breakfast and lunch (ate 100%) went to the gym, had a good day and was currently with visitors.

In a face-to-face interview on 11/05/10 at 8:45am Mental Health Tech (MHT) S7 indicated that on the way back from the cafeteria, Patient #11 started picking on another child. Further S7 indicated when the children returned to the unit they went to the little boy's day room to watch TV and some of the eight boys sat on the floor. S7 explained it is the routine for the boys to remove their shoes and place them at their side. MHT S7 indicated one of the boys (he could not recall which one) said that Patient #11 threw his show at him and he (S7) told Patient #11 to go and stand in the corner. S7 indicated he did not document the behavior of Patient #11 on his observation sheet or report the behavior to the charge nurse.

Review of the hospital policy titled "Observation Status Categories", revised 10/22/10 and submitted by Administrator S1 as their current policy for observation levels, revealed, in part, "... It is the policy of Crossroads Regional Hospital that each patient will be monitored throughout his or her hospitalization according to an assigned observation status. ... Documentation for "1:1", "Constant Visual Observation During Waking Hours" (B-UR and B-OUP)" and "Special Observation During Waking Hours" statuses will have an entry made, every 15 minutes, on the Tech Notes/Observation Sheet. Documentation on the Tech Note/Observation Sheet must be done at 15-minute intervals by gender to gender staff member ...When patient exhibits acting out behaviors such as kicking, screaming, banging head, fighting, yelling crying uncontrollably, throwing objects, attempting to destroy property, attempting to harm self, etc. ... a narrative note must be charted by the assigned MHT on page 2, Narrative Summary. Notes on the Tech Sheet Narrative Summary should reflect notification of behaviors to the RN/LPN and be signed off by the RN/LPN Signature ...".

3) Failure to monitor staff to ensure duties were performed as assigned by having no documented evidence of patient behaviors on the observation sheets as required by hospital policy:
Patient #1
Review of Patient #1's medical record revealed he was admitted on 10/20/10 with the diagnoses of Unspecified Episodic Mood Disorder and Oppositional Defiant Disorder. Further review revealed no documented evidence by the MHT (Mental Health Tech) of behaviors exhibited during the observations of Patient #1.

Patient #2
Review of Patient #2's "Physician's Admit Order" on 11/06/10 at 8:50pm revealed the provisional diagnosis of Intermittent Explosive Disorder (IED). Further review revealed no documented evidence by the MHT of behaviors exhibited during the observations of Patient #2.

Patient #3
Review of Patient #3's medical record revealed he was admitted on 11/02/10 with diagnoses of Intermittent Explosive Disorder and Oppositional Defiant Disorder. Further review revealed no documented evidence by the MHT of behaviors exhibited during the observations of Patient #3.

Patient #4
Review of Patient #4's medical record revealed he was admitted on 11/03/10 with diagnoses of suicidal ideation, intermittent explosive disorder, and oppositional deviant disorder. Further review revealed no documented evidence by the MHT of behaviors exhibited during the observations of Patient #4.

Patient #5
Review of Patient #5's medical record revealed he was admitted on 11/05/10 with the diagnoses of suicidal ideation and depression. Further review revealed no documented evidence by the MHT of behaviors exhibited during the observations of Patient #5.

Patient #6
Review of Patient #6's medical record revealed he was admitted on 11/04/10 with diagnoses of Intermittent Explosive Disorder, Oppositional Defiant Disorder, and Attention Deficit/ Hyperactive Disorder. Further review revealed no documented evidence by the MHT of behaviors exhibited during the observations of Patient #6.

Patient #7
Review of Patient #7's medical record revealed he was admitted on 10/11/10 with a provisional diagnosis of Depression. Review of the Psychiatric Evaluation performed on 10/12/10 revealed diagnoses of Psychotic Disorder Not Otherwise Specified and Rule Out Cannabis Induced Psychotic Disorder With Hallucinations. Further review revealed no documented evidence by the MHT of behaviors exhibited during the observations of Patient #7.

Patient #8
Review of Patient #8's medical record revealed an admit date of 11/03/10 with the diagnosis of Depression. Review of the Psychiatric Evaluation performed 11/04/10 revealed diagnoses of Mood Disorder and Oppositional Defiant Disorder. Further review revealed no documented evidence by the MHT of behaviors exhibited during the observations of Patient #8.

Patient #9
Review of Patient #9's medical record revealed an admit date of 10/21/10 and diagnoses of Intermittent Explosive Disorder, Oppositional Defiant Disorder, Rule Out Parent/Child Relational Problem, and Episodic Marijuana Abuse. Further review revealed numerous days and times of no documented evidence by the MHT of behaviors exhibited during the observations of Patient #9.

Patient #10
Review of Patient #10's medical record revealed he was admitted on 10/18/10 with a provisional diagnosis of Depression. Review of his Psychiatric Evaluation performed on 10/19/10 revealed diagnoses of Intermittent Explosive Disorder and Conduct Disorder Childhood Onset. Further review revealed no documented evidence by the MHT of behaviors exhibited during the observations of Patient #10.

Patient #11
Review of Patient #11's medical record revealed he was admitted on 10/22/10 with a provisional diagnosis of Depression. Review of physician progress notes revealed diagnoses of Major Depressive Disorder Recurrent Severe With Psychotic Features and Anxiety Disorder. Further review revealed no documented evidence by the MHT of behaviors exhibited during the observations of Patient #11.

Patient #12
Review of Patient #12's medical record revealed he was admitted on 10/20/10 with a provisional diagnosis of Depression. Review of the Psychiatric Evaluation performed 10/21/10 revealed diagnoses of Intermittent Explosive Disorder, Rule Out Bipolar Disorder, Oppositional Defiant Disorder, History of Attention Deficit Hyperactive Disorder (ADHD), Obesity, Asthma, Seasonal Allergies, and GERD (gastro-esophageal reflux disease). Further review revealed no documented evidence by the MHT of behaviors exhibited during the observations of Patient #12.

Patient #13
Review of Patient #13's medical record revealed an admit date of 09/29/10 with a provisional diagnosis of Intermittent Explosive Disorder. Review of physician progress notes of 10/01/10 revealed diagnoses of Major Depressive Disorder Recurrent Without Psychotic Features, Intermittent Explosive Disorder, Oppositional Defiant Disorder, ADHD By History, and History of Bronchitis. Further review revealed numerous days and times of no documented evidence by the MHT of behaviors exhibited during the observations of Patient #13.

Review of "Staff Development Sign In Sheet" revealed in-services were conducted on 10/14/10 to educate staff on the "Observation Status Categories" policy and procedure.

In a face-to-face interview on 11/08/10 at 2:30pm, Director of Nursing (DON) S2 indicated she held in-services on 10/14/10, 10/15/10, and 10/18/10 to address policies and procedures that required either changes and/or re-education since the prior survey that was conducted in October 2010. She further indicated there was no monitoring tool implemented for performing chart audits of MHT observation of patient behaviors. She confirmed that the RNs were not taking an active role in monitoring the assignment of observation of patients by the MHTs. S2 confirmed there had been no disciplinary action, suspension, and/or termination of MHTs related to the lack of documentation of observation of behaviors of patients since the in-service was conducted in October.

In a face-to-face interview on 11/09/10 at 3:10pm, Administrator S1 confirmed that staff continued to not document patient behaviors as required by hospital policy. She also confirmed that there was no monitoring currently being done, such as chart audits to check MHT documentation.

Review of the hospital policy titled "Observation Status Categories", revised 10/22/10 and submitted by Administrator S1 as their current policy for observation levels, revealed, in part, "... It is the policy of Crossroads Regional Hospital that each patient will be monitored throughout his or her hospitalization according to an assigned observation status. ... Documentation for "1:1", "Constant Visual Observation During Waking Hours" (B-UR and B-OUP)" and "Special Observation During Waking Hours" statuses will have an entry made, every 15 minutes, on the Tech Notes/Observation Sheet. Documentation on the Tech Note/Observation Sheet must be done at 15-minute intervals by gender to gender staff member ...When patient exhibits acting out behaviors such as kicking, screaming, banging head, fighting, yelling crying uncontrollably, throwing objects, attempting to destroy property, attempting to harm self, etc. ... a narrative note must be charted by the assigned MHT on page 2, Narrative Summary. Notes on the Tech Sheet Narrative Summary should reflect notification of behaviors to the RN/LPN and be signed off by the RN/LPN Signature ...".

4) Failure of the RN to perform a daily physical assessment:
Patient #1
Review of Patient #1's medical record revealed he was admitted on 10/20/10 with the diagnoses of Unspecified Episodic Mood Disorder and Oppositional Defiant Disorder. Review of the entire medical record revealed no documented evidence that a daily physical assessment of Patient #1 was performed after the review of systems performed during the admission assessment.

Patient #2
Review of Patient #2's "Physician's Admit Order" on 11/06/10 at 8:50pm revealed the provisional diagnosis of Intermittent Explosive Disorder (IED). Review of the entire medical record revealed no documented evidence that a daily physical assessment of Patient #2 was performed after the review of systems performed during the admission assessment.

Patient #3
Review of Patient #3's medical record revealed he was admitted on 11/02/10 with diagnoses of Intermittent Explosive Disorder and Oppositional Defiant Disorder. Review of the entire medical record revealed no documented evidence that a daily physical assessment of Patient #3 was performed after the review of systems performed during the admission assessment.

Patient #4
Review of Patient #4's medical record revealed he was admitted on 11/03/10 with diagnoses of suicidal ideation, intermittent explosive disorder, and oppositional deviant disorder. Review of the entire medical record revealed no documented evidence that a daily physical assessment of Patient #4 was performed after the review of systems performed during the admission assessment.

Patient #5
Review of Patient #5's medical record revealed he was admitted on 11/05/10 with the diagnoses of suicidal ideation and depression. Review of the entire medical record revealed no documented evidence that a daily physical assessment of Patient #5 was performed after the review of systems performed during the admission assessment.

Patient #6
Review of Patient #6's medical record revealed he was admitted on 11/04/10 with diagnoses of Intermittent Explosive Disorder, Oppositional Defiant Disorder, and Attention Deficit/ Hyperactive Disorder. Review of the entire medical record revealed no documented evidence that a daily physical assessment of Patient #6 was performed after the review of systems performed during the admission assessment.

Patient #7
Review of Patient #7's medical record revealed he was admitted on 10/11/10 with a provisional diagnosis of Depression. Review of the Psychiatric Evaluation performed on 10/12/10 revealed diagnoses of Psychotic Disorder Not Otherwise Specified and Rule Out Cannabis Induced Psychotic Disorder With Hallucinations. Review of the entire medical record revealed no documented evidence that a daily physical assessment of Patient #7 was performed after the review of systems performed during the admission assessment.

Patient #8
Review of Patient #8's medical record revealed an admit date of 11/03/10 with the diagnosis of Depression. Review of the Psychiatric Evaluation performed 11/04/10 revealed diagnoses of Mood Disorder and Oppositional Defiant Disorder. Review of the entire medical record revealed no documented evidence that a daily physical assessment of Patient #8 was performed after the review of systems performed during the admission assessment.

Patient #9
Review of Patient #9's medical record revealed an admit date of 10/21/10 and diagnoses of Intermittent Explosive Disorder, Oppositional Defiant Disorder, Rule Out Parent/Child Relational Problem, and Episodic Marijuana Abuse. Review of the entire medical record revealed no documented evidence that a daily physical assessment of Patient #9 was performed after the review of systems performed during the admission assessment.

Patient #10
Review of Patient #10's medical record revealed he was admitted on 10/18/10 with a provisional diagnosis of Depression. Review of his Psychiatric Evaluation performed on 10/19/10 revealed diagnoses of Intermittent Explosive Disorder and Conduct Disorder Childhood Onset. Review of the entire medical record revealed no documented evidence that a daily physical assessment of Patient #10 was performed after the review of systems performed during the admission assessment.

Patient #11
Review of Patient #11's medical record revealed he was admitted on 10/22/10 with a provisional diagnosis of Depression. Review of physician progress notes revealed diagnoses of Major Depressive Disorder Recurrent Severe With Psychotic Features and Anxiety Disorder. Review of the entire medical record revealed no documented evidence that a daily physical assessment of Patient #11 was performed after the review of systems performed during the admission assessment.

Patient #12
Review of Patient #12's medical record revealed he was admitted on 10/20/10 with a provisional diagnosis of Depression. Review of the Psychiatric Evaluation performed 10/21/10 revealed diagnoses of Intermittent Explosive Disorder, Rule Out Bipolar Disorder, Oppositional Defiant Disorder, History of Attention Deficit Hyperactive Disorder (ADHD), Obesity, Asthma, Seasonal Allergies, and GERD (gastro-esophageal reflux disease). Review of the entire medical record revealed no documented evidence that a daily physical assessment of Patient #12 was performed after the review of systems performed during the admission assessment.

Patient #13
Review of Patient #13's medical record revealed an admit date of 09/29/10 with a provisional diagnosis of Intermittent Explosive Disorder. Review of physician progress notes of 10/01/10 revealed diagnoses of Major Depressive Disorder Recurrent Without Psychotic Features, Intermittent Explosive Disorder, Oppositional Defiant Disorder, ADHD By History, and History of Bronchitis. Review of the entire medical record revealed no documented evidence that a daily physical assessment of Patient #13 was performed after the review of systems performed during the admission assessment.

In a face-to-face interview on 11/08/10 at 2:30pm, DON S2 could offer no explanation for physical assessments of patients not being performed every 24 hours by the RN when they performed the mental status exam.

Review of the hospital policy titled "Assessments, Initial Screening and Other", revised 07/21/06 and submitted by Administrator S1 as one of their current policies for assessments, revealed, in part, "...Nursing Admission Assessment The RN will complete the nursing admission assessment within eight hours of patient's arrival on the unit. ... A review of systems will be completed by the RN with documentation of any identified medical problems. The patient's body will be examined for any marks, i.e. (that is) bruises, swelling, scratches, and appropriate documentation noted. ... Nursing Reassessment Post admission re-assessment of a patient's status will be accomplished by the RN charge nurse in the event of an injury, return from therapeutic assignment (pass), at the time of discharge or any other time physical impairments may be identified by staff ...". Review of the entire policy revealed no documented evidence that a physical assessment was required to be performed every 24 hours by the RN.

Review of the hospital policy titled "Multidisciplinary Progress Notes & (and) Nursing Mental Status Exam", revised 01/20/06 and submitted by Administrator S1 as one of their policies for nursing assessments, revealed, in part, "... A mental status assessment must be completed once in every 24 hour period by the Registered Nurse (this assessment is to be completed during hours that the patient is awake which routinely will be during the 7/3 and 3/11 shifts). This form also includes a narrative section which can be considered the 24 hour R.N. note. However, should there be an occurrence related to patient behavior or treatment requiring further documentation by the R.N., the information must be documented in the multi-disciplinary progress note ...". Review of the entire policy revealed no documented evidence that a physical assessment was required to be performed every 24 hours by the RN at the time the mental status assessment was completed.

Based on record review and interview the hospital failed to ensure the nursing care plan/ treatment plan included the revisions according changes in the patient's condition for 6 of 6 patients reviewed for nursing care plans/treatment plans (Patient #2, #7, #13) for 3 of 3 nursing care plans/treatment plans reviewed out of 13 sampled medical records. Findings:

Patient #2
Review of the medical record for Patient #2 revealed an eight year old male admitted to the hospital on 11/06/10 with the diagnosis of Intermittent Explosive Disorder. Further review of the medical record revealed no documented evidence the Initial Treatment Plan/Nursing Care Plan had been implemented for Patient #2.

Review of the Quality/Risk Management Report of Event form dated 11/07/10 1930 (7:30pm) revealed a 3x5cm abrasion was located on the left lateral thigh of Patient #2 when the patient was showered. Further review revealed the patient indicated the injury happened in the gym, but could offer no details.

Review of the Quality/Risk Management Report of Event form dated 11/08/10 0650 (6:50am) revealed Patient #2 was heard crying and stated that a peer had kicked him while both of the children had an order to be under continuous visual contact.

Review of the Initial Treatment Plan dated 10/11/10 revealed no documented evidence the Initial Treatment Plan/Nursing Care Plan had been initiated as of 11/08/10 at 10:000am.

Patient #7
Review of the medical record revealed Patient #7 a 16 year old male admitted to the hospital on 10/11/10 with the diagnosis of severe Psychosis. Review of the Initial Treatment Plan/Nursing Care Plan dated 10/11/10 revealed Patient #7 was unable to perform hygiene ADLs (Activities of Daily Living) and was a threat to himself and others due to his altered mental status and severe paranoia.

Review of the Quality/Risk Management Report of Event dated/timed 10/13/10 at 11:30 (AM/PM not documented) revealed Patient #7 had been agitating other patients and when the boys went outside one of the boys punched him three times.

Review of the Multidisciplinary Progress Notes dated 10/13/10 revealed the patient had been agitating his peers and was punched in the mouth, did not appear hurt and refused treatment.

Review of the Initial Treatment Plan/Nursing Care Plan dated 10/11/10 revealed no documented evidence of any changes to the plan even though the ones documented (monitor mood, behavior and safety) failed to keep him safe.


Patient #13
Review of the medical record for Patient #13 revealed a sixteen year old female admitted to the hospital on 09/29/10 with the diagnoses of Depression and Suicidal Ideation. Review of the Initial Treatment Plan/Nursing Care Plan dated 09/29/10 revealed nursing identified #13's problem as a potential to harm herself or others.

Review of the Quality/Risk Management Report of Event dated/timed 09/29/10 at 2320 (11:20pm) Patient #13 had attempted suicide by placing a sheet through the curtain and then around her neck.

Review of the Initial Treatment Plan/Nursing Care Plan dated 09/29/10 revealed no documented evidence of any changes to the plan even though #13 had been placed on 2:1 (two staff members to one patient) observations and the previous interventions of provide a safe and therapeutic environment had proven to be ineffective.

Review of Policy No. AS-00-011 titled "Treatment Planning and Review Process" last revised 01/09/08 and submitted as the one currently in use, revealed .... " The Initial Treatment Plan will be completed within 24 hours of admission and functions as the Preliminary Treatment Plan in directing treatment interventions towards resolution of identified problems ..... When indicated, the plan of care and treatment goals may be revised. The appropriate discipline(s) shall note changes in interventions, goals, objectives and other components of the plan of care and document actions on the Master-Treatment plan by the designated scribe " .

In a face to face interview on 11/08/10 at 2:00pm Director of Nursing S2 indicated chart reviews were not performed at present.

Based on record review and interviews, the hospital failed to ensure the RN (registered nurse) assigned the nursing care of each patient according to the needs of the patient and the specialized qualifications, experience, and competence of the nursing staff by having: 1) 5 of 5 RN personnel files reviewed from a total of 25 RNs on staff (either full-time or PRN - as needed) with no documented evidence of orientation, training, and/or assessment for determination of competency (S4, S6, S22, S29); 2) 3 of 3 licensed practical nurses' (LPN) files reviewed from a total of 17 LPNs on staff (either full-time or PRN) with no documented evidence of orientation, training, and/or assessment for determination of competency (S19, S23, S27) and 2 of the 3 with no documented evidence of psychiatric experience when hired (S23, S27); 3)9 of 9 mental health technicians' (MHT) personnel files reviewed from a total of 74 MHTs (either full-time or PRN) with no documented evidence of orientation, training, and/or assessment for competency (S7, S8, S9, S13, S17, S18, S25, S26, S28) and 5 of the 10 with no documented evidence of psychiatric experience when hired (S8, S17, S18, S25, S28); and 4) 2 of 2 contract Agency A RNs' personnel files reviewed from a total of 39 nurses' from Agency A (the list did not indicate whether the nurse was a RN or a LPN) with no documented evidence of orientation, training, assessment for determination of competency (S20, S30) and 1 of the 2 RNs had no documented evidence of psychiatric experience (S30). Findings:

1) 5 of 5 RN personnel files reviewed from a total of 25 RNs on staff (either full-time or PRN - as needed) with no documented evidence of orientation, training, and/or assessment for determination of competency (S4, S6, S22, S24, S29):

Review of the RN job description revealed a standard of performance was to maintain required certifications in CPR (cardiopulmonary resuscitation and aggressive behavior training.

RN S4
Review of RN S4's personnel file, who was the Director of Regulatory Compliance and Staff Development Coordinator, revealed no documented evidence of orientation to the job duties related to regulatory compliance and an assessment of competency in that role. Further review S4's BLS (basic life support) Instructor certification had expired 10/09. Review of the entire personnel file revealed no documented evidence of a performance evaluation since 09/24/09, while hospital policy requires a performance evaluation "approximately every twelve months".

In a face-to-face interview on 11/05/10 at 2:45pm, Director of Regulatory Compliance/Staff Development Coordinator S4 indicated she was responsible for staff development, employee health, infection control, housekeeping, the switchboard department, worker's compensation, and regulatory compliance. She further indicated her LPN nursing background was in the nursing home and labor and delivery, and her RN experience was in medical/surgery, telemetry, and 1 or 2 shifts as an agency nurse in a psychiatric facility. She further indicated as regulatory compliance director she was familiar with the JCAHO (Joint Commission Accreditation of Healthcare Organizations) standards, but she was not knowledgeable of the state licensing and federal certification regulations. S4 indicated she had on-the-job training for regulatory compliance by Administrator S1. She further indicated her only training about abuse and neglect investigations was through a telephone conference with a program manager with DHH (Department of Health and Hospitals). S4 indicated she had requested to attend a workshop on patient rights and abuse and neglect that was held in July or August 2010, but her request was denied by Chairman of the Board S32.

RN S6
Review of RN S6's personnel file revealed she was hired on 07/12/10 with no documented evidence of prior psychiatric hospital experience. Further review revealed she attended STEPS (Supportive Therapeutic Encounters For Positive Success) on 07/16/10 with Administrator S1 listed as the Certified STEPS Instructor, when in interview S1 confirmed that she was not currently certified as a STEPS instructor. There was no documented evidence of certification in aggressive behavior training as required by hospital RN job description and hospital policy.
Review of RN S6's "General Orientation Skills Checklist" revealed no documented evidence of a self assessment and whether she met criteria when she was precepted on 07/13/10.
Review of the "Initial Skill / Competency Validation" revealed S6 self assessed herself as being able to perform with assistance the following duties and/or knowledge of: Psychiatric Patient Rights; Mental Health Advance Directives; Fall Prevention; Americans with Disabilities Act; Grievances; Disciplinary Actions; Safety/Security Codes; Evacuation Plan; Hazardous Materials and Waste Program; Emergency Preparedness Program; Life Safety Management Program; Fire Alarms/Extinguishers; National Patient Safety Goals; Employee Injury/Exposure; Corporate Compliance; Code of Conduct/Ethical Behavior; Environment of Care Manual; Wasting/Witness of Medications; 24 hour chart checks, medication variances/incident reporting; adverse drug reaction; restraint usage with physician order/time limit and alternative methods; assessing for neglect and/or abuse reporting to RN Charge Nurse and/or Director of Nurses and completes appropriate referral; receives and responds to complaints; secures and labels patient belongings; provides a safe and secure environment for patient; obtains crash cart/AED; determines teaching effectiveness; wear your name badge at work; expected outcomes are mutually formulated with patient, family and health care team; formulates measurable expected outcomes using patient profile, pathways and standards of care as guides; identifies expected outcomes which are realistic in respect to patient's present and potential capabilities; develops plan of care consistent with assessment data; individualizes plan based upon identified patient needs; prioritizes implementation of diagnoses and interventions based on patient condition; implements the interventions identified in the plan of care; incorporates evidenced-based treatments in care of patient; documents interventions and implementation noting exceptions/modifications; utilizes an organized ongoing process to determine outcome attainment based on the plan of care; documents evaluation findings and uses data to revise as necessary diagnoses, outcome, plan, and implementation process; judicial commitment; search with metal detector wand (self assessed as having never performed); psychological, emotional, spiritual, and psychosocial assessments; formulate a treatment plan; discharge planning; patient orientation; demonstrates understanding of psychotropic medications side effects and desired effects, neuroleptic malignant syndrome, lithium toxicity, and artane psychosis; knowledge and understanding of disease processes of alzheimer's, anxiety, attention deficit hyperactivity disorder, bipolar disorder and mania, chemical dependency, eating disorders, mood behavior disorders, and psychoses; understanding of psychiatric legal issues and facility regulations; guardianship; medication refusal/involuntary medication procedure; voluntary commitment; court, commitment proceedings; directing the unit with staffing, oversight of staff, patient safety, staff safety, infection control, and reporting errors; documentation using the A.P.I.E. (assessment, problem, intervention, evaluation) format; understands documentation of symptoms, reactions, treatments, and changes in patient condition; restraint procedures with documentation, assessments/interventions, and application/removal of restraints; and precautions including continuous observation, one-to-one, suicidal, homicidal, and elopement. Further review revealed no documented evidence that S6, who had been hired to be a charge RN on the unit, had been educated on the areas identified by S6 as needing assistance to perform. Further review revealed no documented evidence of the method of evaluation by the preceptor to the following sections on the checklist: performs basic core competencies (includes physical assessment, respiratory care, medication administration, pain management, glucometer, restraint usage, specimen collection/handling, wound care, application of dressings, environmental responsibilities, patient rights, code blue management); participates in patient/family teaching; portrays hospital cultural expectations; assessment; diagnosis; identification of outcomes; planning; implementation; evaluation; quality of care; performance appraisal; education; analytical factors; clinical/technical expertise; influence and impact; insight into others; insight into self/self-awareness; knowledge transfer; patient focus/customer service; teamwork; change management; innovation; unit specific competencies (includes admissions procedure, forms of admission, performs searches, assessments, formulate treatment plan, discharge planning, patient orientation, medication administration procedure, knowledge and understanding of disease processes); demonstrates understanding of psychiatric legal issues and facility regulations; directing the unit (includes staffing, oversight of staff, patient safety, staff safety, infection control, reporting events, use of the communication system); documentation; restraint procedures; and observation precautions. Further review revealed all items were documented as evaluated on 10/25/10 and 10/29/10, more than 3 months after the date of hire, and had no documented evidence of the signature of the evaluator.
Review of the entire personnel file of RN S6 revealed no documented evidence of a 90 day performance evaluation as required by hospital policy.

In a face-to-face interview on 11/04/10 at 2:40pm, Administrator S1 indicated STEPS was the only education being provided for non-crisis intervention and/or aggressive behavior training. She further indicated she was not currently certified as a STEPS instructor.

In a face-to-face interview on 11/05/10 at 10:05am, RN S6 indicated she had been employed at Crossroads Regional Hospital since 07/12/10. She further indicated her prior nursing experience included emergency, dialysis, operating room, medical/surgical, and working with the developmentally disabled. She confirmed that she did not have previous psychiatric hospital experience when she was hired. When asked if she felt her orientation provided by the hospital was adequate, S6 indicated she did not feel she was oriented enough for her to feel comfortable with whatever may happen on the unit. She indicated that she continues to call and ask a lot of questions of the LPN who does scheduling. When asked why she doesn't get direction from the DON, S6 indicated the DON was so busy, S6 couldn't ' always reach her. S6 indicated she received STEPS training as part of her orientation, and the class was taught by Director of Regulatory Compliance/Staff Development Coordinator S4, an activity therapist, and a man whose name and title she did not remember. She further indicated Administrator S1 was not present during the class as listed on the sign-in sheet.

RN S22
Review of RN S22's personnel file revealed she was hired on 05/03/10. Further review revealed no documented evidence of the instructor who had evaluated her physical intervention skills. Further review revealed no documented evidence of certification in aggressive behavior training as required by the hospital's RN job description and hospital policy.
Review of RN S22's "Initial Skill / Competency Validation" revealed sections had been evaluated on 05/03/10, 05/04/10, 05/11/10, and 05/12/10 with no documented evidence of the method of evaluation and the validator and title of the individual. Further review revealed no documented evidence of assessment of competency for the following: auditory/visual privacy; mental health advance directives, spiritual care; fall prevention; cultural competencies; sexual harassment; American with Disabilities Act; grievances; security management program; hazardous materials and waste program; life safety management program; National Patient Safety Goals; corporate compliance; code of conduct/ethical behavior; basic core competencies (physical assessment, respiratory care, medication administration, pain management, restraint usage, specimen collection/handling of urine, wound care, application of dressings, latex allergies, patient rights, code blue management); patient/family teaching; hospital cultural expectations; quality of care; performance appraisal; education; analytical factors; clinical/technical expertise; influence and impact; insight into others; insight into self/self-awareness; knowledge transfer; patient focus/customer service; teamwork; change management; innovation; unit specific competencies (perform searches; physical, psychological, emotional, spiritual, and psychosocial assessments; formulate treatment plan; patient orientation; medication administration procedure; knowledge and understanding of disease processes; understanding of psychiatric legal issues and facility regulations; oversight of the staff; reporting errors; use of the communication system; knowledge of cultural awareness; health care teaching; documentation using the APIE format; and restraint procedures.
Review of the entire personnel file of RN S22 revealed no documented evidence of a performance evaluation after 90 days of employment as required by hospital policy.

RN S24
Review of RN S24's personnel file revealed she was hired 05/17/10. Further review revealed no documented evidence of orientation to the psychiatric unit, assessment of competency, evaluation of performance in 90 days of employment, and certification in aggressive behavior training as required by the hospital's RN job description and hospital policy.

RN S29
Review of RN S29's personnel file revealed she was hired 10/25/04. Review of the "Initial Skill/Competency Validation" revealed the evaluation was performed on 07/27/10 by RN S47 as evidenced by her name or initials at the top of each column with a line drawn down each column of the 16 pages of the checklist and her signature and date on the final page. Further review revealed no documented evidence of the method of evaluation for competencies listed on pages 4 through 16 which included the basic core competencies and unit specific competencies.
Review of RN S29's personnel file revealed no documented evidence of certification in aggressive behavior training as required by the hospital's RN job description and hospital policy. Further review revealed S29's performance was not evaluated "approximately every 12 months" as required by hospital policy as evidenced by the last performance evaluation of 02/02/05.

In a face-to-face interview on 11/05/10 at 12:30pm, Administrator S1 confirmed that no current employee was certified in aggressive behavior training. She could offer no explanation regarding why this was not done, since the job descriptions and policies required certification in either STEPS or aggressive behavior training.

In a face-to-face interview on 11/09/10 at 11:15am, Chairman of the Board S32, when informed of new employees and agency nursing personnel with no documented evidence of orientation, assessment of competency, and certification in aggressive behavior training, indicated he was not aware that there were no current staff who were trained in non-crisis prevention interventions. He could offer no explanation for Administrator S1 being documented as the certified STEPS instructor for classes that were held when she was not currently certified and was not present at the class as confirmed by staff interviews.

Review of the "STEPS (Supportive Therapeutic Encounters for Positive Success) A Program of Supportive Management" information presented by Administrator S1 as their current in-service material for the STEPS program revealed, in part, "... The STEPS program ... is a course designed to detect and therapeutically intervene before a situation escalates to crisis proportions. The developmental theoretical model on which STEPS is based affords an individualized therapeutic approach. STEPS emphasizes verbal interventions and de-escalation with supportive, protective physical interventions to be utilized in those instances where violent, out-of-control persons are attempting harm to themselves or others. ... The purpose of STEPS is to reduce potential harm to oneself and others by early detection and intervention to prevent a person from behaving in a physically aggressive manner. The techniques emphasize verbal intervention and the least restrictive amount of physical control necessary. ... Steps Program Part One: I. Therapeutic Skill Development (empathetic skill development, ...verbal interventions, ... nonverbal interventions ...); II. Therapeutic Relationships (positive relationships ...negative relationships) ...Part Two I. Therapeutic Assessment Process ... II. Therapeutic Interventions ... III. Team Concept ... IV. Role Reversal ... V. Follow-Up Process ...".

Review of the hospital's policy titled "Plan for the Provision of Patient Care - 2008", revised 02/26/08 and submitted by Administrator S1, revealed, in part, "...Staff Development (education) Department ... Objectives: 1. Provide information and certification to Crossroads employees and its associates involving the mandatory education areas, which are: ... g. STEPS ...".

Review of the hospital policy titled "Staff Development - Inservice", revised 07/03/00 and submitted by Administrator S1 as their current policy for orientation, revealed, in part, "...All hospital employees will receive mandatory orientation at the beginning of their employment. Mandatory orientation includes education on the following CRH (Crossroads Regional Hospital) policy and procedures: ...5. Non-Violent Crisis Intervention Techniques (Clinical Staff) ... All clinical staff members will be re-certified annually in non-violent crisis intervention techniques (S.T.E.P.S., CPI [crisis prevention intervention], PMAB [Prevention and Management of Aggressive Behavior] and CPR. The re-certification process will consist of cognitive and behavioral education and will include written tests as well as skills checklists ...".

Review of the hospital policy titled "Initial Employment Period", revised 05/01/02 and submitted by Administrator S1 as their current policy for performance evaluations during the initial employment period, revealed, in part, "...The initial employment period, which is generally the first ninety (90) days of employment will be heavily concentrated on training in the new role. During this period of time, the supervisor will observe and determine the employee's ability to do the work which is assigned, as well as suitability for the position with regard to facility standards of attitude, punctuality and attendance. ... Guidelines 1. All employees will receive a performance evaluation during the initial employment period. The immediate supervisor shall be responsible for completion of the evaluation on a timely basis ...".

Review of the hospital policy titled "Performance Evaluations", developed 06/27/00 and submitted by Administrator S1 as their current policy for performance evaluations, revealed, in part, "...Formal performance evaluations are scheduled approximately every twelve (12) months for full-time and part-time employees ...".

2) 3 of 3 LPN files reviewed from a total of 17 LPNs on staff (either full-time or PRN) with no documented evidence of orientation, training, and/or assessment for determination of competency (S19, S23, S27) and 2 of the 3 with no documented evidence of psychiatric experience when hired (S23, S27):
LPN S19
Review of LPN S19's personnel file revealed she was hired on 04/25/01 with no documented evidence of prior psychiatric hospital experience. Further review revealed she no documented evidence S19 had been assessed to be competent in or certified in aggressive behavioral training as required by hospital LPN job description and hospital policy.
LPNS23
Review of LPN S23's personnel file revealed she was hired on 06/14/10. Review of the "Employment Application" revealed no documented evidence of psychiatric hospital nursing experience. Review of the "Initial Skill / Competency Validation" revealed S23 self assessed herself as being able to perform all skills listed without assistance and was signed off as being competent without any documented evidence her skills had been observed by her preceptor.
Review of the S.T.E.P.S. Physical Intervention Skills Checklist for used at the hospital for employee orientation for education on management of aggressive behavior revealed no documented evidence S23's skills had been assessed for competency.
Review of the entire personnel file of RN S23 revealed no documented evidence of a 90 day performance evaluation as required by hospital policy.
LPN S27
Review of LPN S27's personnel file revealed she was hired on 08/23/10 with no documented evidence of any prior psychiatric experience. Review of the "Initial Skill / Competency Validation" revealed no documented evidence an orientation or competency assessment had been performed on S27 prior to being assigned patient care.

In a face-to-face interview on 11/05/10 at 12:30pm, Administrator S1 confirmed that no current employee was certified in aggressive behavior training. She could offer no explanation regarding why this was not done, since the job descriptions and policies required certification in either STEPS or aggressive behavior training.

In a face-to-face interview on 11/09/10 at 11:15am, Chairman of the Board S32, when informed of new employees and agency nursing personnel with no documented evidence of orientation, assessment of competency, and certification in aggressive behavior training, indicated he was not aware that there were no current staff who were trained in non-crisis prevention interventions. He could offer no explanation for Administrator S1 being documented as the certified STEPS instructor for classes that were held when she was not currently certified and was not present at the class as confirmed by staff interviews.

See policy review of "Staff Development - Inservice", "Plan for the Provision of Patient Care - 2008", "Initial Employment Period", and "Performance Evaluations" policies listed above.
3) 9 of 9 MHTs' personnel files reviewed from a total of 74 MHTs (either full-time or PRN) with no documented evidence of orientation, training, and/or assessment for competency (S7, S8, S9, S13, S17, S18, S25, S26, S28) and 5 of the 10 with no documented evidence of psychiatric experience when hired (S8, S17, S18, S25, S28):

MHT S7
Review of MHT S7's personnel file revealed he was hired on 02/08/10. Further review revealed no documented evidence of certification in aggressive behavior training as required by the MHT job description and hospital policy. Review of S7's "Initial Skill/Competency Validation" revealed no documented evidence of the signature and title of the evaluator of competency. Further review revealed no documented evidence of assessment of competency for restraint usage, code blue management, unit specific competencies including the admission procedure, performing searches, patient orientation, documentation, and observation precautions.

MHT S8
Review of MHT S8's personnel file revealed a hire date of 02/22/10 with no documented evidence of psychiatric experience. Further review revealed no documented evidence of unit orientation and assessment of competency prior to performing job duties. Further review revealed his performance evaluation was not performed within 90 days of employment as required by hospital policy. Further review revealed no documented evidence of certification in aggressive behavior training as required by the MHT job description and hospital policy.

In a face-to-face interview on 11/05/10 at 7:45am, MHT S8 indicated his current employment at Crossroads Regional Hospital was his first time working in a hospital, and he did not have prior psychiatric experience.

MHT S9
Review of MHT S9's personnel file revealed he was hired on 03/08/10. Further review revealed no documented evidence of certification in aggressive behavior training as required by the MHT job description and hospital policy.
Review of S9's "Initial Skill/Competency Validation" revealed all areas were documented as assessed on 06/16/10 with no documented evidence of the signature and title of the evaluator and the method of validation that was used.
Review of MHT S9's personnel file revealed his initial performance evaluation was not performed in 90 days of employment as required by hospital policy.

MHT S13
Review of MHT S13's personnel file revealed a hire date of 05/03/10. Further review revealed no documented evidence of certification in aggressive behavior training as required by the MHT job description and hospital policy.
Review of S13's "Initial Skill/Competency Validation" revealed no documented evidence of the method used to validate/evaluate for competency. Further review revealed no documented evidence of assessment of competency for code blue management, patient rights, and observation precautions.

MHT S17
Review of MHT S17's personnel file revealed a hire date of 09/06/10 with no documented evidence of psychiatric experience. Further review revealed no documented evidence of certification in aggressive behavior training as required by the MHT job description and hospital policy. Further review revealed no documented evidence of assessment of competency prior to providing direct patient care.

MHT S18
Review of MHT S18's personnel file revealed a hire date of 01/25/10 with no documented evidence of psychiatric experience. Further review revealed no documented evidence of certification in aggressive behavior training as required by the MHT job description and hospital policy.
Review of S18's "Initial Skill/Competency Validation" revealed no documented evidence of an assessment of competency prior to performing direct patient care.

MHT S25
Review of MHT S25's personnel file revealed a hire date of 05/03/10 with no documented evidence of psychiatric experience. Further review revealed no documented evidence of certification in aggressive behavior training as required by the MHT job description and hospital policy. Further review revealed no documented evidence of assessment of competency of MHT job duties.

MHT S26
Review of MHT S26's personnel file revealed a hire date of 05/17/10. Further review revealed no documented evidence of certification in aggressive behavior training as required by the MHT job description and hospital policy. Further review revealed no documented evidence of assessment of competency of MHT job duties.

MHT S28
Review of MHT S28's personnel file revealed a hire date of 09/06/10 with no documented evidence of hospital or psychiatric experience. Further review revealed no documented evidence of certification in aggressive behavior training as required by the MHT job description and hospital policy. Further review revealed no documented evidence of an assessment for competency prior to S28 performing direct patient care.

In a face-to-face interview on 11/09/10 at 7:55am, MHT S28 confirmed he had no hospital or psychiatric experience prior to coming to Crossroads Regional Hospital. He indicated he had 5 days of classroom instruction where he was taught "safety, fire hazards, the way to talk to patients, how to deal with patients, ways to grab and restrain patients, and was shown around the unit". He further indicated after those 5 days, he followed another MHT for 3 shifts, then he was on his own.

In a face-to-face interview on 11/05/10 at 12:30pm, Administrator S1 confirmed that no current employee was certified in aggressive behavior training. She could offer no explanation regarding why this was not done, since the job descriptions and policies required certification in either STEPS or aggressive behavior training.

In a face-to-face interview on 11/09/10 at 11:15am, Chairman of the Board S32, when informed of new employees and agency nursing personnel with no documented evidence of orientation, assessment of competency, and certification in aggressive behavior training, indicated he was not aware that there were no current staff who were trained in non-crisis prevention interventions. He could offer no explanation for Administrator S1 being documented as the certified STEPS instructor for classes that were held when she was not currently certified and was not present at the class as confirmed by staff interviews.

See policy review of "Staff Development - Inservice", "Plan for the Provision of Patient Care - 2008", "Initial Employment Period", and "Performance Evaluations" policies listed above.

4) 2 of 2 contract Agency A RNs' personnel files reviewed from a total of 39 nurses' from Agency A (the list did not indicate whether the nurse was a RN or a LPN) with no documented evidence of orientation, training, assessment for determination of competency (S20, S30) and 1 of the 2 RNs had no documented evidence of psychiatric experience (S30):

Review of RN S20's (from Agency A) personnel file revealed a packet titled "Orientation Of Nursing Agency Personnel" that included the following topics: confidentiality; ethical issues; maintaining a professional relationship; fire safety and security; fire safety/rules for the prevention of fires; safety; emergency codes; infection control; reporting of unusual occurrences; patient rights; documentation charting checklist; documentation don'ts; EMTALA (emergency medical treatment and active labor act); patient abuse and neglect; seclusion and restraint. The packet was signed by RN S20 and Administrator S1 (who is not a nurse) on 10/17/10. Further review of the personnel file revealed no documented evidence of a job description, certification in aggressive behavior training as required by hospital policy, and evaluation to assess the effectiveness of job performance as required by hospital policy.

Review of RN S30's (from Agency A) personnel file revealed a packet titled "Orientation Of Nursing Agency Personnel" that included the following topics: confidentiality; ethical issues; maintaining a professional relationship; fire safety and security; fire safety/rules for the prevention of fires; safety; emergency codes; infection control; reporting of unusual occurrences; patient rights; documentation charting checklist; documentation don'ts; EMTALA (emergency medical treatment and active labor act); patient abuse and neglect; seclusion and restraint. The packet was signed by RN S30 on 10/20/10 and Staff Development Coordinator S4 on 10/20/10. Further review of the personnel file revealed no documented evidence of a job description, certification in aggressive behavior training as required by hospital policy, and evaluation to assess the effectiveness of job performance as required by hospital policy.

In a face-to-face interview on 11/09/10 at 8:30am, RN S30 with Agency A indicated she had been a RN for 10 years, and her experience was in ICU (intensive care unit). She further indicated she had no experience in caring for psychiatric patients. S30 indicated when she arrived for her first shift, she was given a thick packet of orientation material to sign, she was not asked to see her nursing license, and then she was "thrown to the wolves". She further indicated she had to call for assistance, because she had 2 admits and had no knowledge of the paperwork. She confirmed she was the only RN assigned to the unit. S30 indicated when she worked the day shift, she received assistance from the LPN (licensed practical nurse) when she had 6 to 7 discharges to complete and one admit towards the end of the shift. S30 indicated she has had no interaction as a nurse with the DON since beginning as an agency nurse at the hospital, and she had never seen or signed an evaluation of her performance.

Review of the hospital policy titled "Temporary Agency Personnel", revised 02/04/03 and submitted by Administrator S1 as their current policy for use of agency personnel, revealed, in part, "...Purpose: To describe a system for ensuring appropriate licensure, orientation and evaluation of the performance of agency personnel. ... Procedure: A. When a facility utilizes outside registry personnel the following items must be immediately availa

Based on record review and interview the hospital failed to ensure all non-employee personnel was supervised by a hospital employee as evidenced by assigning the charge nurse duty (and only Registered Nurse on the unit) to agency nurses for 44 of 180 shifts during the time period of 10/19/10 through 11/07/10. Findings:

Review of the Patient/Charting Assignment sheets submitted by Director of Nursing (DON) S2 for the time period of 10/19/10 through 11/07/10 for all hospital units revealed the following shifts which agency nurses were assigned as the charge (and only) nurse on the unit:
Male Adolescent/Children's Unit
10/19/10 (7a-3p shift), 10/23/10 (3p-11p shift) and (11p-7a shift), 10/24/10 (7a-3p shift), 10/26/10 (None of the shifts had been documented on the assignment sheets; however one shift was staffed with an agency nurse), 10/28/10 (11p-7a shift), 10/29/10 (None of the shifts had been documented on the assignment sheets; however one shift was staffed with an agency nurse), 10/30/10 (7a-3p, 3p-11p, 11p-7a shifts), 10/31/10 (7-3 and 3p-11p shifts), 11/01/10 (11p-7a shift), 11/03/10 (11p-7a), 11/04/10 (11p-7a shift), 11/06/10 (3p-11p shift), 11/07/10 (None of the shifts had been documented on the assignment sheets; however one shift was staffed with a nurse who was not listed on the list for Agency A or B or the hospital's present roster of full-time or PRN employees).
Female Adolescent/Children's Unit
10/19/10 ((None of the shifts had been documented on the assignment sheets; however one shift was staffed with a nurse who was not listed on the list for Agency A or B or the hospital's present roster of full-time or PRN employees), 10/20/10 (None of the shifts had been documented on the assignment sheets; however one shift was staffed with an agency nurse), 10/22/10 (7a-3p, 3p-11p, 11p-7a shifts), 10/23/10 (None of the shifts had been documented on the assignment sheets; however one shift was staffed with an agency nurse), 10/24/10 (None of the shifts had been documented on the assignment sheets; however two shifts were staffed with an agency nurse), 10/27/10 (11p-7a shift), 10/29/10 (3p-11p shift), 10/30/10 (7a-3p, 3p-11p, 11p-7a shifts), 10/31/10 (11p-7a shift), 11/01/10 (3p-11p, 11p-7a shifts), 11/02/10 (7a-3p), 11/04/10 (11p-7a shift), 11/05/10 (11p-7a), 11/06/10 (7a-3p, 3p-11p, 11p-7a shifts), and 11/01/10 (11p-7a shift).
Adult Unit
10/22/10 (7a-3p shift), 10/27/10 (11p-7a), 10/29/10 (7a-3p shift), 10/31/10 (3p-11p shift), and 11/07/10 (11p-7a shift).

Review of the Position Control Report submitted by the hospital as currently the one being used for staffing revealed the following: eight full-time RNs employed by the hospital to cover approximately 180 shifts for the period of 10/19/10 through 11/07/10.

In a face-to-face interview on 11/09/10 at 3:10pm, Administrator S1 indicated she did not know that agency nurses could not be the charge nurse on the unit.

Based on observations, record reviews, and interviews, the hospital failed to ensure the hospital environment was maintained in a manner to assure the safety and well-being of patients as evidenced by: 1) failing to implement interventions regarding the six foot chain link fence surrounding the South Wing Courtyard (Adult Unit) once it was identified by the hospital as an elopement risk, which contributed to the elopement of 6 patients in a 12 month period; 2) failing to maintain two trees located in the Boy's Unit outdoor area resulting in two large trees with thick limbs protruding over the ten foot chain link fence which could enable a child to climb the tree over the fence as a means of elopement; 3) failing to repair a hole in the wall with a temporary thermostat placed in the hole in the little boys dayroom; 4) failing to repair the carpet in Room "a" that had three raised areas that posed a fall hazard; and 5) failing to maintain the gym to ensure safety of patients by having electrical outlets without safety plugs, missing pieces of carpet that posed a threat for falls, and airflow vents with a thick buildup of dust. Findings:

1) Failing to implement interventions regarding the six foot chain link fence surrounding the South Wing Courtyard (Adult Unit) once it was identified by the hospital as an elopement risk, which contributed to the elopement of 6 patients in a 12 month period:
Observation on 11/01/10 at 9:20am in the presence of Administrator S1 revealed an outdoor area off the patio area surrounded by a six foot chain link fence.

In a face-to-face interview on 11/04/10 at 9:30am, Director of Nursing S2 confirmed the height of the fence could be a means of elopement after being brought to her attention by the surveyor.

Review of the Performance Improvement (PI) Statistical data for 08/10 through 07/10 revealed 6 documented elopements in a10 month period all occurring in the outdoor area of the adult unit. Review of the PI Meeting minutes dated 01/25/10 revealed the information had been sent to the Governing Body for corrective action.

Review of the Governing Body Meeting Minutes revealed no documented evidence a meeting had been held before September 15, 2010.

In a face-to-face interview on 11/10/10 at 9:35am, Quality/Risk Manager S3 indicated the quarterly meeting were scheduled for 03/11/10 and 06/10/10; however no members of the Governing Body showed up for the meetings.

Review of the hospital policy titled "Hazardous Condition - Authority to Act", reviewed 01/22/03 and contained in the hospital policy and procedure manual presented by Administrator S1 as their current policies and procedures, revealed, in part, "...It is the responsibility of every hospital employee to watch for hazardous conditions and to respond appropriately. Procedure: ...2. Report hazard to the Maintenance Department. 3. It is then the responsibility of the Director of Maintenance to remedy the hazard in an expeditious manner ...".

2) Failing to maintain two trees located in the Boy's Unit outdoor area resulting in two large trees with thick limbs protruding over the ten foot chain link fence which could enable a child to climb the tree over the fence as a means of elopement:
Observation on 11/09/10 at 10:05am of the outdoor area of the male adolescent/children's unit revealed 2 large trees with thick limbs protruding beyond the top of the fence. Further the tree limbs were at a height accessible to some male patients and could be used as a means of elopement.

In a face-to-face interview on 11/09/10 at 10:10am, Administrator S1 and Risk Manager S3 both confirmed the tree could be used as a means of elopement and needed to be cut.

Review of the hospital policy titled "Hazardous Condition - Authority to Act", reviewed 01/22/03 and contained in the hospital policy and procedure manual presented by Administrator S1 as their current policies and procedures, revealed, in part, "...It is the responsibility of every hospital employee to watch for hazardous conditions and to respond appropriately. Procedure: ...2. Report hazard to the Maintenance Department. 3. It is then the responsibility of the Director of Maintenance to remedy the hazard in an expeditious manner ...".

3) Failing to repair a hole in the wall with a temporary thermostat placed in the hole in the little boys dayroom:
Observation of the little boys' dayroom on 11/04/10 at 9:40am, with Administrator S1 present, revealed a hole in the wall to the left of the door with a temporary thermostat about 4 feet from the floor.

In a face-to-face interview on 11/04/10 at 9:40am, Administrator S1 indicated the thermostat should not be placed in an open hole in the wall.

Review of the hospital policy titled "Hazardous Condition - Authority to Act", reviewed 01/22/03 and contained in the hospital policy and procedure manual presented by Administrator S1 as their current policies and procedures, revealed, in part, "...It is the responsibility of every hospital employee to watch for hazardous conditions and to respond appropriately. Procedure: ...2. Report hazard to the Maintenance Department. 3. It is then the responsibility of the Director of Maintenance to remedy the hazard in an expeditious manner ...".

Review of the hospital policy titled "Patient Room Inspection", reviewed 01/22/03 and contained in the hospital policy and procedure manual presented by Administrator S1 as their current policies and procedures, revealed, in part, "Items listed below are to be checked monthly by personnel on Environmental Rounds. Maintenance requisitions will be made on deficiencies and logged when repaired. Procedures 1. Check for air conditioning and heating for operation, loose covers and temperature ...".

4) Failing to repair the carpet in Room "a" that had three raised areas that posed a fall hazard:
Observation of Room "a" on 11/04/10 at 10:00am, with Administrator S1 present, revealed the carpet with three areas that were raised due to buckling.

In a face-to-face interview on 11/04/10 at 10:00am, Administrator confirmed the raised carpeting posed a fall threat to patients.

Review of the hospital policy titled "Patient Room Inspection", reviewed 01/22/03 and contained in the hospital policy and procedure manual presented by Administrator S1 as their current policies and procedures, revealed, in part, "Items listed below are to be checked monthly by personnel on Environmental Rounds. Maintenance requisitions will be made on deficiencies and logged when repaired. Procedures ... 7. Check walls, floors and ceiling for integrity".
.
5) Failing to maintain the gym to ensure safety of patients by having electrical outlets without safety plugs, missing pieces of carpet that posed a threat for falls, and airflow vents with a thick buildup of dust:
Observation of the gym on 11/09/10 at 5:30pm, with Activity Therapist S10 present, revealed the electrical outlets did not have safety plugs. Further observation revealed the carpet had missing pieces of carpet that resulted in different floor levels that could result in a fall when patients ran over the area while playing basketball. Further observation revealed the airflow vents had a thick buildup of dust.

In a face-to-face interview on 11/09/10 at 5:30pm, Activity Therapist S10 confirmed the above findings.

Review of the hospital policy titled "Patient Room Inspection", reviewed 01/22/03 and contained in the hospital policy and procedure manual presented by Administrator S1 as their current policies and procedures, revealed, in part, "Items listed below are to be checked monthly by personnel on Environmental Rounds. Maintenance requisitions will be made on deficiencies and logged when repaired. Procedures 1. Check duplex outlets for broken and loose covers and loose female plugs. ...7. Check walls, floors and ceiling for integrity".

Review of the hospital policy titled "Hazardous Condition - Authority to Act", reviewed 01/22/03 and contained in the hospital policy and procedure manual presented by Administrator S1 as their current policies and procedures, revealed, in part, "...It is the responsibility of every hospital employee to watch for hazardous conditions and to respond appropriately. Procedure: ...2. Report hazard to the Maintenance Department. 3. It is then the responsibility of the Director of Maintenance to remedy the hazard in an expeditious manner ...".

Based on observation, record review, and interview, the hospital failed to meet the Condition of Participation of Special Provisions Applying to Psychiatric Hospitals by:

failing to be in compliance with the hospital Conditions of Participation specified in ?482.1 through ?482.23 by failing to meet the CoP of Patient Rights at ?482.13 and the CoP of Nursing Services at ?482.23. (See findings at Tag A0115 and A0385)

Based on observation, record review, and interview, the Psychiatric hospital failed to meet the Conditions of Participation specified in ?482.1 through ?482.23 by failing to be in compliance with the Hospital's Condition of Participation requirements for Patient Rights at ?482.13 and Nursing Services at ?482.23.

Based on record review, interview and observations, the hospital failed to meet the Condition of Participation for Psychiatric Hospital's Special Staffing requirements specified in ?482.62. (See findings at Tag B0150 and B0158)

Based on record review and interview the hospital failed ensure an individualized inventory of the patient's assets as evidenced by utilizing the same standard checklist for all adolescent and child patients for 9 of 9 medical records reviewed for assets (Patients #2, #3, #4, #6, #7, #10, #11, #12, #13) of a total of 13 sampled medical records. Findings:

Review of the form titled Psychiatric Evaluation Child/Adolescent" used by all of the credentialed psychiatrists practicing at this hospital revealed under the section "Assets" which all adolescent's and children's are individually evaluated using the same twelve assets are as follows: hobbies, physically intact, good social skills, accepts need for treatment, supportive social network, sports, average IQ, ambitions, capable of insight, supportive family, good positive job and school success.

Patient #2
Review of the medical record for Patient #2 revealed an eight year old male admitted on 11/06/10 with a diagnosis of Impulse Control Disorder and ADHD (Attention Deficit Hyperactive Disorder) with Borderline Intellectual Functioning. Review of the Psychiatric Evaluation performed by MD S35 on 1/07/10 at 1930 (7:30pm) revealed..... "Assets: The patient has the following assets which will aid in the treatment process: (The following were circled) hobbies, physically intact, and supportive family.

Patient #3
Review of the medical record for Patient #3 revealed a 13 year old male admitted on 11/02/10 with the diagnosis of Intermittent Explosive Disorder and Oppositional Defiant Disorder, Mood Disorder. Review of the Psychiatric Evaluation performed by MD S34 on 11/03/10 at 0630 (6:30am) revealed..... "Assets: The patient has the following assets which will aid in the treatment process: (The following were circled) hobbies, physically intact, accepts need for treatment, sports, average IQ, Ambition, Capable of Insight, and School Success.

Patient #4
Review of the medical record for Patient #4 revealed a seven year old male admitted on 11/03/10 with the diagnosis of Intermittent Explosive Disorder, Oppositional Defiant Disorder and a history of ADHD. Review of the Psychiatric Evaluation performed by MD S34 on 11/04/10 at 0700 (7:00am) revealed..... "Assets: The patient has the following assets which will aid in the treatment process: (The following were circled) hobbies, physically intact, accepts need for treatment, sports, average IQ, ambition, capable of insight, supportive family and school success.

Patient #6
Review of the medical record for Patient #6 revealed a ten year old male admitted to the hospital on 11/04/10 with the diagnosis of Intermittent Explosive Disorder, Oppositional Defiant Disorder and a history of ADHD. Review of the Psychiatric Evaluation performed by MD S36 on 11/04/10 (No time documented) revealed..... "Assets: The patient has the following assets which will aid in the treatment process: (The following were circled) hobbies, physically intact, accepts need for treatment, sports, average IQ, ambition, and capable of insight.

Patient #7
Review of the medical record for Patient #7 revealed a 16 year old male admitted to the hospital on 10/11/10 with the diagnosis of Psychotic Disorder, rule out Cannibus Induced Psychotic Disorder with Hallucinations. Review of the Psychiatric Evaluation performed by MD S36 on 10/12/10 (No time documented) revealed..... "Assets: The patient has the following assets which will aid in the treatment process: (The following were circled) physically intact, average IQ, ambition, and supportive family.

Patient #10
Review of the medical record for Patient #10 revealed a ten year old male admitted to the hospital on 10/18/10 with the diagnosis of Intermittent Explosive Disorder, Chronic Depression, history of ADHD, and rule out Cannibus Use Disorder. Review of the Psychiatric Evaluation performed by MD S36 on 10/19/10 (No time documented) revealed..... "Assets: The patient has the following assets which will aid in the treatment process: (The following were circled) hobbies, physically intact, sports, and ambition.

Patient #11
Review of the medical record for Patient #11 revealed an eleven year old male admitted to the hospital on 10/22/10 with the diagnosis of Major Depressive Disorder. Review of the Psychiatric Evaluation performed by MD S34 on 10/23/10 at 12 noon revealed..... "Assets: The patient has the following assets which will aid in the treatment process: (The following were circled) hobbies, physically intact, accepts the need for treatment, sports, average IQ, ambition, capable of insight, supportive family, and school success.

Patient #12
Review of the medical record for Patient #12 revealed a ten year old male admitted to the hospital on 10/20/10 with the diagnosis of Intermittent Explosive Disorder, rule out Intermittent Explosive Disorder, Oppositional Defiant Disorder, and a history of ADHD. Review of the Psychiatric Evaluation performed by MD S36 on 10/20/10 (No time documented) revealed..... "Assets: The patient has the following assets which will aid in the treatment process: (The following were circled) hobbies, average IQ, ambition, capable of insight and supportive family.

Patient #13
Review of the medical record for Patient #13 revealed a 16 year old female admitted to the hospital on 09/29/10 with the diagnosis of Intermittent Explosive Disorder. Review of the Psychiatric Evaluation performed by MD S35 on 09/29/10 2210 (9:10pm) revealed..... "Assets: The patient has the following assets which will aid in the treatment process: (The following were circled) hobbies, physically intact, good social skills, accepts need for treatment, average IQ, ambition, capable of insight and school success.

In a face to face interview on 11/09/10 at 10:15am the Director of Nursing S2 could offer no explanation as to why individual assets were not being used to assess strengths for patient's treatment plans.

Based on record review and interview the hospital failed to ensure the treatment plan included measurable goals for 6 of 6 patients reviewed for treatment plans (Patient #3, #5, #7, #8, #10, #13) out of 13 sampled medical records. Findings:

Patient #3
Review of the medical record for Patient #3 revealed a thirteen year old male admitted to the hospital on 11/02/10 with the diagnoses of Intermittent Explosive Disorder and Oppositional Defiant Disorder. Review of the Initial Treatment Plan dated 11/02/10 revealed the following short term goals: Patient will develop alternative methods of expressing angry feelings; be in classroom for maintenance of subjects on grade level; and no harm to others while at the hospital. Review of the medical record revealed no documented evidence the goals had been attained before discharge or any changes had been made to the treatment plan during Patient #3's hospital admission.

Patient #5
Review of the medical record for Patient #5 revealed a nine year old male admitted to the hospital on 11/05/10 with the diagnoses of Depression and Suicidal Ideation. Review of the Initial Treatment Plan dated 11/05/10 revealed the following short term goal: patient will develop alternative methods of expressing angry feelings; be in classroom for maintenance of subjects on grade level; and no harm to others while at the hospital. Review of the medical record revealed no documented evidence the goals had been attained before discharge or any changes had been made to the treatment plan during Patient #3 ' s hospital admission.

Patient #7
Review of the medical record for Patient #7 revealed a sixteen year old male admitted on to the hospital on 10/11/10 with the diagnosis of sever Psychosis. Review of the Initial Treatment Plan dated 10/11/10 revealed the following short term goal: Patient will not harm self or others while at the hospital. Review of the medical record revealed no documented evidence the goals had been attained before discharge or any changes had been made to the treatment plan during Patient #7 ' s hospital admission.

Patient #8
Review of the medical record for Patient #8 revealed a sixteen year old male admitted on to the hospital on 11/03/10 with the diagnoses of Depression and cutting himself. Review of the Initial Treatment Plan dated 11/03/10 revealed the following short term goals: Patient will not harm self or others while at the hospital. Review of the medical record revealed no documented evidence the goals had been attained before discharge or any changes had been made to the treatment plan during Patient #8 ' s hospital admission.

Patient #10
Review of the medical record for Patient #10 revealed a10 year old male admitted to the hospital on 10/18/10 with the diagnoses of Aggression and Intermittent Explosive Disorder. Review of the Initial Treatment Plan dated 10/18/10 revealed the following short term goals: Patient will develop alternative methods of expressing angry feelings; Maintain skill and concept level with practice; and No harm to others while at the hospital. Review of the medical record revealed no documented evidence the goals had been attained before discharge or any changes had been made to the treatment plan during Patient #10 ' s hospital admission.

Patient #13
Review of the medical record for Patient #13 revealed a sixteen year old female admitted to the hospital on 09/29/10 with the diagnoses of Depression and Suicidal Ideation. Review of the Initial (and only) Treatment Plan dated 09/29/10 revealed the following short -term goals: maintain skill and concept level practice and will not harm self or others during stay in hospital. Review of the medical record revealed no documented evidence the goals had been attained before discharge or any changes had been made to the treatment plan during Patient #10 ' s hospital admission.

Review of Policy No. AS-00-011 titled " Assessment and Treatment of Patients " last revised 01/09/08 and submitted as the one currently in use revealed no documented evidence the goals (short or long term) were to be written as to be measured.

In a face to face interview on 11/09/10 at 10:15am the Director of Nursing S2 could offer no explanation as to why the nursing staff failed to develop measurable goals. Further she indicated this information has been discussed on numerous times; however she confirmed the hospital did not perform any chart audits which would have identified this problem.

Based on record review and interview the hospital failed to ensure the treatment plan included specific activities measurable goals for 5 of 5 patients reviewed for treatment plans (Patient #3, #5, #7, #10, #13) out of 13 sampled medical records. Findings:

Patient #3
Review of the medical record for Patient #3 revealed a thirteen year old male admitted to the hospital on 11/02/10 with the diagnoses of Intermittent Explosive Disorder and Oppositional Defiant Disorder. Review of the Psychiatric Evaluation dated 11/03/10 under the section " Initial Treatment Plan " revealed .... " The patient will have the following treatment modalities while in the hospital: Family Therapy, Individual Therapy, Group Therapy and Recreational Therapy. " Further review of the medical record revealed no documented evidence the specific focus for the patient had been included.

Patient #5
Review of the medical record for Patient #5 revealed a nine year old male admitted to the hospital on 11/05/10 with the diagnoses of Depression and Suicidal Ideation. Review of the Psychiatric Evaluation dated 11/07/10 under the section " Initial Treatment " revealed ... " The patient will have the following treatment modalities while in the hospital: Family Therapy, Individual Therapy, Group Therapy and Recreational Therapy. " Further review of the medical record revealed no documented evidence the specific focus for the patient had been included.

Patient #7
Review of the medical record for Patient #7 revealed a sixteen year old male admitted on to the hospital on 10/11/10 with the diagnosis of sever Psychosis. Review of the Psychiatric Evaluation dated 10/12/10 under the section " Initial Treatment " revealed ... " The patient will have the following treatment modalities while in the hospital: Family Therapy, Individual Therapy, Group Therapy, Recreational Therapy, Family/Patient Education and Medication Management by the attending physician. " Further review of the medical record revealed no documented evidence the specific focus for the patient had been included.

Patient #10
Review of the medical record for Patient #10 revealed a10 year old male admitted to the hospital on 10/18/10 with the diagnoses of Aggression and Intermittent Explosive Disorder. Review of the Psychiatric Evaluation dated 10/19/10 under the section " Initial Treatment Plan " revealed " The patient will have the following treatment modalities while in the hospital: Family Therapy, Individual Therapy, Group Therapy, Recreational Therapy, Family/Patient Education and Medication Management by the attending physician. " Further review of the medical record revealed no documented evidence the specific focus for the patient had been included.

Patient #12
Review of the medical record for Patient #12 revealed a ten year old male admitted to the hospital on 10/19/10 with the diagnoses of Intermittent Explosive Disorder and Oppositional Defiant Disorder. Review of the Psychiatric Evaluation dated 10/21/10 under section titled " Initial Treatment Plan " revealed .... " The patient ' s treatment modalities will include: family therapy, individual therapy, recreational therapy, group therapy, family/patient education and medication management by the attending physician " . Further review of the medical record revealed no documented evidence the specific focus for the patient had been included.

In a face to face interview on 11/09/10 at 10:15am the Director of Nursing S2 could offer no explanation as to why the nursing staff failed to develop measurable goals. Further she indicated this information has been discussed on numerous times; however she confirmed the hospital did not perform any chart audits which would have identified this problem.

Based on record review and interview the hospital failed to ensure the nursing progress notes included the patient' s progress according to the treatment plan treatment plan 6 of 6 patients reviewed for treatment plans (Patient #2, #7, #13) for 3 of 3 treatment plans reviewed out of 13 sampled medical records. Findings:

Patient #2
Review of the medical record for Patient #2 revealed an eight year old male admitted to the hospital on 11/06/10 with the diagnosis of Intermittent Explosive Disorder. Further review of the medical record revealed no documented evidence the Initial Treatment Plan had been implemented for Patient #2.

Review of the Quality/Risk Management Report of Event form dated 11/07/10 1930 (7:30pm) revealed a 3x5cm abrasion was located on the left lateral thigh of Patient #2 when the patient was showered. Further review revealed the patient indicated the injury happened in the gym, but could offer no details.

Review of the Quality/Risk Management Report of Event form dated 11/08/10 0650 (6:50am) revealed Patient #2 was heard crying and stated that a peer had kicked him while both of the children had an order to be under continuous visual contact.

Review of the Initial Treatment Plan dated 10/11/10 revealed no documented evidence the Initial Treatment Plan had been initiated as of 11/08/10 at 10:000am.


Patient #7
Review of the medical record revealed Patient #7 a 16 year old male admitted to the hospital on 10/11/10 with the diagnosis of severe Psychosis. Review of the Initial Treatment Plan dated 10/11/10 revealed Patient #7 was unable to perform hygiene ADLs (Activities of Daily Living) and was a threat to himself and others due to his altered mental status and severe paranoia.

Review of the Quality/Risk Management Report of Event dated/timed 10/13/10 at 11:30 (AM/PM not documented) revealed Patient #7 had been agitating other patients and when the boys went outside one of the boys punched him three times.

Review of the Multidisciplinary Progress Notes dated 10/13/10 revealed the patient had been agitating his peers and was punched in the mouth, did not appear hurt and refused treatment.

Review of the Initial Treatment Plan dated 10/11/10 revealed no documented evidence of any changes to the plan even though the ones documented (monitor mood, behavior and safety) failed to keep him safe.


Patient #13
Review of the medical record for Patient #13 revealed a sixteen year old female admitted to the hospital on 09/29/10 with the diagnoses of Depression and Suicidal Ideation. Review of the Initial Treatment Plan dated 09/29/10 revealed nursing identified #13 ' s problem as a potential to harm herself or others.

Review of the Quality/Risk Management Report of Event dated/timed 09/29/10 at 2320 (11:20pm) Patient #13 had attempted suicide by placing a sheet through the curtain and then around her neck.

Review of the Initial Treatment Plan dated 09/29/10 revealed no documented evidence of any changes to the plan even though #13 had been placed on 2:1 (two staff members to one patient) observations and the previous interventions of provide a safe and therapeutic environment had proven to be ineffective.

Review of Policy No. AS-00-011 titled " Treatment Planning and Review Process " last revised 01/09/08 and submitted as the one currently in use, revealed .... " The Initial Treatment Plan will be completed within 24 hours of admission and functions as the Preliminary Treatment Plan in directing treatment interventions towards resolution of identified problems ..... When indicated, the plan of care and treatment goals may be revised. The appropriate discipline(s) shall note changes in interventions, goals, objectives and other components of the plan of care and document actions on the Master-Treatment plan by the designated scribe " .

In a face to face interview on 11/08/10 at 2:00pm Director of Nursing S2 indicated chart reviews were not performed at present.

Based on record review and interview the hospital failed to follow their staffing policy as evidenced by failing to staff an LPN for 21 of 180 shifts resulting in one Registered Nurse having to perform all nursing care on his/her assigned unit for as many as 16 patients. Findings:

Review of the "Patient/Charting Assignment" sheets submitted by the Director of Nursing (DON) RN S2 revealed the following shifts which did not have an LPN (Licensed Practical Nurse) assigned according to the policy and procedure for staffing:
Adult Unit
10/19/10 (11p-7a shift) with a census of 13 patients; 10/20/10 (11p-7a shift) with a census of 14 patients; 10/21/10 (7a-3p shift) with a census of 12 patients; 10/22/10 (3p-11p shift) with a census of 14 patients and the (11p-7a shift) with a census of 11 patients; 10/23/10 (11p-7a shift) with a census of 15 patients; 10/24/10 (11p-7a shift) with a census of 15 patients; 10/25/10 (11p-7a shift) with a census of 14 patients; 10/27/10 (11p-7a shift) with a census of 10 patients; 10/28/10 (3p-11p shift) with a census of 9 patients and the (11p-7a shift) with a census of 12 patients; 10/29/10 (11p-7a shift) with a census of 9 patients; 10/30/10 (7a-3p shift) with a census of 11 patients and the (3p-11p shift) with a census of patients; 11/03/10 (11p-7a shift) with a census of 12 patients; 11/04/10 (11p-7a shift) with a census of 16 patients; 11/05/10 (11p-7a shift) with a census of 14 patients; 11/06/10 (11p/7a shift) with a census of 14 patients; and 11/07/10 (11p-7a shift) with a census of 13 patients
Female Adolescent/Children's Unit
10/31/10 (11p-7a shift) with a census of 16 patients
Male Adolescent/Children's Unit
10/31/10 (7a-3p shift) with a census of 16 patients

Review of Policy No. TX.00.022 titled "Nursing Staffing and Patient Classification Acuity System" last revised 10/14/10 and submitted by the hospital as the one currently in use revealed an LPN would be assigned to the units with a census of 1-9 patients.

Review of the Position Control Report (List of Employees) submitted by the hospital as current and the one being used for scheduling of staff revealed 8 LPNs employed full time by the hospital to provide coverage for approximately 270 shifts per month. Also listed on the roster are 9 PRN (as needed) LPNs.

In a face to face interview on 11/05/10 at 10:00am DON RN S2 indicated the hospital has an LPN staffing coordinator who makes out the schedules and is responsible for calling the PRN and agency staff for filling in the staffing needs. The charge nurses are responsible for assessing the patient acuity, making the assignments and contacting the staffing coordinator if additional staff is required. Further S2 indicated it is her responsibility to review the acuity data daily.

Based on record review and interview the hospital failed to employ an adequate number of qualified therapists as evidenced by: 1) employing one college graduate in Kinesiology to perform the duties of a certified Activity Therapist; 2) having one full-time employee assigned to meet the needs of the hospital population which could include as many as 68 patients; 3) failing to perform an activity assessment on all patients (Patients #2, #5, #6, #12, #13) according to hospital policy and procedure for 5 of 13 sampled medical records; and 4) failing to provide recreational activities 7 days per week. Findings:

1) employing a college graduate in Kinesiology to perform the duties of a certified Activity Therapist;
Review of the Job Description titled "Activity Therapist" submitted by the hospital as the one currently in use, revealed the following position qualifications:
a. Must have a Bachelor's degree and certified in Activity Therapy.
b. Must have at least 6 months experience in Health Related Field.

Review of the personnel file for Activity/Recreational Therapist S10 revealed he graduated from college with a Bachelor's degree in Kinesiology, no previous hospital experience and no documentation of any certification in activity or recreational therapy.

In a face to face interview on 11/09/10 at 5:30pm Recreational Therapist S10 indicated he has been employed at the hospital for six months and has a degree in Kinesiology and Sports Management; however he is neither a certified or registered activity therapist. Further S10 indicated he had no previous experience working in health care.

2) having one full-time employee assigned to meet the needs of the hospital population which could include as many as 68 patients;
Review of the Position Control Report (Staffing Roster) as of October 31, 2010 submitted as the one currently in use revealed there were two full-time positions allocated for activity therapists, one position (no documentation specifying full-time or part-time for a Certified Recreational Therapist and one position (no documentation specifying full-time or part-time for a Lifeguard/Activity Therapist. Further review revealed a vacancy in the position for Activity Therapist (1); resignation accepted last Friday for Activity Therapist (2); S45 Recreational Therapist (3) and Lifeguard/Activity Therapist (4) no longer at the facility due to the pool being closed.

Review of Policy No. LD-00-003 titled "Plan for the Provision of Patient Care" , last revised 02/26/08 and submitted as the one currently in use revealed Recreational Therapy Services are provided seven (7) days a week throughout the hospital. The services provided are 1. Evaluation of each service. 2. Scheduled therapy for selected services. 3. Group sessions

In a face to face interview on 11/09/10 at 5:30pm Recreational Therapist S10 verified he is the only Recreational/Activity Therapist employed by the hospital at the present time. S10 indicated he was aware recreational therapy was supposed to be provided on the weekend; however, Social Services Director S14 instructed him to complete all assessments first and then provide at least one group activity per day.

3) failing to perform an activity assessment on all patients (Patients #2, #5, #6, #7) according to hospital policy and procedure;
Patient #2
Review of the medical record for Patient #2 revealed an eight year old male admitted to the hospital on 11/06/10 with the diagnosis of Intermittent Explosive Disorder. Further review of the record revealed no documented evidence an " Activity and Recreational Therapy " assessment had been performed.

Patient #5
Review of the medical record for Patient #5 revealed a nine year old male admitted to the hospital on 11/05/10 with the diagnosis of Depression and Suicidal ideation. Further review of the record revealed no documented evidence an " Activity and Recreational Therapy " assessment had been performed.

Patient #6
Review of the medical record for Patient #6 revealed a ten year old boy admitted to the hospital on 11/04/10 with the diagnosis of Intermittent Explosive Disorder. Further review of the record revealed no documented evidence an " Activity and Recreational Therapy " assessment had been performed.

Patient #7
Review of the medical record for Patient #7 revealed a sixteen year old boy admitted to the hospital on 10/11/10 with the diagnosis of Psychotic Disorders wand Hallucinations. Further review of the record revealed no documented evidence an " Activity and Recreational Therapy " assessment had been completed by discharge.

Patient #12
Review of the medical record for Patient #13 revealed a 10 year old male admitted to the hospital on 10/20/10 with the diagnoses of Depression. Further review of the record revealed no documented evidence an " Activity and Recreational Therapy " assessment had been completed by discharge.

Patient #13
Review of the medical record for Patient #13 revealed a sixteen year old female admitted to the hospital on 09/29/10 with the diagnosis of Manic Depressive Disorder with Severe Psychosis. Further review of the medical record revealed an " Activity and Recreational Therapy " assessment had been initiated on 09/30/10; however it had not been completed.

In a face to face interview on 11/09/10 at 5:30pm Recreational Therapist S10 indicated it was difficult to be the only one in the department and perform assessments, recreational groups, and plan and monitor activities performed in the activity room; however, Social Services Director S14 gave him the instructions to complete all assessments first and then provide at least one group activity per day

Review of Policy No. AS-00-001 titled " Assessments, Initial Screening and Other " , last date of revision 07/21/06 and submitted as the one currently in use revealed .... " The Activities Therapist will complete the Activities Therapy Assessment within 72 hours after admission. "

4) failing to provide recreational activities 7 days per week.
Review of the Adolescent/Children Schedule revised 06/14/10 of the revealed a time schedule of activities from 6:00am through 9:00pm. Further review revealed no documented evidence of any planned activities on the weekend.

In a face to face interview on 11/09/10 at 4:35pm Director of Social Services S14 verified she has the responsibility for the Recreation/Activity Department and indicated the hospital has lost all but one therapist. S14 indicated there is no scheduled activity on the weekend; however the MHT (Mental Health Techs) are asked to provide a recreational activity on the weekend.

In a face to face interview on 11/09/10 at 5:30pm Recreational Therapist S10 verified he is the only Recreational/Activity Therapist employed by the hospital at the present time. Further he indicated he is not allowed to work overtime so there is no way he can provide activities to the patients on the weekend.