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Based on observation, record review and interview the hospital failed to ensure all patients were provided care in a safe setting as evidenced by: 1) failing to monitor a patient who was removed from his room because he was touching his roommate', covering and placing the patient in the seclusion room with the door open but without direct visualization resulting in the patient falling, sustaining a head injury and requiring hospitalization in an intensive care unit at a local hospital (#5) and 2) failing to monitor a patient being brought through an unsecured area (front lobby) to the smoking area resulting in his elopement from the hospital and failure to be found (#8). Findings:

1) failing to monitor a patient who was removed from his room because he was touching his roommate' covers, placing the patient in the seclusion room
Review of the medical record for Patient #5 revealed an 80 year old male who was readmitted to the hospital after being transferred to Hospital "a" for poor appetite and increased confusion. Patient #5 was treated at Hospital "a" for a UTI (Urinary Tract Infection), delirium and psychosis and transferred back to Community Care Hospital on 10/29/11. Further review revealed Patient #5 had a history of a brain tumor, craniotomy and permanent ventricular shunt.

Review of the Nursing Daily Progress Note dated 11/02/11 at 0200 (2:00am) documented by RN S5, revealed.... "Heard pt. (patient) fall out of bed, was on the floor when I went to his room. Bleeding over right eye. Orders to send patient to hospital (Hospital "a"). Late entry: (also documented by RN S5 and with no time documented) Pt. was sleeping in seclusion room with door open due to pulling on roommate's covers. Was informed by tech". Further review of the medical record revealed no documented evidence of a neuro-assessment post head injury, assessment of the cut above the right eye or interventions performed for Patient #5.

RN S5 who was assigned to the care of Patient #5 at the time of the fall on 11/02/11 was on vacation and could not be reached for an interview.

Review of the medical record for Patient #5 from the Emergency Department of Hospital " a " revealed he was admitted on 11/02/11 at 06/25am with altered mental status, a fall and a facial laceration. Review of the CT scan dated 11/02/11 at 12:07pm revealed the following .... " New right anterior scalp laceration contusion. New tiny bilateral subdural hematoma collections right temporal, anterior lateral frontal, left anterior lateral frontal parietal under 0.2cm on thickness right anterior frontal image series 20 " . Further review revealed Patient #5 was admitted to the ICU (Intensive Care Unit) to the Neuro Service in guarded condition.

In a face to face interview on 12/22/11 at 8:50am MHT S4, on duty at the time Patient #5 fell out of the bed in the seclusion room, indicated she (S4) could not remember if she was assigned to the care of the patient. After review of the Observation Record for Patient #5 and verification of S4's initials as having observed Patient #5 on 11/01/11 15 minutes prior to the incident, S4 indicated she did not know why Patient #5 was placed in the seclusion room and the only thing she can remember is that he fell.

RN S5 was not available for an interview as she was on vacation and could not be reached for an interview.

In a face to face interview on 12/20/11 at 3:00pm RN S2 Director of Nursing indicated she had spoken to the family of Patient #5 after he was admitted to the hospital. Further she indicated his problem was the UTI (Urinary Tract Infection) had never improved.

2) failing to monitor a patient being brought through an unsecured area (front lobby)
Observation on 12/20/11 at 10:00am of the unsecured lobby revealed the elevator, which transports the patients from the upper floor units, opens directly into the small front lobby. The cafeteria is located through a door to the left approximately three feet away and the unsecured front door leading to a covered area with two open gates leading to two different streets approximately four feet away. The security guard is positioned in the rear of the lobby behind a desk across from an unlocked bathroom. Further observation revealed the restroom located in the cafeteria was unlocked. Further observation revealed the smoke area located outside of the cafeteria cannot be visualized by the security guard from his post in the lobby.

Observation on 12/22/11 at approximately 12:15pm revealed one adult unit leaving the cafeteria being escorted to the lobby and the elevator opening with the patients from the other adult unit resulting in having over twenty people in a small area being monitored by 3 MHTs and the security guard.

In a face to face interview on 12/21/11 at 3:00pm Administrator S1 indicated the patients are brought down to the cafeteria to eat and smoke the same way which is one unit at a time. Further S1 indicated the number of MHTs accompanying the patients depends on the number of patients coming down each time. She cited for example if all of the patients on the unit smoke, both of the MHT would come down with the patients.

Review of the medical record for Patient #8 revealed a 24 year old male admitted to the hospital by a CEC (Coroner's Emergency Certificate) on 121/05/11 for schizophrenia, paranoia and bizarre behavior. Further review of the medical record revealed Patient #8 was delusional and thought he was pregnant. Lab results revealed he was positive for cocaine and marijuana.

Review of the Physician's Admit Orders for Patient #8 dated/timed 12/05/11 at 3:30pm revealed no documented orders for observation or precautions. According to the Nursing Daily Progress Note CO w/o UR (Close observation without unit restrictions) was circled.

Review of the Nursing Daily Progress Notes for Patient #8 revealed the following nursing assessments: 12/11/11 7A-7P and 7P-7A Patient delusional and isolative; 12/12/11 7A-7P Patient appropriate and isolative and 12/12/11 7P-7A Patient withdrawn; 12/13/11 7A-7P Patient withdrawn, delusional and isolative and 12/13/11 7P-7A Patient confused and isolative; 12/14/11 7A-7P Patient remains withdrawn, isolative (no peer interaction) and delusional and 12/14/11 at 2030 (8:30pm) Patient stated he was irritated because the group home did not accept him. Further he was withdrawn with poor reasoning.

Review of the Nursing Daily Progress Note dated 12/14/11 at 2030 (8:30pm) revealed .... "He was taken by staff to smoke area and while in the smoke area he was noted to be missing. The building was searched and the premises but he could not be found".

Based on record review and interview the hospital failed to ensure assessments were performed after a change in condition as evidenced by: 1) failing to assess a patient with a past history of a craniotomy and permanent ventricular shunt after sustaining a fall to the head and a cut to the eye (#5); 2) failing to ensure range orders were clarified and/or incomplete orders when written by the physician (#3, #7) and before administration of the medication to patients (#3); 3) failing to ensure all patients were searched upon admit according to policy and procedure resulting in the patient maintaining possession of his cell phone and a bag of "Mojo" (drugs) for a period of 20 hours after admission and having to place the patient in 4-point restraints when attempts were made to remove the phone from his possession (#3) for 3 of 8 sampled patients; 4) failing to ensure all patients were monitored when being escorted to the smoking area through an unsecured lobby resulting in the elopement of Patient #8. This has the potential to affect all patients who smoke in the facility. Findings:


1) failing to assess a patient with a past history of a craniotomy and permanent ventricular shunt after sustaining a fall to the head and a cut to the eye
Review of the medical record for Patient #5 revealed an 80 year old male who was readmitted to the hospital after being transferred to Hospital "a" for poor appetite and increased confusion. Patient #5 was treated at Hospital "a" for a UTI (Urinary Tract Infection), delirium and psychosis and transferred back to Community Care Hospital on 10/29/11. Further review revealed Patient #5 had a history of a brain tumor, craniotomy and permanent ventricular shunt.

Review of the Nursing Daily Progress Note dated 11/02/11 at 0200 (2:00am) and documented by RN S5 revealed.... "Heard pt. (patient) fall out of bed, was on the floor when I went to his room. Bleeding over right eye. Orders to send patient to hospital (Hospital "a"). Late entry: (no time documented and documented by RN S5) Pt. was sleeping in seclusion room with door open due to pulling on roommates' covers. Was informed by tech". Further review of the medical record revealed no documented evidence of a neuro-assessment post head injury, assessment of the cut above the right eye or interventions performed for Patient #5.

Review of the Incident Report dated/timed 11/02/11 at 0330 (3:30am) revealed Patient #5 was in the seclusion room with the door open. Further review revealed... "RN S5 and MHT S4 heard Pt (#5) fall out of bed. Found pt on the floor". Patient sustained a cut over the R (right) eye. Vital signs: T (temperature) 98.2 Fahrenheit; P (pulse) 100, R (respirations) 18, BP (blood pressure) 117/80. The psychiatrist and administrator notified. Acting Administrator S1 and RN S2 Director of Nursing signed the form on 11/02/11 at 12:15pm. Further review revealed the section "Special Investigation Recommended Yes or No" had been left blank.

Review of the medical record for Patient #5 from the Emergency Department of Hospital " a " revealed he was admitted on 11/02/11 at 06/25am with altered mental status, a fall and a facial laceration. Review of the CT scan dated 11/02/11 at 12:07pm revealed the following .... " New right anterior scalp laceration contusion. New tiny bilateral subdural hematoma collections right temporal, anterior lateral frontal, left anterior lateral frontal parietal under 0.2cm on thickness right anterior frontal image series 20 " . Further review revealed Patient #5 was admitted to the ICU (Intensive Care Unit) to the Neuro Service in guarded condition.

RN S5 was on vacation and could not be reached for an interview.

In a face to face interview on 12/20/11 at 2:35pm RN S2 Director of Nursing indicated a neuro assessment should have been performed on Patient #5 after a fall involving his head and a cut over the right eye.

2) failing to ensure range orders were clarified and/or incomplete orders when written by the physician
Patient #3
Review of the medical record for Patient #3 revealed an 18 year old male admitted to the hospital by a Formal Voluntary Admission on 10/27/11 at 1700 (5:00pm) for bi-polar disorder and Mojo abuse.

Review of the Physician's Orders for Patient #3 dated/timed 10/28/11 at 1320 (1:20pm) revealed an order for the following: Ativan ii mg, Benadryl 50mg and Haldol 5mg po/IM (by mouth/Intramuscular)Q6 (every 6 hours) prn (as needed) agit. (agitation). Further review of the orders revealed no documented evidence the orders was clarified by the nursing staff before administration to the patient.

Review of the Nursing Daily Progress Notes for Patient #3 dated/timed 10/28/11 at approximately 1300 (1:00pm) revealed...."Ativan ii mg, Benadryl 50mg, Haldol 5mg given IM (Intramuscular) R (right) hip".

Patient #7
Review of the medical record for Patient #7 dated 10/30/11 revealed a 50 year old male admitted via a PEC (Physician Emergency Certificate) to the hospital from the nursing home with suicidal ideations. Further review revealed Patient #7 had a history of chronic diarrhea, protein malnutrition, bilateral sacral ulcers, Stage II, bilateral heel ulcers and urinary retention.

Review of the Physician's Admit Orders for Patient #7 dated/timed 10/30/11 at 11:00am revealed orders for the following medications: Megace 400mg BID (twice a day), Calcium Carbonate 600mg tid, Folic Acid 1mg daily, Sustina 600mg QHS, Zovirax 800mg tid and Benadryl 25mg po Q6 hours prn. Further review of the medical record revealed no documented evidence the orders were clarified for route and the Benadryl prn for indication of usage.

In a face to face interview on 12/22/11 at 1:00pm RN S2 Director of Nursing indicated all orders need to be clarified before administration of any medication.

3) failing to ensure all patients were searched upon admit according to policy and procedure resulting in the patient maintaining possession of his cell phone and a bag of "Mojo" (drugs)
Review of the medical record for Patient #3 revealed an 18 year old male admitted to the hospital by a Formal Voluntary Admission on 10/27/11 at 1700 (5:00pm) for bi-polar disorder and Mojo abuse. Review of the Nursing Daily Progress Note dated/timed 10/27/11 at 1930 (7:30pm) revealed...."Oriented to unit and tour given. Belongings checked and secured".

Review of the Patient Belongings: Money Form dated/timed 10/27/11 at 1707 (5:05pm) revealed Patient #3 was allowed to keep $105.00 on his possession on admit. Further review revealed on 10/29/11 Patient #3 deposited $100.00 into the hospital lockbox.

Review of the List of Patient Belongings for Patient #3 dated/timed 10/27/11 at 5:10pm revealed 1 black belt, 1 cell phone charger, blue jeans (quantity not documented), blue polo shirt, 1 black polo book, and 1 black shoe string. Further review revealed on 10/28/11 (no time documented) 1 cell phone found in room.

Review of the Nursing Daily Progress Note dated/timed 10/28/11 0630 -1830 (6:30am-6:30pm).... Pt. M (mother) reported that patient (#3) had been calling her all night on a cell phone. Pt. was approached about having cell phone. Pt. denied having cell phone but handed over a bag of "Mojo". Pt. went down for lunch, at which time inspection of room required, a cell phone found behind bed. Phone was confiscated".

Review of the Nursing Assessment and Physician Order for Restraint and Seclusion for Patient #3 dated/timed 10/28/11 at 1330 (1:30pm) revealed.... "Pt. (Patient) threatening staff; code called. Entering RN (Registered Nurse) station and pounding fist on table of break room. Pt. stated 'I'm going to stick you with that needle and attempted to assault RN. Staff intervened with pt. resisting physically. Entered 4-point restraint at 1330". Further review of the form revealed least restrictive interventions of verbal redirection, increased observation, removal from stimuli and medication intervention had been implemented before restraints were applied.
Review of the debriefing session revealed the removal of Patient #3's cell phone led to the incident and the staff felt nothing could have been handled differently.

Review of the policy titled "Patient Safety" last reviewed June 2011 and submitted as the one currently in use, revealed..... "Procedure: 3. Tape recorders, cell phones, and cameras are prohibited from being in a patient's possession".

The hospital could not submit any documented evidence an investigation had been performed to determine how the patient maintained possession of drugs and a cell phone after a documented search was performed.

In a face to face interview on 12/21/11 at Acting Administrator S1 was not aware of the drugs and could not explain why the patient would have a cell phone in his possession.

4) failing to ensure all patients were monitored when being escorted to the smoking area through an unsecured lobby
Observation on 12/20/11 at 10:00am of the unsecured lobby revealed the elevator, which transports the patients from the upper floor units, opens directly into the small front lobby. The cafeteria is located through a door to the left approximately three feet away and the unsecured front door leading to a covered area with two open gates leading to two different streets approximately four feet away. The security guard is positioned in the rear of the lobby behind a desk across from an unlocked bathroom. Further observation revealed the restroom located in the cafeteria was unlocked. Further observation revealed the smoke area located outside of the cafeteria cannot be visualized by the security guard from his post in the lobby.

Observation on 12/22/11 at approximately 12:15pm revealed one adult unit leaving the cafeteria being escorted to the lobby and the elevator opening with the patients from the other adult unit resulting in having over twenty people in a small area being monitored by 4 MHTs and the security guard.

In a face to face interview on 12/21/11 at 3:00pm Administrator S1 indicated the patients are brought down to the cafeteria to eat and smoke the same way which is one unit at a time. Further S1 indicated the number of MHTs accompanying the patients depends on the number of patients coming down each time. She cited for example if all of the patients on the unit smoke, both of the MHT would come down with the patients.

Review of the medical record for Patient #8 revealed a 24 year old male admitted to the hospital by a CEC (Coroner's Emergency Certificate) on 121/05/11 for schizophrenia, paranoia and bizarre behavior. Further review of the medical record revealed Patient #8 was delusional and thought he was pregnant. Lab results revealed he was positive for cocaine and marijuana.

Review of the Physician's Admit Orders for Patient #8 dated/timed 12/05/11 at 3:30pm revealed no documented orders for observation or precautions. According to the Nursing Daily Progress Note CO w/o UR (Close observation without unit restrictions) was circled.

Review of the Nursing Daily Progress Notes for Patient #8 revealed the following nursing assessments: 12/11/11 7A-7P and 7P-7A Patient delusional and isolative; 12/12/11 7A-7P Patient appropriate and isolative and 12/12/11 7P-7A Patient withdrawn; 12/13/11 7A-7P Patient withdrawn, delusional and isolative and 12/13/11 7P-7A Patient confused and isolative; 12/14/11 7A-7P Patient remains withdrawn, isolative (no peer interaction) and delusional and 12/14/11 at 2030 (8:30pm) Patient stated he was irritated because the group home did not accept him. Further he was withdrawn with poor reasoning.

Review of the Nursing Daily Progress Note dated 12/14/11 at 2030 (8:30pm) revealed .... "He was taken by staff to smoke area and while in the smoke area he was noted to be missing. The building was searched and the premises but he could not be found".

Based on record review and interview the hospital failed to ensure all staff assigned to patient care were competent as evidenced by no documented evidence of a competency assessment, completion of the required crisis intervention education as per policy and procedure, and/or the implementation of corrective action to improve identified performance deficits by the nursing staff for 3 of 3 personnel files reviewed (S3, S4, S5). Findings:

Review of the personnel file for MHT (Mental Health Technician) S3 with the hire date of 03/11/11 revealed no documented evidence a competency assessment was performed.

Review of the personnel file for MHT (Mental Health Technician) S4 with the hire date of 06/21/11 revealed no documented evidence a competency assessment was performed. Further review revealed no documented evidence S4 had successfully passed the post-test for CPI (Crisis Prevention Intervention) which was taken 08/11.

Review of the personnel file for RN S5 with the hire date of 11/02/11 revealed no documented evidence a competency assessment was performed or completed a crisis intervention course. Further review of the personnel file revealed S5 had had been written up on 03/23/11 for documentation concerning a patient's observations status; 04/26/11 for multiple deficiencies in documentation and a high number of medication variances; 05/11/11 for failing to administer oxygen to a patient as ordered by the physician; and 05/12/11 for a missing narcotic (Xanax 0.5mg which was discrepancy number two; however there was no documented evidence in S5's file for discrepancy number 1. Review of the personnel file revealed no documented evidence corrective action had been taken to improve the identified performance deficits of RN S5.

In a face to face interview on 12/22/11 at 1:00pm Administrator S1 indicated the hospital was aware of this problem and was working to correct the situation. Further she indicated the previous employee who was delegated this duty had failed to ensure it was done.

Review of the policy titled "Staffing Plans and Delivery of Care" last reviewed June 2011 and submitted as the one currently in use, revealed..... "Procedure- Staffing Qualifications: Personnel assigned to patient care shall have completed competency documentation for that area or be under the supervision of a preceptor".

Review of the "Competency-Based Job Description for a Psychiatric Nurse (RN)" submitted as the one currently being used revealed....... "Education and/or Experience/Qualifications: 3. Current Crisis Prevention Intervention (CPI) Certificate. 4. Successful completion of orientation and demonstration of competence".

Review of the "Competency-Based Job Description for a Mental Health Technician" submitted as the one currently being used revealed....... "Education and/or Experience/Qualifications: Current Crisis Prevention Intervention (CPI) Certificate (if not current, must be completed within 30 days of hire). 4. Successful completion of orientation and demonstration of competence".

Based on record review and interview the hospital failed to follow their policy and procedure for medication administration as evidenced by failing to clarify range orders and/or incomplete orders when written by the physician (#3, #7) and before administration of the medication to patients (#3) for 2 of 8 sampled medical records.

Patient #3
Review of the medical record for Patient #3 revealed an 18 year old male admitted to the hospital by a Formal Voluntary Admission on 10/27/11 at 1700 (5:00pm) for bi-polar disorder and Mojo abuse.

Review of the Physician's Orders for Patient #3 dated/timed 10/28/11 at 1320 (1:20pm) revealed an order for the following: Ativan ii mg, Benadryl 50mg and Haldol 5mg po/IM (by mouth/Intramuscular)Q6 (every 6 hours) prn (as needed) agit. (agitation). Further review of the orders revealed no documented evidence the orders was clarified by the nursing staff before administration to the patient.

Review of the Nursing Daily Progress Notes for Patient #3 dated/timed 10/28/11 at approximately 1300 (1:00pm) revealed...."Ativan ii mg, Benadryl 50mg, Haldol 5mg given IM (Intramuscular) R (right) hip".

Patient #7
Review of the medical record for Patient #7 dated 10/30/11 revealed a 50 year old male admitted via a PEC (Physician Emergency Certificate) to the hospital from the nursing home with suicidal ideations. Further review revealed Patient #7 had a history of chronic diarrhea, protein malnutrition, bilateral sacral ulcers, Stage II, bilateral heel ulcers and urinary retention.

Review of the Physician's Admit Orders for Patient #7 dated/timed 10/30/11 at 11:00am revealed orders for the following medications: Megace 400mg BID (twice a day), Calcium Carbonate 600mg tid, Folic Acid 1mg daily, Sustina 600mg QHS, Zovirax 800mg tid and Benadryl 25mg po Q6 hours prn. Further review of the medical record revealed no documented evidence the orders were clarified for route and the Benadryl prn for indication of usage.

In a face to face interview on 12/22/11 at 1:00pm RN S2 Director of Nursing indicated all orders need to be clarified before administration of any medication.

Review of the policy titled "Medication Administration" last reviewed June 2011 and submitted as the one currently in use revealed.... "Orders for Medication: Obtain a doctor's order for designating name of medication, the dose, route of administration, frequency/time for all scheduled medication....... The RN LPN (Licensed Practical Nurse) must contact the ordering physician to clarify any medication order that is incomplete, illegible, unclear or improperly written prior to administration".

Based on record review and interview the hospital failed to ensure all ordered medications were available for administration for 3 of 8 sampled patients (#2, #5, #7) Findings:

Patient #2
Review of the medical record for Patient #2 revealed a 57 year old male admitted via a PEC (Physician Emergency Certificate) to the hospital on 10/28/11 for confusion, depression and hallucinations. Further review revealed Patient #2 was being treated for cellulitis and had a history of Diabetes Mellitus (DM).

Review of the Physician's Orders for Patient #2 dated 10/27/11 at 1750 (5:50pm) revealed an order for Clindamycin 600mg po (by mouth) tid (Three times a day) X (times) 2 weeks.

Review of the MAR (Medication Administration Record) for Patient #2 dated 10/29/11 revealed no documented evidence the 0900 (9:00am), 1500 (3:00pm) or 2100 (9:00pm) doses of Clindamycin 600mg po had been administered. Further review revealed a notation next to the times indicating drug "NA (not available) non-formulary". Review of the MAR (Medication Administration Record) for Patient #2 dated 10/30/11 revealed no documented evidence the 0900 (9:00am), 1500 (3:00pm) or 2100 (9:00pm) doses of Clindamycin 600mg po had been administered. Further review revealed a notation next to the times indicating drug "not available".

Patient #5
Review of the medical record for Patient #5 revealed an 80 year old male admitted for dementia with delirium. Further review revealed he had a Urinary Tract Infection and hypertension.

Review of the Physician's Order's for Patient #5 dated/timed 10/31/11 at 4:00pm revealed an order for "Risperdal Consta 25mg IM (Intramuscular) today, then q (every) 4 weeks".

Review of the MAR (Medication Administration Record) dated 10/31/11 at 2100 (9:00pm) revealed the time had been circled with "not available" documented in the space.

Patient #7
Review of the medical record for Patient #7 dated 10/30/11 revealed a 50 year old male admitted via a PEC (Physician Emergency Certificate) to the hospital from the nursing home with suicidal ideations. Further review revealed Patient #7 had a history of chronic diarrhea, protein malnutrition, bilateral sacral ulcers, Stage II, bilateral heel ulcers and urinary retention.

Review of the Physician's Admit Orders for Patient #7 dated/timed 10/30/11 at 11:00am revealed orders for the following medications: Viread 300mg Q HS (every hour of sleep), Megace 400mg BID (twice a day), Zofran 4mg po (by mouth) Q6 (every six hours), Marinol 5mg po tid (three times a day), Calcium Carbinate 600mg tid, Zovirax 800mg tid, and Emtriva 200mg po QHS.

Review of the MAR (Medication Administration Record) for Patient #7 dated/timed 10/30/11 revealed the following medications were documented as not available and therefore not administered to the patient: Viread 300mg Q HS 10/30/11 and 10/31/11at 2100 (9:00pm); Megace 400mg BID 10/30/11at 2100 (9:00pm); Zofran 4mg po 10/30/11, 10/31/11, 11/01/11, 11/02/11 at 2100 (9:00pm); Marinol 5mg po tid 10/30/11, 10/31/11, 11/01/11, 11/02/11 at 2100 (9:00pm); Calcium Carbonate 600mg tid 10/30/11 at 2100 (9:00pm); Emtrina 200mg po QHS 10/30/11at 2100 (9:00pm); and Zovirax 800mg tid 10/30/11 2100 at (9:00pm).

In a face to face interview on 12/21/11 at 1:00pm RN S2 Director of Nursing and Administrator S1 indicated medications are available 24 hours a day in the facility. Further they indicated the pharmacist can be reached 24/7 if a medication was ordered and if it was not available in the pharmacy, it could be obtained through a local drug store. S1 indicated "not available" should not be documented in the chart by the nursing staff.

Based on record review and interview the hospital failed to designate an infection control officer with the training, experience and/or education to implement and monitor the hospital's infection control program. Findings:

Review of the personnel file of RN S2 Director of Nursing and designated Infection Control Officer revealed no documented evidence of any experience, additional training or certification in infection control.

In a face to face interview on 12/22/11 at 1:30pm RN S2 Director of Nursing and designated Infection Control Officer verified she had no additional experience, training, or education in infection control other than being a nurse.

In a face to face interview on 12/22/11 at 1:30pm Acting Administrator S1 indicated the hospital did not have a separate Infection Control Committee. Further S1 indicated all of the Infection Control information was reported to the Quarterly Manager's Meetings.

Based on record review and interview the hospital failed to follow their policy and procedure for maintaining records on nosocomial (Hospital acquired) infections as evidenced by failing to track and trend organisms identified in infections resulting in the hospital's inability to determine their nosocomial infection rate and implement appropriate corrective action to prevent the spread of communicable disease. Findings:

Review of the data submitted by the Infection Control Officer as the Infection Control Log dated September and October of 2011, revealed the report was submitted by the hospital pharmacy and contained the following information: name of patient, date antibiotic initiated, whether it was ordered on admit, name of medication, frequency and duration of use and indication of use. Further review revealed no documented evidence the hospital had reviewed the type of organism identified in each infection or determined if it was hospital acquired.

In a face to face interview on 12/22/11 at 1:30pm RN S2 Director of Nursing and designated Infection Control Officer indicated she had not been trending for hospital acquired infections or monitoring patient records for physician orders for labs or ensuring antibiotics were administered as ordered.

Review of the policy titled "Duties of Infection Control Officer" last reviewed 2011 and submitted as the one currently in use, revealed..... "Duties: 4. The Infection Control Officer maintains records of all patients with nosocomial infections. i. Clinical data may be compiled from the MAR (Medication Administration Record), patient charts, temperature charts, microbiological reports, laboratory and radiology reports. ii. Useful data may include: Admission data, temperature, antibiotics used, dates and types of instrumentation, culture dates, organisms cultured, colony counts for urine specimens, admission urinalysis, and CDC (Center for Disease Control) reports".

Based on record review an interview the hospital failed to ensure assessment of patient assets and/or personal attributes were included in all psychiatric assessments performed by the psychiatrist or designated practitioner for 3 of 3 medical records reviewed for psychiatric evaluations (#3, #7, #8) out of a total sample of 8 medical records. Findings:

Patient #5
Review of the medical record for Patient #5 revealed an 80 year old male admitted on 10/07/11 for dementia with delirium. Further review revealed he had a Urinary Tract Infection and hypertension.

Review of the Psychiatric Evaluation dated 10/09/11 revealed no assets were documented for Patient #5.

Patient #7
Review of the medical record for Patient #7 dated 10/30/11 revealed a 50 year old male admitted via a PEC (Physician Emergency Certificate) to the hospital from the nursing home with suicidal ideations. Further review revealed Patient #7 had a history of chronic diarrhea, protein malnutrition, bilateral sacral ulcers, Stage II, bilateral heel ulcers and urinary retention.

Review of the Psychiatric Evaluation dated 10/31/11 revealed no assets were documented for Patient #7.

Patient #8
Review of the medical record for Patient #8 revealed a 24 year old male admitted to the hospital by a CEC (Coroner's Emergency Certificate) on 121/05/11 for schizophrenia, paranoia and bizarre behavior. Further review of the medical record revealed Patient #8 was delusional and thought he was pregnant. Lab results revealed he was positive for cocaine and marijuana.

Review of the Psychiatric Evaluation dated 12/06/11 revealed Patient #8's assets were documented as a good support system in place to help him.

In a face to face interview on 12/22/11 at 1:00pm RN S2 Director of Nursing indicated the hospital was aware of the problems with assessments of the strengths and weaknesses and was going to give an inservice sometime in January 2012 for all physicians and staff.