HospitalInspections.org

The Condition of Participation is not met as:

Based on observation, interview, and record review, the hospital's Governing Body (GB) failed to assume full legal responsibility for implementing, and monitoring policies governing the hospital's total operation, and provide oversight for quality health care in a safe environment as follows:

1. On 09/20/21, at 5:25 p.m., Immediate Jeopardy (IJ) was declared as:
The hospital failed to ensure patient's bathrooms did not have toilets with a metal stick flush handle which was a potential ligature risk (anything that can be used to attach a cord, rope, or other material for the purpose of hanging or strangulation) in all their four units, Hillside, Mountain View, Ocean view and Seaside. (Cross Reference A-0000 and A-0701).

2. On 9/21/22, at 4:28 p.m.., a second Immediate Jeopardy (IJ) was declared when the hospital failed to ensure patients were properly informed before taking psychotropic medications for 30 out of 36 patients that were currently in the hospital. (Cross Reference A-0000 and A-0398).

3. The hospital's GB failed to have a system in place to provide oversight to ensure physicians followed Medical Staff Bylaws and policies and procedures (P&P).(Cross Reference A-0049).

4. The hospital failed to document that it's Governing Body had appointed the hospital chief executive officer (CEO). The deficient practice had the potential to allow the facility's parent organization to not benefit from the Governing Body's authority over the hospital. (Cross Reference A-0057).

5. The GB failed to ensure the contracted services provided in the hospital were evaluated to ensure compliance with the Conditions of participation (COP) requirements. (Cross Reference A-0083).

6. The GB failed to ensure the contracted services provided in the hospital were evaluated for safety and effectiveness. This failure created the increased risk of substandard services being provided. (Cross Reference A-0084).

7. The hospital failed to implement patient rights in accordance with acceptable standards of practice, and hospital P&P. These failures resulted in the hospital not meeting the Condition of Participation (COP) for Patient Rights (Cross Reference A-0115) as follows:

a. A Patient was pronounced dead after being found on the floor, unresponsive, face blue in color and barely breathing with a bed linen sheet wrapped around his neck and the sheet was tied to the toilet.
(Cross Reference A-0144).

b. Two patients were discharged AMA (against medical advice) prior to the expiration or discontinuation of their 5150 holds (legal 72 hour involuntary hold for patient because they are a danger to themselves, others, or gravely disabled). (Cross Reference A-0144).

c. Five patients were physically restrained (preventing movement of body and limbs) and/or placed in seclusion (confining a person in a room preventing free exit), without obtaining a physician's order. (Cross Reference A-0168)

d. Two patients were physically restrained and/or placed in seclusion longer than the physician ordered. (Cross Reference A-0171)

e. Five patients did not receive a face-to-face examination within one hour of being placed in restraints and/or seclusion. (Cross Reference A-0178)

8. The hospital failed to ensure its GB, medical staff, and administrative officials were responsible and accountable for ensuring that specific Quality and Performance Improvement (QAPI) program requirements were met, when the hospital failed to have on-going program for quality improvement that was defined, implemented, and maintained. (Cross Reference A-0263) when:

a. The hospital failed to ensure its GB, medical staff, and administrative officials were responsible and accountable for ensuring that an on-going program for patient safety included the reduction of medical errors, was defined, implemented and maintained. (Cross Reference A-0309).

b. The hospital failed to ensure its GB, medical staff, and administrative officials were responsible and accountable for ensuring that adequate resources were allocated for measuring, assessing, improving and sustaining the hospital's performance. (Cross Reference A-0315).

9. The hospital failed to ensure nursing services were provided in a safe manner when hospital P&Ps were not followed, and the Nursing Services Condition of Participation (COP) requirements were not met (Cross Reference A-0385), when:

a. Nursing progress notes, intake assessments, and nursing admission assessments were missing, incomplete and/or inaccurate. Against medical Advice (AMA) forms were missing for several patients and hospitals designated comfort rooms were also used as seclusion rooms. (Cross Reference A-0398).

b. Psychotropic medication consent forms were incomplete and missing for 23 patients. (Cross Reference A-0000 and Cross Reference A-0398).

10. The Hospital failed to ensure a safe environment when the Physical Environment Condition of Participation (Cross Reference A-0700) requirements were not met when:

a.Thirty-six (36) patients had access to the ligature risk which created an unsafe environment for which every patient in the hospital was affected. California Department of Public Health (CDPH) declared Immediate Jeopardy on 9/20/22, for the potential risk of every patient in the hospital to have access to a ligature risk thus endangering them. (Cross Reference A-0000, A-0701).

b. The hospital potentially exposed patients to unsanitary equipment that could result in cross-contamination.
(Cross Reference A-0724).

11. The hospital failed to ensure that each individual patient record contained information relative to the reason for the patient's admission, assessments, treatment plans interventions, and the treatment team member responsible for treatment modalities. Records also failed to include patient's response to interventions, and safe discharge planning. The Condition of Participation-Special Medical Record Requirements for Psychiatric Hospitals (Cross Reference A-1620) was not met when:

a. Psychosocial assessments were incomplete and not timely (Cross reference A-1625).

b. An individualized and comprehensive treatment plan was not developed for each patient within 72 hours of admission. (Cross reference A-1640)

c. The treatment plan did not include a substantiated diagnosis, upon which the treatment plan is based. (Cross reference A-1641)

d. The treatment plan did not include short term and long range goals with specific dates for achievement. (Cross reference A-1642)

e. The treatment plan did not include the treatment modalities to be used to treat the patient during hospitalization. (Cross reference A-1643)

f. The identification of members of the treatment plan responsible for particular aspects of the patient's care is not in the medical record. (Cross reference A-1644)

g. The medical record did not contain recommendations for revisions in the treatment plan.
(Cross reference A-1661)

h. The medical record did not contain information about discharge and after care planning. (Cross reference A-1671)

12. The Hospital failed to ensure a Special Staff Requirement's Condition of Participation (Cross Reference A-1680) was met when:

a. Patient active treatment programs were not provided. (Cross Reference A- 1687)
b. Discharge planning not provided. (Cross Reference A-1688)
c. Inadequate number of licensed nurses and mental health workers were provided to care for psychiatric patients. (Cross Reference A-1704)
d. Inadequate number of staff to provide therapeutic activities to patients. (Cross Reference A-1720)
e. Admission assessments not completed to ensure appropriate patient care. (Cross Reference A- 1726)

The cumulative effects of these systemic problems resulted in the hospital's inability to ensure the provision of quality patient care in a safe environment.

Based on interview and record review, the hospital's Governing Body (GB) failed to have a system and provide oversight to ensure physicians followed Medical Staff Bylaws and policies and procedures (P&P) when:

Psychotropic medication consent forms were incomplete or missing for 30 out of 33 sampled patients (N200, N201, N202, N203, N204, N205, N206, N100, N103, N106, N107, N600, N601, N602, N300, N301, N302, N303, N305, N306, N400, N401, N402, N403, N404, N405, N406) and 3 unsampled patients (35,36,37).

This failure placed the following at risk, patient safety, the quality of care rendered with the potential to contribute to poor patient outcomes for all admitted, in house patients receiving psychiatric care.


Findings:


During an observation, interviews, and record reviews on 9/21/11, starting around 9:50 a.m., 30 patients' consent forms were with missing elements ranging from the dosage or range of the medications, the frequency of the medications, the method of administration, and the probable duration of taking the medications.


During record review the physicians and patients' signatures were also missing from consent forms (signatures are an acknowledgment that the patients were informed about taking psychotropic medications and potential serious side effects). Consent forms were either missing and noted to be dated after the psychotropic medications had been ordered and given to the patients.


During multiple interviews conducted with the Quality Director (Admin 1) on 9/21/22, starting from 2:30 p.m., to 3:00 p.m., Administrator (Adm 1) acknowledged, elements (range, dose, frequency, signatures) were missing from the 30 patients' consent forms and it should have been there. Adm 1 further acknowledged, the consent forms were incomplete.


During a review of the facility's P&P titled, "Informed Consent for Medications, Treatments, and Procedures," dated 10/03, indicated, in part ..."The attending psychiatrist will be responsible for the informed consent procedure for psychotropic meds...the consent form must include the medication and dosage ranges...the informed consent procedure maybe done in person with the patient or by a 3-way phone conversation between the patient, physician and nurse and any family member for adolescent patients...this will be documented on the consent form prior to psychotropic meds being given."


Review of the hospital document titled, "Medical Staff Bylaws and Regulations," dated 12/29/20, indicated, in part...pg 3..."1.2 Purposes and Responsibilities. (a) To assure that all patients admitted or treated in any hospital services receive care at a level and efficiency consistent with generally accepted standards attainable within the hospital's means and circumstances..."pg 8 "Basic Responsibilities of Medical Staff Membership...(c) Abide by all applicable laws and regulations of governmental agencies and comply with applicable standards of the (hospital deeming agency)."

Based on interview and record review, the facility failed to ensure the Governing Body (GB) had documentation in place about hiring, appointment, and agenda for a hospital's chief executive officer (CEO).


This failure had the potential for the hospital operate without a CEO, or if a CEO is hired, there is no agenda in place as to the role the CEO will have on the hospital's day to day operation.


Findings:


Review of the hospital document titled,"(name of hospital) Board of Trustees Bylaws," dated 2/18/22, included,..."Section 1.2-Management of the Hospital" indicated, in part..."The Board serves as the Governing Body of the Hospital and retains ultimate responsibility for the Hospital's compliance with all applicable federal, state and local laws and regulations"... pg 3... "2.5-Meetings -Regular meetings of the Board shall be held at least quarterly ..."


Review of the document "Hire list," received from the hospital on 9/22/22, indicated in part "CEO hired 7/1/22."


During an interview and concurrent record review, on 9/22/22, at 11:20 a.m., with contracted medical staff consultant (Consultant 1- responsibilities include medical staff credentialing), the quarterly GB meeting minutes were requested for the year 2022. GB minutes for 2/2022 was made available and none afterwards. Review of the GB meeting minutes dated 2/2/2022 indicated, no documentation about plans to hire a CEO, if the hospital has a CEO, or any agenda item for the CEO. Consultant 1 acknowledged, the quarterly GB meetings for May and August 2022 did not occur and the CEO was just hired on 7/1/2022.

Based on interview and record review, the Governing Body (GB) failed to ensure the contracted services provided in the hospital were evaluated to ensure compliance with the Centers for Medicare & Medicaid Services (CMS) Conditions of Participation (COP) requirements and the evaluation was/were documented.


This failure created the increased risk of substandard services being provided with no follow up and evaluation.


Findings:


During a review of hospital document titled,"(name of hospital) Board of Trustees Bylaws," dated 2/18/22, indicated..., "Section 1.2-Management of the Hospital" indicated, in part..."The Board serves as the Governing Body of the Hospital and retains ultimate responsibility for the Hospital's compliance with all applicable federal, state and local laws and regulations"... pg.10 ..."Section 6.5- Contracted services" indicated in part, "The Board shall ensure that contracted services are performed safely and effectively through implementation of the performance improvement program and through mechanisms used to ensure that contracted services staff members are qualified and competent..." pg 3..."2.5-Meetings -Regular meetings of the Board shall be held at least quarterly..."


During an interview and concurrent record review, on 9/22/22, at 11:20 a.m., with contracted medical staff consultant (Consultant 1- responsibilities include medical staff credentialing and Quality Assurance Program Improvement -QAPI), Consultant 1 acknowledged, the quarterly GB meetings for May and August 2022 did not occur. Further review of only GB meeting minutes for year 2022, dated 2/2/22, the minutes did not reflect any agenda item for contracted services and or of any performance improvement program activities completed. Consultant 1 stated, "We (hospital) use to do this, we did it in 2021 but this has not occurred in 2022."

Based on interview and record review, the Govering Body (GB) failed to ensure the contracted services provided in the hospital were evaluated for safety, and effectiveness with documentation in place for follow up or improvement.

This failure had the potential for unsafe and ineffective services to continue with no monitoring and accountability placing patients at risk for poor quality and unsafe care.

Findings:


Review of hospital document titled, "(name of hospital) Board of Trustees Bylaws,"dated 2/18/22, included,..."Section 1.2-Management of the Hospital" indicated, in part..."The Board serves as the Governing Body of the Hospital and retains ultimate responsibility for the Hospital's compliance with all applicable federal, state and local laws and regulations... pg.10 ..."Section 6.5- Contracted services" indicated in part, "The Board shall ensure that contracted services are performed safely and effectively through implementation of the performance improvement program and through mechanisms used to ensure that contracted services staff members are qualified and competent..." pg 3..."2.5-Meetings -Regular meetings of the Board shall be held at least quarterly..."


During a concurrent interview, and record review on 9/22/22, at 11:20 a.m., with contracted medical staff consultant (Consultant 1- responsibilities include medical staff credentialing and Quality Assurance and Program Improvement- QAPI), Consultant 1 acknowledged, the quarterly GB meetings for May and August 2022, did not occur. Further review of only GB meeting minutes for year 2022, dated 2/2/22 indicated the Annual Review of Non-Clinical Contracts was not completed. No further agenda items for contracted services and/or safety or effectiveness of contracted services was noted on the GB minutes dated 2/2/2022. Consultant 1 acknowledged, the GB minutes reflected no contract seervices were evaluated. Consultant 1 stated,"We (hospital ) use to do this, we did it in 2021 but this has not occurred in 2022."

The Condition of Participation was not met as:

Based on observations, interviews, and record reviews, the hospital failed to implement patient rights in accordance with acceptable standards of practice, and hospital policy and procedures as follows:

1.Patient N108 (index case) was pronounced dead after being found on the floor, unresponsive, face blue in color, and barely breathing with a bed linen sheet wrapped around his neck and the sheet tied to the toilet. (Refer to A0144)

2. Patients N603 and N205 were discharged against medical advice (AMA) prior to the expiration or discontinuation of their 5150 holds (legal 72 hour involuntary hold for patient because they are a danger to themselves, others, or gravely disabled). (Refer to A0144)

3. Patients N400, N401, N402, N404, and N406) were physical restrained (preventing movement of body and limbs) and/or placed in seclusion (confining a person in a room preventing free exit) without obtaining a physician's order. (Refer to A0168)

4. Patients N404 and N406) were physical restrained and/or placed in seclusion longer than what the physician ordered. (Refer to A0171)

5. Patients N400, N403, N404, N405, and N406 did not receive a face-to-face examination within one hour of being placed in restraints and/or seclusion. (Refer to A0178)

The cumulative effects of these systemic problems resulted in the hospital's failure to protect and promote patient's rights, and to provide quality patient care in a safe environment.

Based on observation, interview, and record review, the facility failed to ensure safe care was delivered to patients when their rights were not honored as evidenced by:

1. Patient N603 was discharged against medical advice (AMA) prior to the expiration or discontinuation of the 5150 hold order (legal 72 hour involuntary hold for patient because a patient is a danger to self, others, or gravely disabled).

2. Patient N205 was discharged AMA prior to the expiration or discontinuation of the patient's 5150 hold, with no clarification from the physician about the status of the hold order.

3. Patient N108 was pronounced dead after being found on the floor, unresponsive, face blue in color, and barely breathing with a bed linen sheet wrapped around his neck and the sheet was tied to the toilet.

These failures created an unsafe hospital environment and placed patients at risk for further harm.

Findings:


1. During a review of the facility policy and Policy& Procedure (P&P) titled,"Involuntary Patients," revised 5/21, indicated, in part ..."All patients on a 5150, 5250, T-CON, LPS Conservatorship, or any involuntary hold will be housed on a locked unit until the hold is removed or expired, or until the patient status changes to voluntary (VOL)."


During a concurrent closed record review, and interview on 9/21/22, from 11:25 a.m., to 11:55 a.m., with director of risk and accreditation (DRA) and chief executive officer (CEO), of Patient N603's medical record (MR), the MR indicated, Patient N603's 5150 hold started on 9/6/21, at 1456, and will end on 9/9/21, at 1456. Further review of the MR indicated, Patent N603 left the facility on 9/9/21 at 1157 before the hold expires on 1456. The discharge summary indicated, in part ..."When his hold expired he refused to sign in voluntarily and requested discharge." CEO verbalized, documentation should have read, "MD is releasing patient from 5150 hold and that the patient can either voluntary hold or leave." The DRA confirmed there is no documentation in Patient N603's MR indicating the MD released the patient from the 5150 hold. The DRA further confirmed, Patient N603 was discharged /released from the hospital before the 5150 expired on 9/9/21 at 1456.


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2. During a review of Patient N205's MR, the "Physician Orders (PO)," dated 9/20/22, the PO indicated, Patient N205 was on a 5150 hold. The PO expiration date for the 5150 was 9/22/22 at 12:00 p.m.


During a review of Patient N205's "Discharge Order/Aftercare Plan (DOAP),"dated 9/22/22 indicated, Patient N205 initiated a AMA discharge, and the physician was notified and gave a telephone order of AMA on 9/22/22 at 11:24 a.m. Further review of the DOAP indicated, no order for the discontinuance of the 5150 hold. The box to discontinue 5150 was left blank.


During a concurrent interview, and record review on 9/23/22, at 9:52 a.m., with the quality director (Adm 1), Adm 1 confirmed, Patient N205 was discharged AMA at 11:27 a.m. Adm 1 acknowledged, the 5150 hold did not expire until 12:00 p.m. and there was no documentation that the 5150 had been lifted or discontinued. Adm 1 further acknowledged, Patient N205 was discharged AMA before the 5150 hold had expired.


During a review of the facility P&P titled, "Involuntary Patients," revised 5/21, indicated in part ..."All patients on a 5150, 5250, T-CON, LPS Conservatorship, or any involuntary hold will be housed on a locked unit until the hold is removed or expired, or until the patient status changes to voluntary (VOL)."


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3. A review of the MR for Patient N108 was conducted on 9/21/22. The MR indicated, Patient N108 was a 15 year old male patient with an admission date of 4/29/22, and in on a voluntary status for evaluation and treatment of major depressive disorder (feelings, mental, behavior of being down) and suicidal ideation (SI-with thoughts and attempts to kill harm self). The MR further indicated, Patient N108 attempted to hang self with a bed sheet wrapped around the neck inside the bathroom on 4/30/22. The attempt was unsuccesful secondary to staff intervention.

Further review of the MR for Patient N108 indicated, Patient N108 was placed on a 1:1 (one patient: one mental health worker-MHW) observation status by the physician after the suicide attempt on 4/30/22. On 5/3/22, the psychiatrist (MD2) was asked by registered nurse (RN 1) to re-evaluate Patient N108 to see if the 1:1 observation status could be discontinued, because another patient was going to be admitted who needed the 1:1 staff.

MD 2 evaluated Patient N108 on 5/3/22, and discontinued the 1:1 observation status. Patient N108 was placed on every (Q)5 minutes observation around the clock (ATC) on 5/3/22, at 4:00 p.m. On 5/4/22, at 10:21 a.m., Patient N108 was found by MHW 2, on the bathroom floor, unresponsive, face blue in color, and barely breathing with a bed linen sheet wrapped around the neck with the sheet tied/anchored to the toilet. Patient N108 was transferred to the Emergency department (ED) and was diagnosed with anoxic brain injury (caused by a complete lack of oxygen to the brain, which results in the death of brain cells after approximately four minutes of oxygen deprivation) due to strangulation. Subsequently, Patient N 108 was declared brain dead and pronounced dead on 5/7/22.

During an interview with registered nurse (RN 1) on 9/21/22, at 2:37 p.m., RN 1 confirmed, asking the MD2 on 5/3/22 to re-evaluate Patient N108 to see if the 1:1 observation status could be discontinued because RN1's supervisor had made the said request. MD 2 evaluated Patient N108 and discontinued the 1:1 observation status, but ordered Q 5 minutes rounds. Apparently, every 5 minutes rounds as ordered by MD2, were not performed by the assigned MHW. Patient N108 committed suicide in the bathroom.

During an interview with MD 2 on 9/21/22, at 3:05 p.m., MD 2 confirmed, MD2 evaluated Patient N 108 on 5/3/22, and ordered to discontinue the 1:1 observation status, and for staff to do the Q 5 minutes observation rounds. MD2 further confirmed, the Q 5 minutes observation rounds were not implemented by staff.

During an interview with mental health worker (MHW 2) on 9/21/22 at 12:35 p.m., MHW 2 confirmed, MHW 2 found Patient N108 on the floor in the bathroom with a bed sheet tied around the neck with the sheet that was tied/anchored to the toilet on 5/4/22, around 10:21 a.m. MHW 2 was assigned to perform Q 15 minutes rounds, and another MHW was assigned every Q 5 minutes rounds which were not performed.

Based on record review and interview, the facility failed to obtain a physician's order (PO) for physical restraints (preventing movement of body and limbs) and seclusion (confining a person in a room preventing free exit) for five of 33 sampled patients (N400, N401, N402, N404, N406).

This failure resulted in an unauthorized use of restraints on Patients N400, N401, N402, N404, and N406 with the potential for inappropriate, unnecessary, and prolonged use.

Findings:

During a medical record (MR) review with the Chief Nursing Officer (CNO) on 9/22/22, the following MRs for Patients N400, N401, N402, N404, and N406 were reviewed, and noted without any physician's orders for the use of restraints and seclusion:

Patient N400 was placed in seclusion and restraints on 8/4/22, at 6:17 a.m. The patient's restraints application started on 8/4/22, at 1:37 p.m., and seclusion with restraints on 8/5/22, at 6 a.m. No PO was noted in the MR for the restraint and seclusion use.

Patient N401 was placed in physical restraints on 8/21/22, at 10:50 p.m.. No documentation was found in the patient's MR for a PO to justify the use of the restraints.

Patient N402 was placed in physical restraints and seclusion on 8/2/22, at 7:39 a.m. No PO was located in the patient's MR for the use of the restraints.

Patient N403 was placed in physical restraints and seclusion on 7/10/22, at 8:15 p.m.. No PO was located in the patient's MR for the use of the restraints.

Patient N404 was placed in seclusion on 6/15/22, at 11:29 a.m. No PO was located in the patient's MR for the seclusion.

Patient N406 was physically restrained on 6/15/22 at 8:21 p.m., 6/19/22 at 9:15 p.m., 6/23/22 at 9:47 a.m., 6/26/22 at 7:57 p.m., 6/30/22 at 6:40 p.m., 7/1/22 at 1:44 p.m., 7/3/22 at 12 a.m., and 7/9/22 at 6:45 p.m. No PO was located in the patient's MR to justify and authorize the use of restraints.

During an interview with the CNO on 9/22/22, at 11:48 a.m., the CNO verbalized, Patients N400, N401, N402, N404, and N406 were either restrained or placed in seclusion with no POs in place. The CNO acknowledged, the POs were not obtained.

The hospital policy and procedure titled "Seclusion/Restraint," dated 8/20, indicated in part, "Seclusion is the involuntary confinement of a patient in a locked room...physically prevented from leaving for a period of time...Restraint is the emergency use of a physical hold to...protect him/her or other from injury...In all cases, an order for restraint/seclusion must be obtained from a psychiatrist within one (1) hour of the initiation of the use of the restraint/seclusion ..."

Based on record review and interview, the facility failed to ensure physical restraints (preventing movement of body and limbs) and seclusion (confining a person in a room preventing free exit) did not exceed four hours for adults, and 2 hours for children and adolescents, 9 to 17 years of age, for two of 33 sampled patients (N404, N406).

This facility failure caused a prolonged, unauthorized use of seclusion and restraint on both patients.

Findings:

During a concurrent medical record (MR) review and interview, with the Chief Nursing Officer (CNO) on 9/22/22, at 11:48 a.m., Patients N404 and N406 's MR were reviewed and:

For Patient N404, the MR indicated, the patient was placed into seclusion on 6/13/22 at 2:21 p.m. for four hours and 19 minutes, in seclusion on 6/15/22 at 11:29 a.m. for 12 hours 30 minutes. Review of Patient N404's physician's order (PO) dated 6/13/22 and 6/15/22 indicated, "Seclusion Not to exceed 4 hr (hour - Adult). No documentation was located in the patient's MR to indicate the PO for seclusion was extended, revised, or renewed to justify the extended time used.

For Patient N406, the MR indicated, the patient (an adolescent aged 9 to 17) was physically restrained on 7/3/22, at 12 a.m. for 17 hours. The unsigned PO dated, 7/3/22 indicated, "Physical Restraint ...½ hour for Humane Wraps (all ages)."

The CNO acknowledged, no PO for restraints and seclusion extension were obtained for Patient N404 for 6/13/22 and 6/15/22 and for Patient N406 on 7/3/22.

The hospital policy and procedure titled, "Seclusion/Restraint," dated 8/20, indicated, in part "...Orders for physical restraint/seclusion are limited to: ...Four (4) hours for individuals aged 18 and older,...Two (2) hours for ages 12 to 17...If restraint/seclusion needs to continue beyond the expiration of the time-limited order, a new order for restraint is obtained from the psychiatrist (Physician) who is primarily responsible for the individual's ongoing care."

Based on record review and interview, the facility failed to ensure and document, patients received a face-to-face examination within one hour of being placed in restraints (preventing movement of body and limbs) and/or seclusion (confining a person in a room preventing free exit) for five of 33 sampled patients (Patients N400, N403, N404, N405, N406).

This failure had the potential to continue restraints and seclusion application on patients with no discovery of the underlying reason of the patients behaviors which caused them to be restrained or secluded.

Findings:

During a concurrent medical record (MR) review and interview, with the Chief Nursing Officer (CNO) on 9/22/22, at 11:48 a.m., the MR of Patients N400, N403, N404, N405, N406 were reviewed.

The MR for Patient N400 indicated, the patient was placed in seclusion and restraint on 8/4/22 at 6:17 a.m., on 8/4/22 at 1:37 p.m., and into seclusion and restraint on 8/5/22, at 6 a.m. No face to face assessment was documented in Patient N400's MR.

The MR of Patient N403 indicated, the patient was placed restraint and seclusion on 7/10/22 at 8:15 p.m. No documentation of a face to face assessment was located in the patient's MR.

The MR of Patient N404 indicated, the patient was placed in seclusion and restraint on 6/11/22, at 3:55 a.m. and into seclusion on 6/13/22, at 2:21 p.m. No documentation of the face to face assessment was located in the patient's MR.

The MR for Patient N405 indicated, the patient was placed in restraint on 6/15/22, at 8:01 p.m. No face to face assessemnt was documented in the Patient's MR.

The MR for Patient N406 indicated, the patient was physically restrained on 6/19/22, at 9:15 p.m., 6/23/22 at 9:47 a.m., 6/26/22 at 7:57 p.m., 7/1/22 at 1:44 p.m.,7/3/22 at 12 a.m., and 7/9/22 at 6:45 p.m. No face to face assessment was documented in the patient's MR.

During a concurrent medical record (MR) review and interview, with the Chief Nursing Officer (CNO) on 9/22/22, at 11:48 a.m., the CNO acknowledged, no face to face assessment was done for Patients N400, N403, N404, N405, N406, for the restraints and seclusion when it were implemented. The CNO further acknowledged, there is no documentation of the face to face assessemnts in the patients MR as it were not done.

During a review of the hospital's policy and procedure (P&P) titled, "Seclusion/Restraint," dated 8/20, the P&P indicated, "Seclusion is the involuntary confinement of a patient in a locked room... physically prevented from leaving for a period of time...Restraint is the emergency use of a physical hold to involuntarily restrain the movement of the whole or a portion of a patient's body... A psychiatrist, psychologist, or Qualified Registered Nurse conducts an in-person evaluation of the individual within one hour of the initiation of restrain/seclusion."

The Condition of Participation is not met as:

Based on document review and administrative staff interview, the hospital failed to develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program (QAPI) when:


1. The Governing Body (GB-organized group or individual who assumed full legal authority and responsibility for operation of the hospital), medical staff, and administrative officials failed to ensure specific QAPI program requirements were met regarding an on-going program for quality improvement that was defined, implemented, and maintained. (Cross Reference A-0308)

2. The GB, medical staff, and administrative officials failed to ensure an on-going program for patient safety included the reduction of medical errors, was defined, implemented and maintained. (Cross Reference A-0309)


3 The GB, medical staff, and administrative officials were responsible and accountable to ensure an adequate resources were allocated for measuring, assessing, improving and sustaining the hospital's performance. (Cross Reference A-0315)


The cumulative effects of these systemic problems resulted in the hospital's inability to ensure the development of, implementation of, and maintenance of an effective, ongoing, hospital-wide, data-driven QAPI.

Based on interview and record review, the hospital's Governing Body (GB) failed to ensure Quality Council (QC) meetings were done and with documented data collected for quality improvement programs for hospital services including services furnished under contract or arrangement.

This failure had the potential for non implementation of needed quality programs due to lack of data to support, monitor, follow up hospital services that required improvement for the rendition of quality health care .


Findings:


Review of Hospital document titled, "Performance Improvement Plan," revised/approved, "12/19," indicated, in part...pg 4 (page)..."A.The Governing Board of (name of hospital) delegates authority to the Administration and Medical Staff to implement, oversee and respond to the results of a hospital wide system designed to monitor and evaluate the quality and appropriateness of patient care. provided. The Governing Board assumes responsibility for reviewing and responding to the results of the program at least quarterly and for reviewing and approving the Performance Improvement Plan at least annually..." pg 7. indicated, in part..."Data is systematically collected for both improvement priorities and continuing measurement of process... Assessment findings are communicated to the Quality Council monthly and Medical Executive Committee monthly and to the Governing Body at least quarterly..."



During an interview and concurrent record review of the hospital's Performance Improvement Plan (PIP) documents, Quality Council monthly meeting minutes and Governing Body (GB)quarter meeting minutes on 9/20/22, starting at 10 a.m., with the director of QAPI (Adm 1), no PIP documents were presented. Adm 1 was able to locate only two monthly QC meeting minutes dated 3/2022 and 4/2022 and one quarter GB meeting minutes dated 2/2022. Adm 1
stated, "I am new here and I don't think the meetings occurred, that's why I am here and things just weren't being done."


During an interview on 9/22/22, starting at 11:20 a.m., with the contracted medical staff consultant (Consultant 1), Consultant 1 acknowledged, no QC minutes were done before 3/2022 and after 4/2022 and no written reports were documented. Consultant 1 further acknowledged the quarterly GB meetings for May and August 2022 (2 quarters) did not occured or done.

Based on interview and record review, the Governing Body (GB) failed to ensure the hospital's Safety Committee (SC) have oversight on how the hospital's safety maintenance program reports are discussed, documented, evaluated, with data collected correctly then relayed to the hospital's Quality Committee (QC) and Governing Body (GB) for the implementation and monitoring of programs for patient safety and quality care.


This failure had the potential to result in poor oversight of patient and staff safety which can overall affect the hospital's performance on quality care .



Findings:


Review of facility document titled, "Safety Committee," dated, "5/18," indicated, in part..."The safety Committee is responsible for the establishment of and the maintenance of the safety program..." Further document review indicated, "The safety committee will meet at least quarterly..."


During a concurrent interview and record review on 9/22/22, starting at 9:15 a.m., with the quality assurance program implementation (QAPI) director (Adm 1) the document, "Safety/Risk Management Committee minutes," dated 5/23/22, indicated documentation of "No report available" for the topic performance safety , "No report available," for safety management walk through's, and for other agenda items "No report was available." Adm 1 stated, " The documentation didn't get done or reported in this meeting." (5/23/22) and no SC meetings occurred on 8/2022 the next quarter after 5/23/22 . Adm 1 acknowledged since no report was available for the SC meeting on 5/23/22 no data was collected to be reported to QAPI and GB related to patient safety.

Based on interview and record review the hospital failed to ensure oversight, follow up, manpower were in place for the implementation of quality assurance program improvement (QAPI) when:

1.Quarterly Governing Body (GB) Meeting only occurred once for the year of 2022 , (2/2/2022) with no documentation and evidence the non clinical contract services were reviewed.

2. The monthly Quality Council (QC) meeting only occurred twice for the year 2022 (3/2022 and 4/2022) with no Performance Improvement Plan (PIP) to be approved by the GB for the implementation of patient quality care.


3. The quarterly Safety Risk Management Committee (SRMC) meetings only occurred once in 2022 (5/23/22) with no written report as to safety concerns, data collected to ensure patient safety when receiving services in the hospital.


These failures placed all patients in the hospital to received poor care practices and substandard healthcare services.


Findings:


Review of hospital document titled, "(name of hospital) Board of Trustees Bylaws," dated 2/18/22, pg 10, included...,"Section 6.6.1 The Board shall oversee and recommend resources and support systems for an effective, hospital-wide performance improvement program." Further document review included,..."The performance improvement plan shall require participants to implement and report on activities and mechanism for planning, designing, measuring, assessing and improving the processes related to important patient care and organizational functions. All organizational services, including services by a contractor shall be evaluated."

1.During an interview on 9/22/22, starting at 11:20 a.m., with the contracted medical staff consultant (Consultant 1) Consultant 1 indicated quarterly GB meeting only occurred once for the year of 2022 on 2/2/2022. Review of the GB meeting minutes of the 2/2/2022 did not indicate the annual review of non clinical contracts were discussed or if evaluation for quality service or effective deliveryof contracted services was done .Consultant 1 stated,"We (hospital) use to do this, we did it in 2021 but this has not occurred in 2022."


2.During an interview on 9/20/22, starting at 10 a.m., with the director of QAPI (Adm 1), Adm 1 indicated monthly QC meetings were only done twice for the year 2022 on 3/2022 and 4/2022. Admin 1 further indicated there is no documentation or record," No written report " of any PIP or other quality reports thru data collection that was presented to the GB for approval and implementation. Adm 1 stated,"I am new here and I don't think the meetings occurred, that's why I am here and things just weren't being done as it should have been."


3. During an interview with Admin 1 on 9/22/22, starting at 9:15 a.m., the SRMC minutes dated 5/23/22, indicated,"No report available" for "Performance Standards Results", "No report available," for "Safety Management Walk Through's", and agenda items also indicated, "No report was available." Adm 1 stated, "It didn't get done or reported in this meeting." Adm 1 also acknowledged, there was no Safety Committee meeting that occurred in Aug 2022, per calendar of scheduled quarterly meetings.

The Condition of Particiaption is not met as:

Based on observation, interviews and record review, the hospital failed to ensure nursing services were provided in a safe manner when hospital policies and procedures (P&P) were not followed when:

1. Intake assessments were missing and incomplete for six of 33 sampled patients (Patients N103,N104,N105,N106,N603,N604). (Cross Reference A-398)

2. Nursing admission assessments were missing, incomplete, and inaccurate for seven out of 33 sampled patients (Patients N202,N204,N102,N105,N303,N306,N604). (Cross Reference A-398)

3. Nursing progress notes were missing and incomplete for two of 33 sampled patients (Patients N108,N604). (Cross Reference A-398)

4. AMA (against medical advice) forms were missing for 2 patients. (Patients N205,N603). (Cross Reference A-398)

5. Psychotropic medication consent forms were incomplete and missing for 30 of 33 patients ( Patients N200,N201,N202,N203,N204,N205,N206,N100,N103,N106,N107,N600,N601,N602,N300,N301,N302,N303,N305,N306,N400,N401,N402,N403,N404,N405,N406 ans unsampled patients 35,36,37 ). (Cross Reference A-0000 and Cross Reference A-398)

6. Designated comfort rooms were also used as seclusion rooms for seven patients (Patients N400,N401,N402,N403,N404,N405,N406 ). (Cross Reference A-398)

7. Psychotropic medications were administered with no Physician order for two patients (Patients N403, N404). (Cross Reference A405)

The cumulative effects of the hospital's systematic failure to follow P&P resulted in the hospital's inability to ensure the provision of safe patient care and psychiatric treatment.

Based on observations, interviews, and record reviews, the facility failed to ensure nursing services were provided according to policies and procedures (P&P) when:

1. Intake assessments were missing or incomplete for 6 out of 33 sampled patients (patients N103, N104, N105, N106, N603, and N604).

2. Nursing admission assessments were missing, incomplete, or inaccurate for 7 out of 33 sampled patients (patients N202, N204, N102, N105, N303, N306, and N604).

3. Nursing progress notes were missing or incomplete for 2 out of 33 sampled patients (N108 & N604).

4. AMA (against medical advice) signed forms were missing for 2 patients (patients N205 & N603) who left AMA.

5. Psychotropic medication consent forms were incomplete or missing for 30 out of 33 sampled patients (patients N200, N201, N202, N203, N204, N205, N206, N100, N103, N106, N107, N600, N601, N602, N300, N301, N302, N303, N305, N306, N400, N401, N402, N403, N404, N405, and N406) and 3 unsampled patients (35, 36, and 37).

6. Designated comfort rooms were also used as seclusion rooms for seven of 33 sampled patients (Patients N400, N401, N402, N403, N404, N405, and N406).

These failures had the potential to create unsafe patient care and psychiatric treatment throughout the patients' hospitalization.

Findings:

A. During a review of Patient N202's "Nursing Admission Assessment," dated 9/18/22, indicated, Patient N202's chief complaint was "I want to kill myself." Reason for admission 5150 (a 72 hour hold for a person with a mental challenge to be involuntarily detained for psychiatric hospitalization) danger to self. Further review of the nursing assessment, the psychiatric rating scale section was left blank. There was no documentation in this section. The nursing assessment was incomplete.

During a review of Patient N204's "Nursing Admission Assessment," dated 9/13/22, indicated, Patient N204's chief complaint was "I had thoughts of killing myself, but I don't know the reason." Reason for admission 5150 danger to self. Further review of the nursing assessment, the skin integrity, and strengths and liabilities (aknowledgement) sections, were left blank.The nursing assessment was incomplete.

During a review of the facility's P&P titled, "Admissions Assessment," dated 9/2020, indicated, in part ..."To ensure each patient is appropriately assessed prior to and during admission ...a licensed member of the clinical staff will evaluate each new patient ...conclusions, indications for treatment, and priorities for nursing care will be determined by a registered nurse... the data generated by the assessment process will be used in planning appropriate patient care and utilized throughout hospitalization in the planning of psychiatric treatment, medical treatment and aftercare. The admission assessment is completed through the use of four assessment components: Intake Assessment; Nursing Assessment; Psychosocial Assessment; Therapeutic Assessment. The Nursing Assessment is to be completed by a licensed member of the nursing staff within 24 hours of admission."

During a review of Patient N205's "Discharge Order/Aftercare Plan," dated 9/22/22, indicated, Patient N205 initiated AMA (leave against medical advice) and the physician gave the telephone order on 9/22/22 at 11:24.

During a review of Patient N603s clinical record indicated Patient N603 intiated an AMA and no signed AMA form was located in the patient's medical record .

During an interview on 9/23/22, at 9:50 a.m., with the quality director (Adm 1), Adm 1 confirmed, Patient N205 and Patient N603 were discharged AMA. Adm 1 acknowledged, the AMA forms for both patients were not in the clinical record.

During a review of the facility's P&P titled, "AMA (Against Medical Advice) Discharge," dated 5/2021, indicated, in part ..."Documentation: If the patient is to be discharged AMA, the patient or guardian will be asked to sign the AMA documentation form in the presence of at least one witness...if the patient or guardian refuses to sign, the RN is to write "patient refuses to sign" on the signature line and then sign his/her own name and title with date and time."

During a review of the facility's P&P titled, "Informed Consent of Psychotropic Medications," dated 10/2020, indicated, in part ..."Informed consent must be obtained from all voluntary patients, as well as all involuntary patients, before the use of psychotropic drugs...the physician must explain to the patient: the reasons for taking the medication ...what benefits can be expected from taking the drug ...the type and amount of the medications and how often it must be taken ...possible side effects ...alternative treatments ...the potential long-term side effects of taking this medication ...the informed consent will be documented on the appropriate consent form...one of the following requirements for administering psychotropic medications must be met: the patient has given informed consent."

During a concurrent interview and record review on 9/21/22, at 2:30 p.m., with the quality director (Adm1), Patient N200's physician orders (PO), dated 9/16/22, were reviewed. The PO indicated Ptient N200 was on Zyprexa 5 mg (drug used to treat schizophrenia and bipolar disorder) one tablet by mouth twice a day as needed., Risperidone 1mg (drug used to treat schizophrenia and bipolar disorder) one tablet by mouth once a day at bedtime and Risperidone 0.5mg one tablet by mouth once a day. Patient N200's consent form (CF)dated 9/15/22, and 9/16/22 for Zyprexa and Risperidone were with missing dosage or range, frequency, the method and durastion of medication administration. Adm 1 acknowledged, these elements were missing from the consent forms and should be there. Adm 1 further acknowledged, the consent forms were incomplete.

During a concurrent interview and record review on 9/21/22, at 2:34 p.m., with Adm 1, Patient N201's PO dated 9/16/22 indicated, orders for Zyprexa 10 mg one tablet by mouth once a day at bedtime and Zyprexa 5 mg one tablet by mouth once a day, Latuda 80 mg (a drug used to treat schizophrenia) one tablet by mouth once a day, Lithium 300 mg (a drug used to treat bipolar disorder and depression) three capsules by mouth twice a day and Lexapro 5 mg (a drug used to treat depression and anxiety) one tablet by mouth once a day. Patient N201's CF dated 9/16/22, was with missing medication dose, range , frequency , method , and duration of medication administration for Lexapro, Zyprexa Lithium, and Latuda. . The physician's signature was also missing from the CF. Adm 1 acknowledged, these elements were missing from the consent forms and should be there. Adm 1 further acknowledged, the consent forms were incomplete.

During a concurrent interview and record review on 9/21/22, at 2:38 p.m., with Adm 1, Patient N202's PO dated 9/18/22, indicated, orders for Xanax 2 mg ( adrug used to treat anxiety and panic disorder) one tablet by mouth once a day at bedtime, Trazadone 100 mg (a drug used to treat depression) three tablets by mouth once a day at bedtime, and Ziprasidone 80 mg (a drug used to treat schizophrenia and bipolar disorder) two capsules by mouth once a day at bedtime. Patient N202's CF for psychotropic medications, dated 9/21/22, no consent was obtained from the patient for the administration of Ziprasidone as ordered by the physician.The physician's signature was also missing from the consent form. Adm 1 acknowledged, these elements were missing from the consent form and should be there. Adm 1 further acknowledged, the consent forms were incomplete. Adm 1 also confirmed, Patient N202 was not consented to the medication Ziprasidone.


During a review of the facility's P&P titled, "Informed Consent of Psychotropic Medications," dated 10/2020, indicated, in part ..."The physician shall obtain and complete the required consent upon ordering psychotropic medications...when nursing notes has such an order they will determine whether a consent form has been completed ...if completed nursing will: review medication consent for completeness...administer medications as ordered ...ensure a copy of the consent form is placed in the medication book and the original is placed in the patient's chart...no nurse shall administer psychotropic medication without one of the following: informed consent ..."

During a concurrent interview and record review on 9/21/22, at 2:42 p.m., with Adm 1, Patient N203's PO dated 9/20/22, indicated, orders for Lexapro 10 mg (a drug used to treat depression and anxiety disorder) one tablet by mouth once a day, Vistaril 50 mg (a drug used to treat anxiety) one capsule by mouth once a day at bedtime as needed and Remeron 30 mg (a drug used to treat depression) one tablet by mouth once a day at bedtime. Patient N203's CF for psychotropic medications, dated 9/21/22, indicated Patient N203 missing medication dosage, range, frequency , method of administration, and duration for Lexapro,Vistaril, and Remeron .Adm 1 acknowledged these elements were missing from the consent forms and should be there. Adm 1 further acknowledged the consent forms were incomplete.


During a concurrent interview and record review on 9/21/22, at 2:46 p.m., with Adm 1, Patient N204's PO an order for Lexapro 10 mg one tablet by mouth once a day with a CF dated 9/15/22 . The CF indicated no documentation of the dosage or range ,frequency ,method of administration, and duration of taking the medication. Patient N204's signature(signifying consent) was also missing from the CF . Adm 1 acknowledged, these elements were missing from the consent form and should be there. Adm 1 further acknowledged the consent forms were incomplete.


During a concurrent interview and record review on 9/21/22, at 2:50 p.m., with Adm 1, Patient N205's PO dated 9/20/22, indicated, orders for Lithium 300 mg one capsule by mouth once a day at bedtime, Trazodone 50 mg one tablet by mouth once a day at bedtime, Prozac 10 mg (a drug used to treat depression and obsessive compulsive disorder) one capsule by mouth once a day, and Vistaril 25 mg one capsule by mouth every 6 hours. Patient N205's CF for psychotropic medications, dated 9/21/22, signed by the patient indicated missing dosage or range , frequency of the medication, the method of administration, and the probable duration of taking the medication.The physician's signature was also missing from the CF. Adm 1 acknowledged, these elements were missing from the consent form and should be there. Adm 1 further acknowledged, the consent form was incomplete.


During a concurrent interview and record review on 9/21/22, at 2:54 p.m., with Adm 1, Patient N206's PO dated 9/15/22, indicated orders for Seroquel 300 mg (a drug used to treat schizophrenia, bipolar disorder and depression) one tablet by mouth once a day at bedtime, Depakote 500 mg (a drug used to treat seizures and bipolar disorder) one tablet by mouth twice a day, and Prozac 10 mg one capsule by mouth once a day. Patient N206's CF dated 9/18/22 indicated patient consented to take Prozac but no consent signed by patient for Seroquel and Depakote was located. The CF also have no dosage or range of the medications, the frequency of the medications, the method of administration, and the duration of taking the medications, documented on the CF for Seroquel, Depakote and Prozac. The physician's signature was also missing from the CF. Adm 1 acknowledged, these elements were missing from the CF and should be there. Adm 1 further acknowledged, the consent form was incomplete. Adm 1 also confirmed, Patient N206 nhas no consent for the Seroquel and Depakote administration.


During a review of the facility's P&P titled, "Informed Consent for Medications, Treatments, and Procedures," dated 10/03, indicated, in part ... "The attending psychiatrist will be responsible for the informed consent procedure for psychotropic meds ...the consent form must include the medication and dosage ranges ...the informed consent procedure maybe done in person with the patient or by a 3-way phone conversation between the patient, physician and nurse and any family member for adolescent patients ...this will be documented on the consent form prior to psychotropic meds being given."


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B. The hospital P&P titled, "Admission Assessment," revised 9/2020, indicated, in part .. "The data generated by the assessment process will be used in planning appropriate patient care and utilized throughout hospitalization in the planning of psychiatric treatment, medical treatment and aftercare. The admission assessment is completed through the use of four assessment components: Intake Assessment; Nursing Assessment; Psychosocial Assessment; Therapeutic Assessment. The Intake Assessment is a pre-admission assessment used to determine the appropriateness of the patient for all admissions. The Intake Assessment is completed by a licensed member of the hospital staff when the patient presents to the hospital. The Registered Nurse on the unit is responsible for reviewing and signing all assessments not completed by him/her."

During a review of Patients' 103, 104, 105 and 106 clinical records and concurrent interview with the house supervisor (HS) on 9/22/22, from 12:35 p.m. to 16:45 p.m., Patient 103's Intake Assessment, dated 9/16/22, was missing the chemical dependency history. Patient 104's Intake Assessment, dated 9/14/22, was missing the chemical dependency history, current medical conditions, medical history and problem list. Patient 105's Intake Assessment, dated 9/11/22, was missing the chemical dependency history. Patient 106's Intake Assessment, dated 9/16/22, was missing the chemical dependency history, medication history, and problem list. The HS acknowledged and confirmed the assessments were not completed because there were elements missing from the assessment. HS stated, "I agreed the assessments are not complete."

The hospital P&P titled, "Admission Assessment," revised 9/2020, indicated, in part ..."The data generated by the assessment process will be used in planning appropriate patient care and utilized throughout hospitalization in the planning of psychiatric treatment, medical treatment and aftercare. The admission assessment is completed through the use of four assessment components: Intake Assessment; Nursing Assessment; Psychosocial Assessment; Therapeutic Assessment. The Nursing Assessment is to be completed by a licensed member of the nursing staff within 24 hours of admission."

During a review of clinical records for Patients 102 and 105 and concurrent interview with the house supervisor (HS) on 9/22/22, at 10:00 a.m., Patient 102's Nursing Admission Assessment, dated 9/12/22, indicated, assessment was not complete, the central nervous system, respiratory, cardiac, initial treatment plan and the narrative nursing documentation was missing. Patient 105's Nursing Admission Assessment, undated, indicated assessment was not complete, the central nervous system and initial treatment plan documentation was missing. The HS acknowledged, and confirmed the assessments were not completed because there were elements missing from the assessment. HS stated, "I agreed the assessments are not complete."

The hospital's P&P titled, "Patient Assessment and Reassessment," dated 10/2020, indicated, "RN assessment completed once per shift and any other time the patient's condition changes."

During a review of the clinical record for patient 108 and concurrent interview with Adm 1 on 9/23/22, at 9:00 a.m., Adm 1 acknowledged and confirmed, there was no nursing progress note for date 5/2/22 day shift on the patient's nursing admission assessment . Adm 1 stated "I agree there is no nursing progress note from the day nurse on 5/2/22."

The hospital's P&P titled, "Informed Consent of Psychotropic Medications," dated 10/20, indicated, "Informed consent must be obtained from all voluntarily patients, as well as all involuntarily patients, before the use of psychotropic drugs." In the PROCEDURE part indicated, "The physician should obtain and complete the required consent upon ordering psychotropic medications. when nursing notes such an order they will determine whether it consent form has been completed ... review medication consent for completeness."

The hospital's P&P titled, "Informed Consent for Medications, Treatments and Procedures," dated 10/2003, in the PROCEDURE part indicated, "the attending psychiatrist will be responsible for the informed consent procedure for psychotropic meds. The consent form must include the medication and dosage ranges ... This would be documented and the consent form prior to psychotropic meds being given."

During a review of the medical records for pcyhotropic informed consent form (ICF) for Patients 100, 103, 106, 107, 600, 601, 602, and unsampled Patients 35, 36, 37 on 9/21/22, ICFs were missing for Patient 103, and 600. ICFs for Patients 100, and 601 were missing the psychiatrist signature and ICFs Patients 106, 107, and 602 was missing the medications dose. The ICFs for unsampled Patients 35, 36, and 37 were missing the psychiatrist signature and medication dose.

During an interview with the chief nurse officer (CNO) on 9/23/22, at 10:00 a.m., the CNO acknowledged
The CFS for Patients 100, 103, 106, 107, 600, 601, 602, and unsampled Patients 35, 36, 37 were either with missing psychiatrist signature, dosage of medications to be administered or totally with missing ICFS. The CNO further acknowledged the process for pscyhotropic ICF were with concerns .


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C. During a review of the facility's P&P, titled "Admission Assessment," dated 9/2020, the policy indicated, "The Nursing Assessment is to be completed by a licensed member of the nursing staff within 24 hours of admission. The completed assessment is to be validated by a Registered Nurse. The Nursing Assessment includes the following: a. Vital Signs".( temperature, respiration, heart rate, pain)

During a review of the "Nursing Admission Assessment," (NAA) dated 09/12/22, for Patients N303 and N306), the NAA of both patients were with missing vital signs.

During an interview and concurrent record review of the NAA for Patients N303 and N306 with the director of risk and accreditation (DRA) on 09/23/22, at 8:30 a.m., the DRA confirmed, the vital signs were missing from the NAA and should have been documented as per the facility P&P.

During a review of the facility's P&P titled, "Informed Consent of Psychotropic Medications," dated 10/2020, the P&P indicated, under PROCEDURE, "1.The physician shall obtain and completed the required consent upon ordering psychotropic medication. 2. When nursing notes such an order they will determine whether a consent form has been completed....nursing will review medication consent for completenes."

During a review of the facility's P&P titled, "Informed Consent for Medications, Treatments and Procedures," dated 10/2003, the P&P indicated, "The attending psychiatrist will be responsible for the informed consent procedure for psychotropic meds. The consent form must include the medication and dosage ranges."

During a concurrent record review and interview on 09/21/22, at 3:30p.m., with the director of intake (ADM 3), the Consent for Psychotropic Medications (CPM) for 6 sampled patients ranging from 9/12/22 to 9/21/22 were with :
Patient N300 was missing medication dosage ranges and a physician signature,
Patient N301 was missing medication dosage ranges as well as all signatures (patient/patient representative signature, physician's signature, and witness signature),
Patients N302, N303, and N305 were missing medication dosage ranges as well as date/time of physician signature,
Patient N306 was missing medication dosage ranges.

ADM 3 confirmed the CPMs for Patients N300,N301,N302,N303, N305, and N306 were missing the identified information.


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D.1. According to the hospital's P&P titled, "Informed Consent of Psychotropic (alters thought processes) Medications," dated 10/2020, the P&P indicated, "Informed consent must be obtained from all...patients, before the use of psychotropic drugs ... The physician must explain to the patient: ...The type and amount of the medications and how often it must be taken ...The informed consent will be documented on the appropriate consent form ...They physician shall obtain and complete the required consent upon ordering psychotropic medications. When nursing notes such an order they will determine whether a consent form has been completed ..."

During a record review and concurrent interview on 9/22/22, at 11:28 a.m., with the Chief Nursing Officer (CNO). the CPM , PO and "Medication Administration Record" (MAR) for patients (Patients N400, N401, N402, N403, N404, N405 and N406) were reviewed and the following were noted .

Patient N400 had four CPMs in place dated from 7/8, 11,12, and 16/2022 . The CPM dated 7/12/22 for Depakote, Seroquel, Trazadone, Ativan and Prozac was not signed by the patient. The CPM dated 7/8,11,12, and 16 /2022 for have no reflection of the Ativan dose and frequency of the adminsitation . The PO dated 8/3/22 indicated an order for Risperdal be given twice daily on 8/3/22 and no signed CPM was located to indicated staff obtained the patient's consent prior to the administration of Risperdal. Review of the MAR for Patient N400 indicated Risperdal was admnsitered twice a day from 8/3/22 through 8/10/22 with no CPM in place.

Patient N401's CPM dated 8/14/22, for Seroquel and Cymbalta had no dose and frequency for administration. A PO for Buspar dated 8/21/22 was noted with no CPM. The MAR of Patient N401 indicated the patient was administered Buspar with no signed consent from 8/21/22 through 8/23/22 .

Patient N402 had a PO dated 8/4/22, for the medication Abilify one tablet by mouth every 12 hours and Desyrel one tablet by mouth once a day. No signed CPM from the patient and physician obtained by staff for the administration of Abilify and Desyrel was located in the patient's medical record.


Patient N403's CPM dated 7/5/22, for the medication Thorazine had no documented dose amount and how often the medication should be given. The MAR indicated, Patient N403 was administered with three psychotropic medications: Depakote and Zyprexa 7/1/22 through 7/11/22 and Haloperidol 7/6/22 through 7/11/22. NO signed CPM by patient and physician was located obtained by staff prior to medication administration.


Patient N404 CPMs dated 6/6/22 and 6/12/2022 for Risperdal, Ambien, Ativan, Abilify, Trazadone, Depakene, Zyprexa, and Lithium had missing dose and frequency for adminsitration . The CPM dated 6/12/22 for Abilify, Trazadone, Depakene, Zyprexa, and Lithium was not signed by the patient authorizing the facility for administration. Haloperidol and Seroquel administered from 6/17/22 through 7/1/22 werwe with no signed CPM from the patient.


Patient N405 CPM for Geodon, dated 6/16/22, and Zydis, dated 6/20/22, had no dose and frequency for administration .


Patient N406 had no signed CPM in place for the the medications Zoloft, Trazodone, Vistaril, Abilify, and Lamictal administered from 7/1/22 through 7/15/22.

The CNO indicated and confirmed the hospital is aware the CPM of patients (Patients N400, N401, N402, N403, N404, N405 and N406) do not contain psychotropic medication dose , frequecy, missing signatures or no obtained signed consent at all .


On 9/21/22, at 5:07 p.m., an Immediate Jeopardy (IJ) was declared as, the hospital failed to have management with the director of nursing (DON) ensure licensed staff follows the hospital's policy and procedures in regards to consents prior to administering psychotropic medications (medications to addressed mental, behavioral outbursts or deviations) in 30 of 36 to patients (Patients N200, N201, N202, N203, N204, N205, N206, N100, N103, N106, N107, N600, N601, N602, N300, N301, N302, N303, N305, N306, N400, N401, N402, N403, N404, N405, and N406) and 3 unsampled patients (35, 36, and 37), when psychotropic medication consent forms were incomplete or missing.

On 09/21/22 at 7:01 p.m., the hospital submitted a plan of correction (POC).

On 09/23/22 at 3:45 p.m., the POC implementation was validated by the survey team. The second Immediate Jeopardy (IJ), declared on 9/21/22, was removed in the presence of the RDRA, confirmed and verified by the survey team onsite.







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D.2. Review of the hospital P&P titled, "Comfort Room," dated 10/2020, indicated, in part, " ...The Comfort Room is never to be used as a containment intervention. The patient must continue to demonstrate self-control to use the Comfort Room and must be using the Comfort Room to assist with tension reduction as an objective toward the goal of maintaining self-control."

During a review of the medical records and concurent interview on 9/20/22, at 9:18 a.m. with the Quality Improvement Coordinator (QIC), the seclusion amd restraint documents for seven patients (Patient N400, N401, N402, N403, N404, N405, and N406) indicated all seven patients were placed in seclusion and/or restraint between 6/11/22 and 8/5/22 inside the comfort room (CR). The QIC confirmed the comfort rooms (CR) are also used as seclusion rooms.


During an observation and concurrent interview on 9/21/22, at 12:20 p.m. with Licensed Nurse 1 (LN1), two CRs located inside the locked nursing station have a bed, a chair, and locks on the outside of the door. LN1 indicated, the CRs are used as both seclusion rooms and comfort rooms. LN1 further indicated, the CRs are locked and used as a seclusion room with 15-minute monitoring for a combative patient with a PO while an unlocked CR are used for patients needing voluntary time away from millieu (social environment) and do not need a PO.


During a record review and concurrent interview with the CNO on 9/22/22, at 2:20 p.m., the seclusion and restraint documents for patients (N400, N401, N402, N403, N404, N405, and N406, the CNO confirmed, the CRs are being used as both comfort rooms and seclusion rooms in violation of the hospital's policy and procedure "Comfort Room" dated 10/2020. E.1 During a review of the facility P&P titled, "Admission Assessment," revised 9/2020, the P&P indicated, in part ..."The data generated by the assessment process will be used in planning appropriate patient care and utilized throughout hospitalization in the planning of psychiatric treatment, medical treatment and aftercare. The admission assessment is completed through the use of four assessment components: Intake Assessment; Nursing Assessment; Psychosocial Assessment; Therapeutic Assessment. The Intake Assessment is a pre-admission assessment used to determine the appropriateness of the patient for all admissions. The Intake Assessment is completed by a licensed member of the hospital staff when the patient presents to the hospital. The Registered Nurse on the unit is responsible for reviewing and signing all assessments not completed by him/her."


During a record review and concurrent interview on 9/21/22, at 10:04 am, with director of risk and accreditation (DRA), Patient N604's "Intake Assessment" (IA) undated was incomplete. The undated IA for Patient N603 was also noted to be incomplete . The DRA confirmed the IAs for Patients N604 and N603 were not completed.



During a review of the facility P&P titled, "Admission Assessment," revised 9/2020, indicated, in part ..."The data generated by the assessment process will be used in planning appropriate patient care and utilized throughout hospitalization in the planning of psychiatric treatment, medical treatment and aftercare. The admission assessment is completed through the use of four assessment components: Intake Assessment; Nursing Assessment; Psychosocial Assessment; Therapeutic Assessment. The Nursing Assessment is to be completed by a licensed member of the nursing staff within 24 hours of admission."


D.3. During a review of the facility P&P titled, "A.M.A (Against Medical Advice Discharge)," revised 5/2021, indicated, in part..."DOCUMENTATION. If the patient is to be discharged AMA, the patient or gaurdian will be asked to sign the AMA Documentation form in the presence of at least one witness, If the patient or guardian refuses to sign, the RN is to write "patient refuses to sign" on the signature line and then sign his/her own name and title with date and time."

During a record review and concurrent interview on 9/21/22, at 10:04 am, with the DRA, of Patient's N604 and N603 medical record, the following were noted :

Patient N604's admission record indicated the patient was admitted on 5/21/22 at 0301 and the "Nursing Assessment" (NA) was completed on 5/21/22 at 0225 almost an hour prior to admission. The DRA indicated this should not be the case as the NA should be done at least with in 24 hours of admission not prior to admission

Patient N604's medical record had no evidence a nursing progress notes was done for the night shift of 5/22/22. The DRA acknowledged there is no evidence the nursing staff did the patient's nursing progress notes and indicated it should have been done per hospital policy and procedure .


Patient N603's had documentation in the medical record of an undated initiated against medical advice (AMA) leaving of the hospital. No signed form of the AMA can be located in the patients medical record . The DRA confirmed nursing staff failed to have the signed AMA form in place prior to the patient leaving the hospital .

Based on interview and record review, the hospital failed to ensure psychotropic medications (alters thought process) were administered with physician orders in accordance with hospital policy and procedure (P&P) for two of 33 sampled patients, patients (N403 and N404)

This failure had the potential to administer medications to patients without their consents violating rights.


Findings:

During a concurrent record review and interview with the Chief Nursing Officer (CNO) on 9/22/22 at 11:48 a.m., the medical record (MR) for Patients N403 and Patient N404, the following were noted:

Patient N403 was medicated with two 5 milligram (measurement of amount of medication) tablets of Haloperidol (psychotropic medication) twice a day from 7/6/22 through 7/11/22. No physician order (PO) was located in the patient's MR for the administration of haloperidol. The CNO confirmed, there is no PO in place and the medication was administered to Patient N403.

Patient N404 was medicated with one 400 milligram tablet of Seroquel (psychotropic medication) at bedtime on 6/17/2 and 6/18/22, and two 300 milligram tablets of Seroquel at bedtime from 6/18/22 through 7/1/22. Patient N404's MR further indicated, on 6/17/22 through 6/23/22 one 5 milligram tablet of Haloperidol (psychotropic medication) by mouth as needed every six hours was administered to the patient. No PO was located in Patient N404 MR for both medications (Seroquel and Haloperidol ,).

The CNO confirmed, Patient N04 was medicated with haloperidol and Seroquel with no existing PO in place.

The hospital's P&P titled, "Medication Administration," dated 10/2020, indicated, in part,"Medications are only administered after they have been ordered by a member of the medical staff with clinical privileges and transcribed by a licensed nursing staff."

The Condition on Participation was not met as:

Based on observation, interview and record review the hospital failed to ensure a safe physical environment when:

1. Patient's bathroom (total of 26) had a toilet with a metal stick handle which could be used as an anchor thus creating a ligature risk (anything that can be used to attach a cord, rope, or other material for the purpose of hanging or strangulation) for patients to commit suicide in all their units in 36 of 36 patients . (Seaside, Mountain and Ocean View, and Hillside).

Thirty-six (36) patients had access to the ligature risk which created an unsafe environment for which every patient in the hospital was affected. CDPH declared Immediate Jeopardy on 9/20/22 for subjecting every patient in the hospital to have access to a ligature risk thus endangering them and exposing them to unsanitary equipment that could result in cross-contamination. Cross Reference A-000, A-701 and A-724.

2.The glucometer (medical device used to measure the amount of sugar in the blood) was not cleaned and disinfected according to manufacturer's instructions for use (MIFU's) thus failing to maintain the equipment in a safe and sanitary manner in one of one glucometer.

The cumulative effects of the hospital's failure to provide a ligature free environment, and sanitary equipment to prevent cross -contamination for all psychiatric patients, resulted in the hospital's inability to ensure the provision of patient care in a safe environment.

Based on observation, and interview the hospital failed to ensure a safe physical environment was maintained when inside of 26 patient's bathroom toilets were with a metal stick handle which could be used as an anchor to attach a bed sheet thus creating a ligature risk (anything that can be used to attach a cord, rope, or other material for the purpose of hanging or strangulation) for patients to commit suicide in all of four units (Seaside, Mountain and Ocean View, and Hillside) housing 36 of 36 patients and in the case of one sampled closed record patient (Patient N108).

This hospital's failure provided patients with access to an anchor creating a ligature risk which could be used to commit suicide.

Findings:

According to Joint Commission on Accreditation of Healthcare Organizations (The Joint Commission) Joint Commission Resources (2007), Suicide prevention: Toolkit for implementing national safety goal 15A. Oakbrook Terrace, IL: Reports that in behavioral healthcare facilities, long-term care facilities, and acute care hospitals, hanging is the most common way to complete suicide. Seventy five percent of the suicides occurred in bathrooms, bedrooms and closets. The overwhelming majority of the incidents involved environmental concerns. VA study Examination of the Effectiveness of Mental Health Environment of Care Checklist in Reducing Suicide on Inpatient Mental Health Units. Arch Gen Psychiatry. 2012 Jun 1;19 (6) author Watta BV indicated, "Anchor points capable of sustaining the weight of a patient attempting to hang him or herself in bedrooms and bathrooms were the most common and dangerous identified hazards."


A review of the medical record (MR) for Patient N108 was conducted on 9/21/22. The MR indicated, Patient N108 was a 15 year old male patient with an admission date of 4/29/22, and in on a voluntary status for evaluation and treatment of major depressive disorder (feelings, mental, behavior of being down) and suicidal ideation (SI-with thoughts and attempts to kill harm self). The MR further indicated, Patient N108 attempted to hang self with a bed sheet wrapped around the neck inside the bathroom on 4/30/22. The attempt was unsuccesful secondary to staff intervention.

Further review of the MR for Patient N108 indicated, Patient N108 was placed on a 1:1 (one patient: one mental health worker-MHW) observation status by the physician after the suicide attempt on 4/30/22. On 5/4/22, at 10:21 a.m., Patient N108 was found by MHW 2, on the bathroom floor, unresponsive, face blue in color, and barely breathing with a bed linen sheet wrapped around the neck with the sheet tied/anchored to the toilet. Patient N108 was transferred to the Emergency department (ED) and was diagnosed with anoxic brain injury (caused by a complete lack of oxygen to the brain, which results in the death of brain cells after approximately four minutes of oxygen deprivation) due to strangulation. Subsequently, Patient N 108 was declared brain dead and pronounced dead on 5/7/22.

During a tour of the Seaside Adolescence unit and concurrent interview with the chief nurse officer (CNO) on 9/20/22, from 11:10 a.m., to 12:30 p.m., in room 207's bathroom, a toilet with a metal stick handle was observed. An inspection of the bathroom toilet in rooms 201 to room 208 was conducted. All the bathrooms had the same type of toilet with a metal stick handle. The CNO was notified the toilet stick handle could be used as an anchor to tie a bed sheet and patient could hang himself. An unoccupied room's bathroom toilet was used to demonstrate to CNO how the stick toilet handle could be use by a patient to hang himself. A bed sheet was wrapped around the metal stick toilet handle (anchor), sheet was pulled to the right side (facing the toilet), the toilet flush but the sheet remained anchored to the stick handle. Then the CNO pulled hard on the sheet and sheet remained anchored on the toilet handle. To continue testing the strength of the stick toilet handle. A male administrator pulled very hard on the sheet and the sheet remained anchored on the handle without slipping off. The CNO acknowledged, the toilet handle can be used as an anchor thus creating a ligature risk for the patients to commit suicide.


39520

2. During a concurrent observation and interview on 9/20/22, at 4:00 p.m., with the quality director (Adm 1), a tour of the bathrooms was conducted on the Ocean View Unit, Rooms 300-307, and the Mountain View Unit, Rooms 308-313, in the G building. Rooms 300-307 had four shared bathrooms with toilets that had a stick handle flush. Rooms 308-313 had four shared bathrooms with toilets that had a stick handle flush. A Sheet Test was also conducted in the empty unoccupied bathrooms. A bed sheet was tied tightly to the toilet stick handle, when the sheet was pulled to the right, the toilet flushed and the sheet slipped off the handle, however when the sheet was pulled to the left, the toilet flushed and the sheet did not slip off the handle. Adm 1 acknowledged, the stick handle flush is a ligature risk (anything that can be used to attach a cord, rope, or other material for the purpose of hanging or strangulation) and further acknowledged, most patients are here for suicide risk.


39106

3. During an observation and concurrent interview, on 09/20/22, at 3:30 p.m., a tour of the Hillside Nursing Unit was done with director of intake (ADM) 3. The Unit was observed to have five total toilets. All five toilets have a metal stick handle mechanism used to flush the toilets. A test was conducted to determine if the stick handle flush mechanism could create a ligature risk (anything that can be used to tie a cord, rope, or other material for the purpose of hanging/strangulation. The test performed by one member of the survey team and ADM 3 concluded that a sheet could be tied or twisted around the stick flush mechanism and pulled without slipping. Therefore, the toilet flush mechanism with a sheet secured to it could be used as an anchor for ligature strangulation. The chief nursing officer (CNO) was present during the test and acknowledged, the results of the test and that the flush handle mechanism posed a safety concern. At the time of the Hillside Unit tour and toilet observations, 6 of the 8 patients on the unit were on suicide precautions.


On 09/20/21, at 5:25 p.m., an Immediate Jeopardy (IJ) was declared as the hospital failed to ensure the toilets in the 26 bathrooms used by 36 of 36 patients were with flush handles that could be used as a ligature anchor to commit suicide.

On 09/20/22 at 7:30 p.m., the hospital submitted a plan of correction (POC).

On 09/22/22 at 9:15 a.m., implementation of the hospital's POC was validated by the survey team. The Immediate Jeopardy (IJ) was removed in the presence of the CEO and RDRA.

Based on observation, interview, and record review, the facility failed to maintain equipment in a safe and sanitary manner when the glucometer (medical device used to measure the amount of sugar in the blood) was not cleaned and disinfected according to manufacturer's instructions for use (MIFU's).

This failure could have resulted in the transmission of infectious blood-borne pathogens (microorganisms that cause disease) to patients.

Findings:

During a concurrent observation and interview on 9/20/22, at 12:00 p.m., with the licensed nurse (LVN 1), at the G building's nurses station, in the medication room, LVN 1 verbalized, using a glucometer to check patients blood sugars. LVN 1 verbalized, the glucometer is cleaned between each patients use. When asked what product is used to clean and disinfect the glucometer, LVN 1 verbalized using alcohol wipes.

During a review of the manufacturer's (MIFU's) for the Assure Platinum Glucometer indicated in part ... "recommends using these wipes to clean and disinfect the meter: Clorox healthcare Bleach Wipes, Super Sani-Cloth Germicidal Disposable Wipes, or CaviWipes ..."

During an interview on 9/21/22, at 4:00 p.m., with the quality director (Adm 1), Adm 1 acknowledged. the glucometer was not being cleaned and disinfected according to the MIFU's and should be. Adm 1 further acknowledged, alcohol wipes were the incorrect cleaning and disinfecting product and further verbalized, the staff should be using the Super Sani-Cloth (purple top) Germicidal Disposable Wipes.

Based on interview and record review, the facility failed to ensure Patient N604's medical records were sent to the after care facility at discharge.

This failure resulted in the aftercare facility not having Patient N604's medical information in a timely manner to understand current coarse of illness and treatment, post discharge goals of care, and treatment preferences.

Findings:

During a review of Patient N604's "Case Manager Progress Note," dated 5/31/22, indicated, Patient N604 had follow-up appointment with Ventura County Behavioral Health Clinic (VCBH) on 6/10/22 at 1:00 p.m.

During a concurrent interview and record review, on 9/23/22, at 10:08 a.m., with the quality director (Adm 1), Patient N604's "Discharge Order/Aftercare Plan" dated 5/31/22, was reviewed. The Transmittal to next level of care section was blank. Adm 1 verbalized, this is where the nurse documents that the medical records were sent to the aftercare facility when the patient is discharged. Adm 1 acknowledged, there was no documentation that Patient N604's medical records were sent to the aftercare facility (VCBH).

During a review of the facility policy titled, "Discharge Planning, Transportation and Patient Aftercare Plan," revised 12/21, indicated, in part ... "Nursing may complete the Nursing section of the Discharge Order/Aftercare form, send a copy, along with medication reconciliation form, to the next level of care providers ...completion of transmittal to the next level of care and aftercare referrals may be documented on the discharge order/aftercare plan form once completed."

The Condition of Participation is not met as:

Based on observation, interview and record review, the hospital failed to ensure the individual patient record contained information relative to the reason for the patient's admission, assessments, plans, interventions, treatment team, responsible for care treatment modalities, response to interventions, and safe discharge planning when:

1. Psychosocial assessments were incomplete and not timely (Cross reference A-1625).

2. An individualized and comprehensive treatment plan was not developed for each patient within 72 hours of admission (Cross reference A-1640).

3. The treatment plan did not include a substantiated diagnosis, upon which the treatment plan is based (Cross reference A-1641).

4. The treatment plan did not include short term and long range goals with specific dates for achievement (Cross reference A-1642).

5. The treatment plan did not include the treatment modalities to be used to treat the patient during hospitalization (Cross reference A-1643.

6. The identification of members of the treatment plan responsible for particular aspects of the patient's care is not in the medical record (Cross reference A-1644)

7. The medical record did not contain recommendations for revisions in the treatment plan (Cross reference A-1661).

8. The medical record did not contain information about discharge and after care planning (Cross reference A-1671)


The cumulative effects of these systemic problems resulted in the hospital's inability to ensure the patient's medical record completely captured, and reflected the care provided to each patient by members of the treatment team, and the patient's response to treatments and progress towards goals and readiness for discharge.

Based on interview, and record review, the facility failed to ensure 14 of 34 sampled patients (N100, N102, N103, N104, N105, N106, N107, N200, N201, N202, N203, N205, N206, and N604) received a completed psychosocial assessment within 72 hours of admission.

This failure had the potential for these patients to receive incomplete treatment planning, interventions, and discharge planning, due to lack of or incomplete psychosocial assessements and history.


Findings:

1. During a review of the facility's policy and procedure (P&P) titled, "Admission Assessment," revised 9/20, indicated, in part ... "The data generated by the assessment process will be used in planning appropriate patient care and utilized throughout hospitalization in the planning of psychiatric treatment, medical treatment and aftercare. The admission assessment is completed through the use of four assessment components: Intake Assessment; Nursing Assessment; Psychosocial Assessment; Therapeutic Assessment. The Psychosocial is to be completed within 72 hours of admission by Social Services staff."

During a oncurrent record review and interview on 9/21/22, at 10:04 am, with director of risk and accreditation (DRA), the DRA reviewed Patient N604's medical record, the medical record indicated, Patient N604 was admitted on 5/21/22 at 0301 and the "Psychosocial Assessment" was completed on 5/24/22 at 1311. Confirmed with DRA, "Psychosocial Assessment" completed over 72 hours of admission.


35399

2. The facility P&P titled, "Admission Assessment," revised 9/20, indicated, in part ... "The data generated by the assessment process will be used in planning appropriate patient care and utilized throughout hospitalization in the planning of psychiatric treatment, medical treatment and aftercare. The admission assessment is completed through the use of four assessment components: Intake Assessment; Nursing Assessment; Psychosocial Assessment; Therapeutic Assessment. The Psychosocial is to be completed within 72 hours of admission by Social Services staff."

During a review of clinical records for Patients' 100, 102, 103, 104, 105, 106, and 107 and concurrent interview with the house supervisor (HS) on 9/22/22 from 10:30 a.m., to 12:45 p.m., the HS acknowledged and confirmed, there was no psychosocial assessment performed on these seven (7) patients. HS stated "No, I can't find the psychosocial assessments in the records for these patients. They were not performed."



39520

3. The facility P&P titled, "Admission Assessment," revised 9/20, indicated, in part ... "The data generated by the assessment process will be used in planning appropriate patient care and utilized throughout hospitalization in the planning of psychiatric treatment, medical treatment and aftercare. The admission assessment is completed through the use of four assessment components: Intake Assessment; Nursing Assessment; Psychosocial Assessment; Therapeutic Assessment. The Psychosocial is to be completed within 72 hours of admission by Social Services staff."

During a concurrent interview and record review on 9/22/22, from 9:40 a.m., to 11:22 a.m., with the quality director (Adm 1), Patients' N201 and N202 medical records were reviewed. Patient N201's medical record indicated, Patient N201 was admitted on 9/15/22 at 2:09 p.m. and the "Psychosocial Assessment" was completed on 9/22/22 at 9:03 a.m. Adm 1 acknowledged, the assessment was late and completed after 72 hours of admission. Patient N202's medical record indicated Patient N 202 was admitted on 9/18/22 at 12:54 p.m. and the "Psychosocial Assessment" was completed on 9/22/22 at 9:48 a.m. Adm 1 acknowledged, the assessment was late and completed after 72 hours of admission.

During a concurrent interview and record review on 9/22/22, from 11:30 a.m., to 12:45 p.m., with the quality director (Adm 1), Patients' N200, N205, and N206 medical records were reviewed. Adm 1 acknowledged and confirmed, there were no psychosocial assessments performed on these three patients. Adm 1 verbalized, psychosocial assessments should be done within 72 hours of admission.

During a concurrent interview and record review on 9/22/22, at 11:25 p.m., with the quality director (Adm 1), Patient N203's medical record was reviewed. Patient N203's medical record indicated, Patient N203 was admitted on 9/19/22 at 10:01 p.m. and the "Psychosocial Assessment" was started on 9/22/22, at 9:48 a.m. Acute symptoms, History and Current Risk Factors, Family/Social/Cultural, and the Patient Interview sections were left blank. The Psychosocial Assessment was incomplete. Adm 1 acknowledged, the assessment was incomplete and should have been complete within 72 hours of admission.

During a concurrent interview and record review on 9/22/22, at 3:28 p.m., with the therapist (MFT 1), MFT 1 verbalized, he completes the "Psychosocial Assessments." Patients' N201, N202, and N203 medical records were reviewed. MFT 1 acknowledged the Psychosocial Assessments were late and incomplete. MFT 1 verbalized being on vacation and that is the reason the Psychosocial Assessments were missing, late, or incomplete. MFT 1 verbalized, when on vacation there was no other MFT to assess the patients. MFT 1 acknowledged, the facility operated 24/7. MFT 1 acknowledged, being short staffed and there is no other MFT for back up if he was not at the facility.

Based on interview and record review, the hospital failed to ensure each patient had an individualized treatment plan developed that was based on the patient's strengths/disabilities assessed by the patients' treatment team, in 20 of 34 patients (patients N100, N106, N200, N203, N204, N206, N300, N302, N303, N304, N305, N400, N401, N402, N404, N403, N404, N405, N406, N603). The entire treatment plan was missing or did not incorporate the patient's strengths/disabilities in the assessment process.

This failure had the potential for the patient to lack a comprehensive and completed treatment plan to direct the care team's interventions, which could lead to lack of progress of the patient, premature discharge, or prolonged hospitalization.

Findings:
The hospital policy and procedure (P&P) titled, "Treatment Planning, revised 3/21, indicated, in part... "3. Within 72 hours of admission, members of the interdisciplinary treatment team should further develop a master treatment plan (MTP) that is based on a comprehensive assessment of the patients' presenting problems, physical health, emotional and behavioral status..." In the TREATMENT PLAN COMPONENTS part indicated "Strength/Weaknesses: listing of strengths and weaknesses that may be utilized in development of the treatment plan interventions."

During a concurrent interview and record review on 09/21/22, at 11:30 a.m., with registered nurse (RN 1), the medical record of patient N300 was reviewed for the presence ,and completion of the document titled, "Master Treatment Plan." RN 1 confirmed, the Master treatment plan was not in the medical record and it should be within 72 hours of the patient's admission. N300 was admitted on 09/12/22.

During an interview on 09/21/22, at 11:30 a.m., with the chief nursing officer (CNO), the CNO acknowledged, patient N300 was missing a master treatment plan.

During a concurrent interview and record review on 09/21/22, at 12:00 p.m., with RN 1, the medical record of patient N303 was reviewed for the presence and completion of the document titled "Master Treatment Plan." RN 1 confirmed, the Master Treatment Plan was not in the medical record and it should be within 72 hours of the patient's admission. N303 was admitted on 09/12/22.

During a concurrent interview and record review on 09/21/22, at 12:30 p.m., with RN 1, the medical record of patient N304 was reviewed for the presence of the Master treatment plan. RN 1 confirmed, the master treatment plan was not in the medical record and it should have been within 72 hours of admission. N304 was admitted on 09/17/22.

During a concurrent interview and record review on 09/23/22, at 8:30 a.m., with the director of risk and accreditation (DRA), the medical record of patient N301 was reviewed for the presence and completion of the master treatment plan. The DRA confirmed, that the master treatment plan was not present in the medical record, but it should have been within 72 hours of admission. N301 was admitted 09/13/22.

During a concurrent interview and record review on 09/23/22, at 8:40a.m., with the director of risk and accreditation (DRA), the medical record of patient N302 was reviewed for the presence and completion of the master treatment plan. The DRA confirmed, that the master treatment plan was not present in the medical record, but it should have been within 72 hours of admission. N302 was admitted 09/12/22.

During a concurrent interview and record review on 09/23/22, at 8:50a.m., with the director of risk and accreditation (DRA), the medical record of patient N305 was reviewed for the presence and completion of the master treatment plan. The DRA confirmed, that the master treatment plan was not present in the medical record, but it should have been within 72 hours of admission. N305 was admitted 09/14/22.


35399

The hospital P&P titled, "Treatment Planning," revised 3/21, indicated, "3. Within 72 hours of admission, members of the interdisciplinary treatment team should further develop a master treatment plan (MTP) that is based on a comprehensive assessment of the patients' presenting problems, physical health, emotional and behavioral status..." In the TREATMENT PLAN COMPONENTS part indicated "Strength/Weaknesses: listing of strains and weaknesses that may be utilized in development of the treatment plan interventions."

During a review of the clinical record for patient 100 and 106 and concurrent interview with the house supervisor HS on 9/22/22, from11:25 a.m., to 12:10 p.m., the records indicated, these two Master Treatment Plan (MTPs) were missing the patients' strengths and weakness. HS acknowledged and confirmed, the patients' strengths and weakness were not identified when the MTP was developed.


40469

3. The facility P&P titled, "Treatment Planning," revised 3/21, indicated, "4. The Master Treatment Plan shall contain specific interventions that relate to goals, ... and include expected achievement dates as well as the person responsible for implementation of the intervention ... will take into consideration patient care standards and program/unit or departmental policies as they relate to the individual patient ... 10. All individuals, including the patient ... shall sign the Plan after completion. 11. The Treatment Plan shall be reviewed and updated as frequently as clinically indicated by the patient's anticipated length of stay and treatment issues, but at a minimum, is to be reviewed once a week ... 12. Treatment Plan reviews and updates shall include ... 12 B ... modifications or additions made to problems/goals ... Treatment Plan Components: Active Problems: ... will be incorporated into the treatment plan ..."

During a record review and concurrent interview on 9/21/22, at 11 a.m., the Quality Improvement Coordinator (QIC) provided the "Master Treatment Plan," "Master Treatment Plan Review," and "Seclusion and Restraint" records for seven patients (N400, N401, N402, N403, N404, N405 and N406). The QIC confirmed and indicated, these are the records for the above documents, no other records are found.

Conducted an interview and concurrent record review on 9/23/22, at 9:18 a.m. with the Chief Nursing Officer (CNO). Reviewed seven Patients' (N400, N401, N402, N403, N404, N405, and N406) "Master Treatment Plan" (MTP), "Master Treatment Plan (MTP) Review," and the "Seclusion and Restraint" records with the CNO. One patient (N402) of seven had no completed MTP. The other six patients' MTP did not include: problem sheets (objectives and solutions), long-term and short-term goals, interventions, and Interdisciplinary Team Members responsible for carrying out interventions. Five patients (N400, N401, N403, and N405) had no weekly "Master Treatment Plan (MTP) Review". Patients N404 and N406 weekly MTP revisions were incomplete and/or blank and missing the Physician's signature. According to the documents titled "Seclusion/Restraints," each of the seven patients had been placed into seclusion/restraints multiple times during their stay.


The CNO agreed and confirmed, the "Master Treatment Plan" for the seven patients are not: complete, problem focused, individualized, updated, accurate, and do not include interventions by appropriate staff. The CNO also acknowledged and agreed, that when a patient is placed on seclusion or restraints the Treatment Plan needs to be modified and /or updated to reflect the use of restraints/seclusion and was not.


40678

2. During a review of the Facility's P&P titled, "Treatment Planning", revised 3/21, indicated in part... "Each patient admitted to the hospital shall have a written, individualized treatment plan. Based on assessments of clinical needs, the scope of the plan shall include the patient's statement to aid in treating planning, and identified if they will be actively treated or not, the substantiated diagnosis, patient strengths and weaknesses, active problem list, discharge criteria/plan, ELOS, goals and objectives of treatment, clinical interventions prescribed, patient progress in meeting goals and objectives ... Within 24 hours the physician will complete the Psych Evaluation (PE) and PE Initial Treatment Plan."

During a record review and concurrent interview on 9/21/22, at 12:12 pm, with director of risk and accreditation (DRA), DRA reviewed Patient N603's medical record. "Physician's Initial Treatment Plan" could not be located, confirmed with DRA.


39520

1. The hospital P&P titled, "Treatment Planning, revised 3/21, indicated, in part... "3. Within 72 hours of admission, members of the interdisciplinary treatment team should further develop a master treatment plan (MTP) that is based on a comprehensive assessment of the patients' presenting problems, physical health, emotional and behavioral status..." In the TREATMENT PLAN COMPONENTS part indicated "Strength/Weaknesses: listing of stengths and weaknesses that may be utilized in development of the treatment plan interventions."

During a concurrent interview and record review on 9/22/22, from 9:40 a.m., to 12:40 p.m., with the quality director (Adm 1), Patients' N200, N203, N204, and N206 medical records were reviewed. The records indicated, these four Master Treatment Plans (MTPs) were missing the patients' strengths and weakness. Adm 1 acknowledged, the MTPs were incomplete for these four patients.

Based on interview and record review the hospital failed to ensure two sampled patients (Patient 100 and 106) Master Treatment Plan (MTP) identified the substantiated diagnosis as indicated by their policy and procedure (P&P).

This failure place the risk of patient not receiving the appropriate treatment relevant to their diagnosis.

Findings:

The hospital P&P titled, "Treatment Planning, revised 3/21, indicated, "3. Within 72 hours of admission, members of the interdisciplinary treatment team should further develop a master treatment plan (MTP) that is based on a comprehensive assessment of the patients' presenting problems, physical health, emotional and behavioral status..." In the TREATMENT PLAN COMPONENTS part indicated "Substantiated Diagnosis: at the time of the first treatment planning meeting, diagnosis will be recorded as determined by the attending physician."

During a review of the clinical record for patient 100 and 106 and concurrent interview with the house supervisor HS on 9/22/22, from11:25 a.m., to 12:10 p.m., the records indicated, these two Master Treatment Plan (MTPs) were missing the patients' diagnosis. HS acknowledged and confirmed, the patients' diagnosis were not identified when the MTP was developed.

Based on interview and record review, the hospital failed to ensure that individualized long term and short term goals had been developed for 18 of 34 patients (patients N100, N102, N103, N104, N105, N106, N200, N201, N203, N204, N206, N300, N301, N302, N303, N304, N305, N603).

The failure had the potential for the treatment team to be unaware of each patient's progress or lack of progress towards goals of treatment, including readiness for a safe discharge.

Findings:

1. The hospital policy and procedure (P&P) titled, "Treatment Planning," revised 3/21, indicated, "3. Within 72 hours of admission, members of the interdisciplinary treatment team should further develop a master treatment plan (MTP) that is based on a comprehensive assessment of the patients' presenting problems, physical health, emotional and behavioral status..." In the TREATMENT PLAN COMPONENTS part indicated "Long term Goals: the long-term goal for the problem is representative of a specific action, measurement and focus designed to be ideally accomplished by time of discharge. Short term goals: short- term goals are stated as "stepping stones" to the accomplishment of a long term goal".

During a concurrent interview and medical record review on 09/21/22, at 11:30 a.m., with registered nurse (RN 1) the medical record of patients (N300, N303, and N304) was reviewed for the presence of short term and long-term goals. RN 1 confirmed, that the short term and long term goals for these patients were not in the medical record.

During a concurrent interview and record review, on 09/23/22, at 10:30 a.m., with the director of risk and accreditation (DRA), the DRA confirmed the medical records for the following patients (N300, N301, N302, N303, N304, N305) did not have short and long term goals, but these goals should have been in the medical record for each patient as per the facility policy and procedure.


35399

2.The hospital P&P titled, "Treatment Planning," revised 3/21, indicated, "3. Within 72 hours of admission, members of the interdisciplinary treatment team should further develop a master treatment plan (MTP) that is based on a comprehensive assessment of the patients' presenting problems, physical health, emotional and behavioral status..." In the TREATMENT PLAN COMPONENTS part indicated "Long term Goals: the long-term goal for the problem is representative of a specific action, measurement and focus designed to be ideally accomplished by time of discharge. Short term goals: short- term goals are stated as "stepping stones" to the accomplishment of a long term goal. Through measurable and observable indicators, they are designed to reduce behaviorisms associated with the indicated problem."

During a review of the clinical record for patients 100, 102, 103, 104, 105 and 106 and concurrent interview with the house supervisor HS on 9/22/22, from10:25 a.m., to 4:46 p.m., the records indicated these six Master Treatment Plan (MTPs) were missing the patients' long- term and short-term goals. HS acknowledged and confirmed, the patients' long term and short-term goals were not identified when the MTP was developed.


40678


3.During a review of the Facility's P&P titled, "Treatment Planning," revised 3/21, indicated, in part..."Each patient admitted to the hospital shall have a written, individualized treatment plan. Based on assessments of clinical needs, the scope of the plan shall include the patient's statement to aid in treating planning, and identified if they will be actively treated or not, the substantiated diagnosis, patient strengths and weaknesses, active problem list, discharge criteria/plan, ELOS, goals and objectives of treatment, clinical interventions prescribed, patient progress in meeting goals and objectives ...Within 24 hours the physician will complete the Psych Evaluation (PE) and PE Initial Treatment Plan."

During a record review and concurrent interview on 9/21/22, at 12:12 pm, with director of risk and accreditation (DRA), DRA reviewed Patient N603's medical record "Master Treatment Plan" did not contain short term goals or specific discharge criteria, confirmed with DRA.


39520

4. The hospital P&P titled, "Treatment Planning," revised 3/21, indicated, "3. Within 72 hours of admission, members of the interdisciplinary treatment team should further develop a master treatment plan (MTP) that is based on a comprehensive assessment of the patients' presenting problems, physical health, emotional and behavioral status..." In the TREATMENT PLAN COMPONENTS part indicated "Long term Goals: the long-term goal for the problem is representative of a specific action, measurement and focus designed to be ideally accomplished by time of discharge. Short term goals: short- term goals are stated as "stepping stones" to the accomplishment of a long term goal. Through measurable and observable indicators, they are designed to reduce behaviorisms associated with the indicated problem."

During a concurrent interview and record review on 9/22/22, 9:40 a.m., to 12:40 p.m., with the quality director (Adm 1), Patients' N200, N201, N204, and N206 medical records were reviewed. The records indicated, these four Master Treatment Plans (MTPs) were missing the patients' long-term and short-term goals. Adm 1 acknowledged and confirmed, the patients' psychiatric problem sheets, which contained the long-term and short-term goals, were not identified when the MTP was being developed. Patient N204's MTP did not have an initial problem list identified, the section was blank. Adm 1 acknowledged, the MTPs were incomplete for these four patients.

During a concurrent interview and record review on 9/22/22, at 11:22 a.m., with the quality director (Adm 1), Patient N 203's medical record was reviewed. The record indicated, the Master Treatment Plan (MTP) was missing Patient N203's long-term and short term goals for the psychiatric problem of suicide. Adm 1 acknowledged, the psychiatric problem sheet was missing and should be there. Adm 1 acknowledged, the MTP was incomplete for Patient N203.

Based on interview and record review the hospital failed to ensure six sampled patients (Patient 100, 102, 103, 104, 105 and 106) Master Treatment Plan (MTP) identified the Interventions/Modalities as indicated by their policy and procedure (P&P).

This failure place the risk of patient not receiving the appropriate treatment relevant to their Interventions/Modalities.

Findings:

The hospital P&P titled, "Treatment Planning," revised 3/21, indicated, "3. Within 72 hours of admission, members of the interdisciplinary treatment team should further develop a master treatment plan (MTP) that is based on a comprehensive assessment of the patients' presenting problems, physical health, emotional and behavioral status..." In the TREATMENT PLAN COMPONENTS part indicated "Interventions: Interventions for each appropriate discipline will be included for each problem."

During a review of the clinical record for patients 100, 102, 103, 104, 105 and 106, and concurrent interview with the house supervisor HS on 9/22/22, from10:25 a.m., to 4:46 p.m., the records indicated, these six Master Treatment Plan (MTPs) were missing the patients' Interventions/Modalities. HS acknowledged and confirmed, the patients' interventions were not identified when the MTP was developed.

Based on interview and record review, the hospital failed to ensure five sampled patients (Patient N201, N203, N204, N205 and N206) Master Treatment Plans (MTP) identified each member of the Multidisciplinary Treatment Team indicated by their policy and procedure (P&P).

This failure places the patients at risk of not receiving the appropriate treatment by failing to identify the persons responsible for planning, reviewing and evaluating the treatment plan and interventions.

Findings:

During a review of the facility's P&P titled, "Treatment Planning," revised 3/21, indicated, in part... "Each patient admitted to the hospital shall have a written, individualized treatment plan ... based on assessments of clinical needs, the scope of the plan shall include the patient's statement to aid in treating planning, and identified if they will be actively treated or not, the substantiated diagnosis, patient strengths and weaknesses, active problem list, discharge criteria/plan, ELOS, goals and objectives of treatment, clinical interventions prescribed, patient progress in meeting goals and objectives, persons responsible for interventions, and provisions for aftercare ...treatment shall be planned, reviewed, and evaluated at regular intervals by a Multidisciplinary Treatment Team ...this team shall consist of the physician and representatives of each clinical discipline involved in the treatment ..."

During a concurrent interview and record review on 9/22/22, from 9:40 a.m., to 12:40 p.m., with the quality director (Adm 1), Patients' N201, N203, N204, N205 and N206 medical records were reviewed. Patient N201's MTP was missing the physician and nursing signatures who are part of the Treatment Team. Patient N203's MTP was missing the nursing signature who is part of the Treatment Team. Patient N204's MTP was missing the social services signature who is part of the Treatment Team. Patient N205's MTP was missing the nursing signature who is part of the Treatment Team. Patient N206's MTP was missing the nursing signature who is part of the Treatment Team. Adm 1 acknowledged, the MTPs were missing signatures of the Multidisciplinary Treatment Team for these five patients and verbalized, the MTP's were incomplete.

Based on interview and record review, the hospital failed to ensure 15 of 34 patients' (N200, N201, N202, N203, N204, N205, N206, N300, N301, N302, N303, N304, N305, N306, N604) treatment plan was reviewed and revised to include any recommendations by the treatment team necessary for each patient to move toward their individualized goals.

This failure had the potential for each patient to deteriorate both mentally and/or physically, which could lead to harm to self or harm to others, prolonged hospitalization or unsafe discharge.

Findings:

1. The facility's P&P titled, "Treatment Planning," dated 03/2021, indicated, "The treatment plan shall be reviewed and updated as frequently as clinically indicated by the patient's anticipated length of stay and treatment issues, but at a minimum, the treatment plan is to be reviewed once a week.

During a concurrent interview and record review on 09/21/22, at 11:30 a.m., with registered nurse (RN 1), the medical record of patients N300, N303, and N304 was reviewed. RN 1 confirmed, treatment plan reviews and revisions were not in the medical record.

During an interview on 09/23/22, at 10:30 a.m., with the director of risk and accreditation (DRA), the DRA acknowledged, the medical records for the following patients (N300, N301, N302, N303, N304, N305, and N306) should have included evidence of review and revisions of treatment plan, at least weekly, as per the facility P&P.


39520


2.The facility's P&P titled, "Treatment Planning," dated 03/2021, indicated, "The treatment plan shall be reviewed and updated as frequently as clinically indicated by the patient's anticipated length of stay and treatment issues, but at a minimum, the treatment plan is to be reviewed once a week."

During a concurrent interview and record review on 9/22/22, form 9:40 a.m., to 12:40 p.m., with the quality director (Adm 1), Patients' N200, N201, N202, N203, N204, N205 and N206 medical records were reviewed. Adm 1 confirmed, treatment plan reviews and revisions were not in the medical record and should be.


40678

3. During a review of the facility's P&P titled, "Treatment Planning," revised 3/21, indicated, in part ... "The patient's progress and current status in meeting the long-term and short-term goals and objectives of his/her treatment plan shall be regularly recorded in the patient's medical record. 2x progress notes and MTP reviews. Treatment Plan reviews and updates shall include the following steps: Review of progress toward goals and effectiveness of interventions for each open problems on the Problem List."

During a record review and concurrent interview on 9/21/22, at 10:04 am, with director of risk and accreditation (DRA), DRA reviewed Patient N604's medical record "Master Treatment Plan" dated 5/30/22, indicated, goal revised, revised "Master Treatment Plan" could not be located. Confirmed with DRA, unable to locate revised goal.

Based on interview and record review, the facility failed to ensure complete discharge order and aftercare plan were provided to one patient (Patient N604).

This failure had the potential to not allow patients, their guardians, and subsequent care providers to be informed of patient's aftercare plan, including follow-up care.

Findings:

During a review of the facility policy titled, "Discharge of Patient," revised 10/20, indicated, in part ... "The nurse completes their section of the Discharge Order/Aftercare Plan form reviews this with the patient and family and gives a copy of this to the patient and family. This will include, special diet regimen, activity restrictions, and outpatient follow-up. R.N. will complete the discharge information in the medical record. The Summary will address all umbered categories: appearance and affect, problems addressed during hospitalization, response to interventions/health teaching, patient/family goals reached, and understanding of discharge instructions."


During a record review and concurrent interview on 9/21/22, at 10:04 am, with director of risk and accreditation (DRA), DRA reviewed Patient N604's medical record "Discharge Order/After Care Plan" review dated 5/31/22, indicated, social services section is blank which includes next level of care appointment. DRA stated, "this should be filled out this is what is printed for the patient and how they know what care follow-up they have" confirmed with DRA this section is blank. Further review of the medical record indicated "RN summary" could not be located. Confirmed with DRA, unable to locate RN summary and it should be there.

The Condition of Participation was not met as:

Based on obsevation, interview, and record review, the hospital failed to ensure the special staff requirements when:


1. Personal active treatment programs were not provided. (Cross Reference
A- 1687).

2. Discharge planning was not provided. (Cross Reference A-1688).

3. Inadequate number of licensed nurses and mental health workers to provide psychiatric care to patients. (Cross Reference A-1704).

4. Inadequate number of staff to provide therapeutic activities to patients. (Cross Reference A-1720).

5. Admission assessments not completed to ensure appropriate patient care. (Cross Reference A- 1726).

The cumulative effects of the hospital's systematic failure to follow policies and procedures, resulted in the hospital's inability to ensure the provision of appropriate patient care, activities, and psychotherapeutic treatments.

Based on interview and record review the hospital failed to ensure there was enough staff to provide active group therapy to support the patient's psychosocial and therapeutic treatment.

The hospital's failure places the patients at risk of not receiving the appropriate psychosocial and therapeutic treatment before returning to society.

Findings:

1. The hospital's policy and procedure (P&P) titled, "Scope of Services/Staff Plan Social Services," revised 8/20, indicated, "The goal of the social services department is to assist patients in adapting or resolving the crisis precipitating hospitalization ... The department provides individual counseling, group therapy ... The social service department will provide seven day a week coverage for groups ... In the DEPARTMENT GOALS part indicated "1. Complete psychosocial within 72 hours of admit. 2. Provide discharge planning assistance to all patients starting at the admission process. 3. Fully educate patient under treatment plan, obtain their signature and document corresponding progress note. 4. Conduct groups on time 90% of the time." "CORE STAFFING: consists of PhD, MFT, LCSW, and LPTs."

A review of the Therapist job description (JB), dated 8/5/17, indicated, "Basic purpose of position: To provide psychotherapeutic services to all patients ... support the organization's treatment program ..."

During a review of the clinical record for patient 100 and concurrent interview with the house supervisor HS on 9/22/22, at 10:50 a.m., the record indicated, patient was admitted on 9/15/22. HS acknowledged and confirmed, patient have not attended or participated in any therapy groups. HS stated, "There are no groups (notes) led by a therapist or social worker. I don't see any."

A review of the Patient Observation Record (Rounds Sheet) for 9/15/22, 9/16/22, 9/17/22, 9/18/22, 9/19/22 and 9/20/22 for Patient 100 indicated, patient was not observed at any group therapy/activity on these dates. Rounds Sheet is where the MHW documents every 15 minutes the observation as to where the patient is, and what the patient is doing at the time. Every 15 minutes rounds occur 24 hours a day.

During a review of the clinical record for patient 102 and concurrent interview with the house supervisor HS on 9/22/22, at 11:25 a.m., the record indicated, patient was admitted on 9/12/22. HS acknowledged and confirmed, patient only attended one process therapy group on 9/19/22 since admission. HS stated, "One therapy group is not enough for patient she needs more. There is no other documentation."

During a review of the clinical record for patient 104 and concurrent interview with the house supervisor HS on 9/22/22, at 3:40 p.m., the record indicated, patient was admitted on 9/14/22. HS acknowledged and confirmed, patient only attended one process therapy group on 9/19/22 since admission. HS stated, "There is no other documentation of any other therapy."

During an interview with MHW 4 on 9/20/22, at 3:20 p.m., MHW 4 stated, "The kids have no schoolteacher, no activities, no therapies so the kids don't do anything else but sit inside this Day Care room..."

During an interview with the chief nurse officer (CNO) on 9/20/22, at 3:45 p.m., CNO was asked regarding the adolescents having group activities and/or group therapies. The CNO acknowledged and confirmed, not having an active activities and/or therapies calendar schedule. CNO stated, "I don't have a current/active activities/groups or therapies calendar or schedule. We lost our pastor who did spiritual & clinical insight, there is no teacher, and we don't have enough therapist ..."

During an interview with registered nurse (RN 1) on 9/21/22 at 2:50 p.m., RN stated, "The kids really need to have expressive therapy, but they have not had any for a while possibly June 2022."


39520

2. The hospital's P&P titled, "Scope of Services/Staff Plan Social Services," revised 8/20, indicated, "The goal of the social services department is to assist patients in adapting or resolving the crisis precipitating hospitalization ... The department provides individual counseling, group therapy ... The social service department will provide seven day a week coverage for groups ... In the DEPARTMENT GOALS part indicated "1. Complete psychosocial within 72 hours of admit. 2. Provide discharge planning assistance to all patients starting at the admission process. 3. Fully educate patient under treatment plan, obtain their signature and document corresponding progress note. 4. Conduct groups on time 90% of the time." "CORE STAFFING: consists of PhD, MFT, LCSW, and LPTs."

A review of the Therapist job description (JB), dated 8/5/17, indicated, "Basic purpose of position: To provide psychotherapeutic services to all patients ... support the organization's treatment program ..."

During an observation on 9/20/22, at 11:45 a.m., in the dayroom on Oceanview Unit, in Building G, three patients were observed sitting in chairs watching T.V. The whiteboard in the day room indicated, the therapist on for the day was MFT 1. The dayroom on Mountain View Unit, in Building G, was empty.

During an interview on 9/20/22, at 12:15 p.m. with Patient N202 who was sitting in the dayroom, Patient N202 verbalized, she was admitted on 9/18/22 and has not seen or talked to a therapist yet, and has not seen a psychiatrist yet. Patient N202 stated, " Aren't we here for therapy, that is the reason why we are admitted, it is not just about receiving medication."

During a review of the posted "Group Activities" for Building G, indicated :
On Tuesday:
8:30-9:00 a.m. Community Meeting & Goals Group- Mental Health Workers (MHW)
10:00-11:00 a.m. Wellness Education therapy group- Clinical Therapy
11:00-12:00 p.m. Expressive Therapy- Expressive Therapy
1:00-2:00 p.m. Skill Building Therapy Group- Clinical Therapy
2:00-3:00 p.m. Expressive Therapy-Expressive Therapy
3:00-4:00 p.m. Spiritual & Clinical Insight- Chaplain
4:00-5:00 p.m. Meditation- MHW
8:00-9:30 p.m. Wrap-up/medications- MHW

During an interview on 9/20/22, at 3:37 p.m., with mental health worker (MHW 5), verbalized the facility should have at least two groups with a therapist scheduled per day. MHW 5 verbalized, therapist teaches coping skills and coping mechanisms. MHW 5 verbalized, community meeting, social skills, creative therapy spiritual services are not happening at this time due to short staffing and the chaplain passed away. MHW 5 verbalized, 90% of the time groups are not happening. When asked if there was a group conducted today, MHW 5 stated, "No groups happened today." When asked if therapy groups were conducted yesterday, MHW 5 stated, "No groups yesterday." MHW 5 verbalized, there is only one therapist on staff and was on vacation last week and further verbalized the facility has not had a therapy group for at least a week. MHW 5 verbalized, there has been no recreation therapist for 6 months or longer.

During a review of the clinical record for Patient N202 and concurrent interview with the quality director (Adm 1) on 9/22/22, at 10:55 a.m., the record indicated, Patient N202 was admitted on 9/18/22. Adm 1 acknowledged and confirmed, Patient N202 only attended 2 social service therapy groups on 9/21/22 since admission. Adm 1 acknowledged, there is no other documentation of Patient N202 having individual or group therapy.

A review of the Patient Observation Record (Rounds Sheet) for 9/18/22, 9/19/22, 9/20/22, for Patient N202 indicated, Patient N202 was not observed at any group therapy/activity on these dates. Rounds Sheet is where the MHW documents every 15 minutes the observation as to where the patient is and what the patient is doing at the time. Every 15 minutes rounds occur 24 hours a day.

Based on interview and record review the hospital failed to ensure there was enough staff to engage in discharge planning.

The hospital's failure place patients at risk for not having appropriate or no discharge planning prior to being discharge home.

Findings:

The hospital's policy and procedure titled, "Scope of Services/Staff Plan Social Services," revised 8/20, indicated, "The goal of the social services department is to assist patients in adapting or resolving the crisis precipitating hospitalization. This includes discharge planning that addresses medication, counseling, and housing needs. Staff duties include case management, discharge planning, which includes referrals for medication, counseling, and housing. The department we'll provide all aspects of case management and discharge planning. In the DEPARTMENT GOALS part indicated "2. Provide discharge planning assistance to all patients starting at the admission process."

During a review of the clinical record for patient 100, and concurrent interview with the house supervisor HS on 9/22/22, at 10:55 a.m., the record indicated, Patient 100 was admitted on 9/15/22, and there was no discharge planning for this patient. HS acknowledged and confirmed, there was no documentation located in the record that discharge planning had been initiated. HS stated, "Yes, discharge planning starts upon admission and there is no documentation of that."

During a review of the clinical record for patient 103, and concurrent interview with the house supervisor HS on 9/22/22, at 4:25 p.m., the record indicated, Patient 103 was admitted on 9/16/22 ,and there was no discharge planning upon admission of patient. HS acknowledged and confirmed, there was no documentation located in the record indicating discharge planning was initiated upon admission. HS stated,"Yes, discharge planning starts upon admission and there is no documentation of that."

During a review of the clinical record for patient 106, and concurrent interview with the house supervisor HS on 9/22/22, at 11:48 a.m., the record indicated, Patient 106 was admitted on 9/16/22 and there was no discharge planning upon admission of patient. HS acknowledged and confirmed, there was no documentation located in the record indicating discharge planning was initiated upon admission. HS stated, "Yes, discharge planning did not start upon admission the documentation addresses discharge on 9/21/22."

Based on interview and record review, the hospital failed to have adequate number of registered nurses (RN) and mental health workers (MHW) to provide psychiatric care to patients.

This hospital's failure resulted in negative outcome to patient N108, and had the potential to result in a negative outcome for more patients.

Findings:

During an interview with MD 2 on 9/21/22, at 3:05 p.m., MD 2 confirmed, evaluating Patient 108 on 5/3/22. MD 2 indicated, that on 5/3/22 he was asked by registered nurse (RN 1) to re-evaluate Patient 108 to see if the 1:1 staff observation status could be discontinued because another patient was going to be admitted who needed the 1:1 staff. MD 2 stated, "Retrospectively, if [RN 1 name] had not come to me to tell me that he needed the 1:1 staff for that other patient. I would have left the 1:1 observation monitoring on this patient (Patient 108) for more days in a cautionary way/status."

During an interview with registered nurse (RN 1) on 9/21/22, at 2:37 p.m., RN 1 confirmed, that on 5/3/22 he was asked by his supervisor to see if Patient N108 1:1 staff observation status could be discontinued because another patient was going to require the 1:1 observation staff.

The acute nursing progress note, day shift, dated 5/4/22, at 1:00 p.m., created by RN 1 was reviewed with RN 1 on 9/21/22 at 2:37 p.m. The note indicated, an assessment was performed at 1:00 p.m., after the patient had been transferred to an emergency department (ED). RN 1 reported, being very busy on 5/4/22 with discharges and admissions of patients. On 5/4/22, RN 1 had approximately 16 patients to performed assessments on which was challenging because he was very busy of the time. RN1 was the only RN in the adolescent unit.

2. On 9/20/22 at 11:46 a.m., inside the Day Care room nine (9) adolescent patients were observed watching television. One mental health worker MHW 4 was observed inside the Day Care room. MHW explained, the adolescent patients all had to be inside the Day Care room together for the MHW to watch them all. There is not enough MHWs to take some of the adolescents outside to play or do any other activities.

During an interview with MHW 3 at 11:48 a.m., MHW 3 explained, at times a MHW was assigned to do activities with the adolescents. But lately this has not happened because there is not enough MHWs staff to do this.

During an interview with MHW 1 at 11:50 a.m., MHW 1 explained, the adolescents spend most of their time in the Day Care room or their room because they don't have anything else to do. There is not enough MHWs to engage adolescents in any stimuli like journaling, art ... MHW is assigned to do some activities with adolescents, but they are assigned to do other tasks as well like head rounds ... and this is not safe for the adolescents.

During an interview with the chief nurse officer (CNO) on 9/23/22, at 10:40 a.m., and concurrent review of the policy and procedure titled, "Staffing Pattern and Patient Acuity', dated 8/22, the policy included staffing ratios without any reference or supporting data as to how the staffing ratios were determined. On the bottom of the night shift staffing ratios document indicated, "The above guidelines do not include additional staff needs for elevated acuity ... staffing will be adjusted to address acuity needs." The CNO was asked to provide supporting data used to determine the patient staffing matrix/ratios/patterns and to provide the method of measuring, calculating, or determining the acuity of the patients. CNO stated, "No, I don't have a method of measuring or determine acuity of patients." Hospital was not able to provide requested information supporting how the staffing ratios/matrix was determine based on the acuity level of their patients. The patient acuity level is calculated based on the clinical patient characteristics and the care involved (workload.).

Based on observation, interview, and record review, the hospital failed to ensure there was enough staff to provide therapeutic activities program to support the patient's psychosocial and therapeutic treatment and failed to complete therapeutic services assessments upon admission.

The hospital's failures placed the patients at risk of not receiving the appropriate psychosocial and therapeutic treatment before returning to society.


Findings:


1. The hospital's policy and procedure (P&P) titled, "Scope of Services/Staff Plan Social Services," revised 8/20, indicated "The goal of the social services department is to assist patients in adapting or resolving the crisis precipitating hospitalization ... The department provides individual counseling, group therapy ... The social service department will provide seven day a week coverage for groups ... In the DEPARTMENT GOALS part indicated "1. Complete psychosocial within 72 hours of admit. 2. Provide discharge planning assistance to all patients starting at the admission process. 3. Fully educate patient under treatment plan, obtain their signature and document corresponding progress note. 4. Conduct groups on time 90% of the time." "CORE STAFFING: consists of PhD, MFT, LCSW, and LPTs."

A review of the Therapist job description (JB), dated 8/5/17, indicated, "Basic purpose of position: To provide psychotherapeutic services to all patients ... support the organization's treatment program ..."

During an observation on 9/20/22, at 11:45 a.m., in the dayroom on Oceanview Unit, in Building G, three patients were observed sitting in chairs watching T.V. The whiteboard in the day room indicated the therapist on for the day was MFT 1. The dayroom on Mountain View Unit, in Building G, was empty.

During an interview on 9/20/22, at 12:15 p.m. with Patient N202 who was sitting in the dayroom, Patient N202 verbalized she was admitted on 9/18/22 and has not seen or talked to a therapist yet, and has not seen a psychiatrist yet. Patient N202 stated, "Aren't we here for therapy, that is the reason why we are admitted, it is not just about receiving medication."

During a review of the posted "Group Activities" for Building G, indicated :
On Tuesday:
8:30-9:00 a.m. Community Meeting & Goals Group- Mental Health Workers (MHW)
10:00-11:00 a.m. Wellness Education therapy group- Clinical Therapy
11:00-12:00 p.m. Expressive Therapy- Expressive Therapy
1:00-2:00 p.m. Skill Building Therapy Group- Clinical Therapy
2:00-3:00 p.m. Expressive Therapy-Expressive Therapy
3:00-4:00 p.m. Spiritual & Clinical Insight- Chaplain
4:00-5:00 p.m. Meditation- MHW
8:00-9:30 p.m. Wrap-up/medications- MHW

During an interview on 9/20/22, at 3:37 p.m., with mental health worker (MHW 5), verbalized the facility should have at least two groups with a therapist scheduled per day. MHW 5 verbalized therapist teaches coping skills and coping mechanisms. MHW 5 verbalized community meeting, social skills, creative therapy spiritual services are not happening at this time due to short staffing and the chaplain passed away. MHW 5 verbalized 90% of the time groups are not happening. When asked if there was a group conducted today, MHW 5 stated, "No groups happened today." When asked if therapy groups were conducted yesterday, MHW 5 stated, "No groups yesterday." MHW 5 verbalized there is only one therapist on staff and was on vacation last week and further verbalized the facility has not had a therapy group for at least a week. MHW 5 verbalized there has been no recreation therapist for 6 months or longer.

During a review of the clinical record for Patient N201, and concurrent interview with the quality director (Adm 1) on 9/22/22, at 10:32 a.m., the record indicated, Patient N201 was admitted on 9/15/22. Adm 1 acknowledged and confirmed, Patient N201 only attended 2 social service therapy groups on 9/21/22 since admission. Adm 1 acknowledged, there is no other documentation of Patient N201 having individual or group therapy.

During a review of the clinical record for Patient N202, and concurrent interview with the quality director (Adm 1) on 9/22/22, at 10:55 a.m., the record indicated, Patient N202 was admitted on 9/18/22. Adm 1 acknowledged and confirmed, Patient N202 only attended 2 social service therapy groups on 9/21/22 since admission. Adm 1 acknowledged, there is no other documentation of Patient N202 having individual or group therapy.

During a review of the clinical record for Patient N203, and concurrent interview with the quality director (Adm 1) on 9/22/22, at 11:22 a.m., the record indicated, Patient N203 was admitted on 9/19/22. Adm 1 acknowledged and confirmed, Patient N203 only attended 2 social service therapy groups on 9/21/22 since admission. Adm 1 acknowledged, there is no other documentation of Patient N203 having individual or group therapy.

During a review of the clinical record for Patient N204, and concurrent interview with the quality director (Adm 1) on 9/22/22, at 12:11 p.m., the record indicated, Patient N204 was admitted on 9/13/22. Adm 1 acknowledged and confirmed, Patient N204 had not attended or participated in any therapy groups. Adm 1 acknowledged, there is no other documentation of Patient N204 having individual or group therapy.

During a review of the clinical record for Patient N205, and concurrent interview with the quality director (Adm 1) on 9/22/22, at 12:34 p.m., the record indicated, Patient N205 was admitted on 9/20/22. Adm 1 acknowledged and confirmed, Patient N205 only attended one social service therapy group on 9/21/22 since admission. Adm 1 acknowledged, there is no other documentation of Patient N205 having individual or group therapy.

During a review of the clinical record for Patient N206, and concurrent interview with the quality director (Adm 1) on 9/22/22, at 12:40 p.m., the record indicated, Patient N206 was admitted on 9/14/22. Adm 1 acknowledged and confirmed, Patient N206 only attended one social service therapy group on 9/21/22 since admission. Adm 1 acknowledged, there is no other documentation of Patient N206 having individual or group therapy.


35399

2.During an observation of the Seaside Unit Day Care room and concurrent interviews with hospital staff and patients on 9/20/22, from 11:30 a.m., to 12:00 p.m., nine (Patients N38, N100, N102, N104, N105, N106,N107, N601 and N602) adolescents were observed inside the room watching TV and sitting around inside the room. One mental health worker (MHW 4) was observed inside the daycare room watching the adolescents. An unsampled Patient 38 was observed approaching MHW 4 and ask if she could do artwork. MHW replied, "No, because there is no one to do artwork." MHW 4 stated, "We used to have a MHW do artwork with the kids, but we have been short staffed there is no one to do that with the kids now."

At 11:34 a.m., Patient N100 was asked how are you doing? Patient 100 stated "I am so bored. I don't do anything here except watch TV."

At 11:35 a.m., MHW 4 further stated, "There has not been anyone available to do activities the kids like. There used to be therapy and groups to keep the kids occupied but there has not been any lately. I think there is not enough therapists either to do activities or groups with the kids. A MHW used to bring her own boom box, create a list of the songs that kids like and play it for the kids. But the MHW does not do that anymore because she has no time for that anymore.

During an interview with MHW 3 at 11:48 a.m., MHW 3 stated, "At times a MHW was assigned to do activities with the adolescents. But lately this has not happened because there is not enough MHWs staff to do this. Doing activities with the kids it's a full-time job but they want us to do both activities and our own assigned task."

During an interview with MHW 1 at 11:50 a.m., MHW 1 explained, the adolescents spend most of their time in the Day Care room or their room because they don't have anything else to do. There is not enough MHWs to engage adolescents in any stimuli like journaling, art, pet therapy etc.

During another observation of the Day Care room and concurrent interviews with staff and patients on 9/20/22, at 3:17 p.m., seven adolescents were observed in the room watching TV and sitting around the room. Patient 100 sated, "I have not had activities for two days. I am so bored."

At 3:20 p.m., MHW 4 stated, "The kids have no schoolteacher, no activities, no therapies so the kids don't do anything else but sit inside this room that's why they're saying that they are bored. We used to have and activity schedule until a few months ago. I don't have the key to the closet or area where they keep the activities equipment. I don't even know what they have for activities or were they have the equipment for the kids to do activities."

During an interview with social worker/therapist SWT on 9/20/22, at 3:15 p.m., SWT reported, she does group therapy with the adolescents. SWT was asked to provide a report or documentation of the groups she has performed with dates and times and which adolescent was present in the groups. SWT indicated, she had no way to produce such document because she has no schedule or calendar of the groups she has performed. Facility was not able to provide documentation supporting that activities groups or therapies took place.

During an interview with registered nurse (RN 1) on 9/21/22, at 2:50 p.m., RN stated, "The kids really need to have expressive therapy, but they have not had any for a while possibly June 2022. I have never seen such a short of therapist throughout my career."

On 9/20/22 at 3:45 p.m., the chief nurse officer (CNO) was asked regarding the adolescents having group activities and/or group therapies. The CNO provided an old calendar listing some activities and therapies. The calendar schedule was compared with the observations today. The CNO acknowledged and confirmed, the activities/groups on the calendar did not occur today as scheduled and not having an active activities and therapies calendar schedule. CNO stated, "I don't have a current/active activities/groups or therapies calendar or schedule. We lost our pastor who did spiritual & clinical insight, there is no teacher, and we don't have enough therapist ..."



39106

3.During an obseervation on 09/20/22, at 11:00 a.m., patients were noted to be walking the halls or in their rooms on the Hillside Unit. No therapeutic group sessions were in place.

During a concurrent observation on the Hillside Unit, and interview with the director of intake (ADM3), on 09/20/22, at 3:00p.m., the Hillside Unit was noted not to have a therapeutic activity group in session. ADM 3 and mental health worker (MHW 6) verbalized, that no therapeutic group sessions have taken place on today. MHW 6 verbalized, the therapeutic group sessions are not consistent.

Based on interview and record review, the facility failed to ensure a therapeutic services assessment for appropriate patient care was completed upon admission when 15 of 33 sampled patients, (patients N604, N100, N102, N103, N104, N105, N106, N107, N108, N200, N201, N202, N203, N204, N206, N300, N301, N302, N303, N306) did not receive an admission assessment within 72 hours.

This failure had the potential to not assess the patient to assist in planning appropriate inpatient and aftercare.


Findings:


40678


1. During a review of the facility's policy and procedure (P&P) titled, "Admission Assessment," revised 9/20, indicated, in part ... "The data generated by the assessment process will be used in planning appropriate patient care and utilized throughout hospitalization in the planning of psychiatric treatment, medical treatment and aftercare. The admission assessment is completed through the use of four assessment components: Intake Assessment; Nursing Assessment; Psychosocial Assessment; Therapeutic Assessment. Therapeutic Services Assessment: This assessment is completed by a member of the Expressive Therapy Program within 72 hours of admission."

During a record review and concurrent interview on 9/21/22, at 10:04 am, with director of risk and accreditation (DRA), DRA reviewed Patient N604's medical record. Patient N604's "Therapeutic Assessment" could not be located. Confirmed with DRA, unable to locate "Therapeutic Assessment".


35399

2. During a review of the facility's P&P titled, "Admission Assessment," revised 9/20, indicated, in part ... "The data generated by the assessment process will be used in planning appropriate patient care and utilized throughout hospitalization in the planning of psychiatric treatment, medical treatment and aftercare. The admission assessment is completed through the use of four assessment components: Intake Assessment; Nursing Assessment; Psychosocial Assessment; Therapeutic Assessment. Therapeutic Services Assessment: This assessment is completed by a member of the Expressive Therapy Program within 72 hours of admission."

During a review of clinical records for Patients' 100, 102, 103, 104, 105, 106, 107, and 108 and concurrent interview with the house supervisor (HS) on 9/22/22, from 10:30 a.m., to 12:45 p.m., the HS acknowledged and confirmed, there was no therapeutic services assessment performed on these eight (8) patients. HS stated, "No, I can't find the therapeutic assessments on these patients. They were not done."


39520

3. During a review of the Facility's P&P titled, "Admission Assessment," revised 9/20, indicated, in part ... "The data generated by the assessment process will be used in planning appropriate patient care and utilized throughout hospitalization in the planning of psychiatric treatment, medical treatment and aftercare. The admission assessment is completed through the use of four assessment components: Intake Assessment; Nursing Assessment; Psychosocial Assessment; Therapeutic Assessment. Therapeutic Services Assessment: This assessment is completed by a member of the Expressive Therapy Program within 72 hours of admission."

During a concurrent interview and record review on 9/22/22, from 9:40 a.m., to 12:40 p.m., with the quality director (Adm 1), Patients' N 200, N201, N202, N203, and N204 medical records were reviewed. Adm 1 acknowledged and confirmed, there were no therapeutic assessments performed on these five patients. Adm 1 verbalized, therapeutic assessments should be done within 72 hours of admission.

During a concurrent interview and record review on 9/22/22, at 12:40 p.m., with the quality director (Adm 1), Patient N 206's medical record was reviewed. Patient N206 was admitted on 9/14/22 at 12:39 p.m. and the "Therapeutic Assessment" was completed on 9/22/22 at 7:18 p.m. QD 1 acknowledged, the assessment was late and completed after 72 hours of admission.


39106

4.During a review of the facility's P&P titled,"Admission Assessment," dated 9/2020, the policy indicated, the Therapeutic Services Assessment "is completed by a member of the Expressive Therapy Program within 72 hours of admission."

During a concurrent interview and record review, with the director of risk and accreditation (DRA), on 09/23/22, at 8:30 a.m., the medical record for the following patients (N300, N301, N302, N303, N304, N305, N306) was reviewed for completion of the "Therapeutic Services Assessment." There was no indication in the medical record that the Therapeutic Services Assessment was completed in 5 (N300, N301, N302, N303, N306) of 7 records reviewed. The DRA confirmed, the "Therapeutic Services Assessment" was missing for these 5 patients and acknowledged, the assessments should have been completed as per the facility's P&P.