HospitalInspections.org

Based on observation, interview, and record review, it was determined that the hospital failed to provide appropriate oversight and overall management of its operations.

Findings include:

1. The hospital failed to ensure patient rights were protected. Refer to tag 0115.

2. The hospital failed to develop and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance program. Refer to tag 0263.

3. The hospital failed to provide nursing services in a safe manner that met the needs of the patients. Refer to tag 0385.

4. The hospital failed to maintain accurate medical records for all patients. Refer to tag 0431.

5. The hospital failed to provide pharmaceutical services in a safe manner that met the needs of the patients. Refer to tag 0489.

6. The hospital failed to have an active hospital-wide program for the surveillance, prevention, and control of hospital acquired infections and other infectious diseases. Refer to tag 0747.

7. The psychiatric hospital failed to meet the Conditions of Participation for hospitals. Refer to tag 1600.

8. The hospital failed to maintain medical records that determined the degree and intensity of the treatment provided to patients who were provided services in the hospital. Refer to tag 1620.

Based on observation, interview, and record review, it was determined the hospital failed to ensure patient rights were protected.

On 9/26/2022 a finding of Immediate Jeopardy (IJ) was identified in the area of Pharmaceutical Services. The hospital was notified of this finding verbally and in writing on 9/26/2022 at 3:20 PM. The Hospital submitted an IJ removal/abatement plan on 9/27/22 at 12:31 PM, via email, alleging removal as of 9/30/2022 at 2:00 PM. The plan was accepted, and the hospital was notified on 9/28/2022 at 8:26 AM. Surveyors were on site and reviewed for IJ removal. It was determined that IJ had been removed on 9/30/2022 based on the steps the hospital had taken. The hospital was notified of this finding at 2:30 PM on 9/30/2022.

Findings include:

1. The hospital did not ensure the patients had a right to participate in their care and the right to refuse treatment. Refer to tag 0129.

2. The hospital did not ensure the privacy of patients. Refer to tag 0143.

3. The hospital did not ensure patients were able to elect their right to remain free from all forms of abuse, neglect, or harassment. Refer to tag 0145.

4. The hospital did not ensure that alternative or other less restrictive interventions were attempted prior to administering psychotropic medications. Refer to tag 0186.

5. The hospital did not ensure that all staff providing care to patients had been trained and demonstrated competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion. Refer to tag 0196.

Based on observation and interview, it was determined the hospital did not ensure the patients had a right to participate in their care and the right to refuse treatment. Specifically, patients were not allowed to leave a group activity when they requested. (Patient identifiers: 2, 19, 21, and 22)

Findings include:

On 9/24/2022 at approximately 10:30 AM, observations were made of a group activity. Patients 2, 19, 21 and 22 were observed sitting outside on the sidewalk in the shade. All four patients were wrapped in blankets. (Note: The temperature at that time was in the low 60's in the sun with a slight breeze.)

Certified nursing assistant (CNA) 1 was observed to be sitting under the covered patio next to the door to the common room watching the patients. There was no organized activity occurring at the time. The patients were observed to be just sitting wrapped in blankets.

Patient's 21 and 22 repeatedly requested to go back into the common room because they were "freezing to death".

CNA 1 stated that it was not time to go back inside just yet. At approximately 10:45 AM, CNA 1 asked if the patients would like a cookie. Patient 21 stated yes if it meant they could go back into the building. CNA 1 brought out cookies for them to eat. At 10:55 AM, CNA 1 allowed the patients to re-enter the building.

At that time, patient 22 stated she was so cold she did not think she could move.

Based on observation, interview, and record review, it was determined the hospital did not ensure the privacy of patients for 1 of 20 sampled patients. (Patient identifier: 12)

Findings include:

On 9/15/22 at 9:15 AM, surveyors observed patient 12 lying on a mattress in the common room. The mattress was pushed up to a wall at the top and had a sofa on one side and two large chairs on the other side. The sofa and chair were up against the edges of the mattress. At 10:30 AM, two staff members repositioned patient 12. At 12:02 PM, staff moved the sofa and two chairs and assisted patient 12 into a wheelchair for lunch.

Patient 12's medical record was reviewed during survey.

Patient 12 was admitted on 9/5/22, with a diagnosis of dementia with behaviors.

Patient 12's Observation Check Sheets for 15 minute checks from 9/5/22 through 9/19/22 were reviewed. Based on the key at the bottom of the form, it was documented that patient 12 was in the common area the majority of his time on the unit and rarely in a bedroom.

The following documentation from the 15 minute check sheets was also revealed:

On 9/12/22 at 9:15 PM patient 12's brief was changed in the dining room.
On 9/13/22 at 5:15 AM patient 12's brief was changed in the TV area.
On 9/14/22 at 5:00 PM patient 12's brief was changed in the TV area.
On 9/16/22 at 5:15 AM and 6:30 PM patient 12's brief was changed in the TV area.
On 9/18/22 at 5:00 AM patient 12's brief was changed in the TV area.
On 9/18/22 at 11:45 PM patient 12's brief was changed in the dining room.
On 9/19/22 at 4:45 AM patient 12's brief was changed in the dining room.

On 9/19/22 at 9:40 AM, an interview was conducted with certified nursing assistant (CNA) 1. CNA 1 stated it was normal for patient 12 to sleep on the floor near the nurses station so they could watch him closely.

On 9/19/22 at 11:40 AM, an interview was conducted with the administrator (ADM). The ADM stated, "Sometimes you need to do things to keep patients safe."

Based on observation, interview, and record review, it was determined the hospital did not ensure patients were able to elect their right to remain free from all forms of abuse, neglect, or harassment. Specifically, patients were not allowed a choice of activity, were not toileted regularly, and allegations of abuse were not reported and documented per hospital policy. (Patient identifiers: 1, 3, 6, 11,12, 21, and 22)

Findings include:

1. On 9/19/22 at 11:00 AM, surveyors were observing patients watching a movie in the common area. The movie had been playing for over 1.5 hours.

a. At 11:10 AM, the recreational therapist (RT) entered the common area and abruptly paused the movie and stated it was time for an activity. Several patients complained that it was the end of the movie and stated they wanted to finish it. The RT stated, "I can't compete with the TV" and invited them to join the new activity. Patient 22 stated there was only five minutes left of the movie. Patient 21 asked the RT to turn the movie back on. The RT said no and went into the activity room. (Note: The RT had arrived 40 minutes late as the group activity had been scheduled for 10:30 AM.)

b. At 11:13 AM, an interview was conducted with registered nurse (RN) 1. RN 1 stated that therapeutic activities were prioritized and that television is not allowed during activities. Surveyors requested a policy regarding the activity schedule. No policy was provided.

c. At approximately 11:13 AM, patient 22 was observed to get out of the recliner and start walking towards her room. Certified nurse assistant (CNA) 4 was observed asking patient 22 if she was going to the activity. Patient 22 replied, "No". CNA 4 was observed following patient 22 to her room and was heard asking the patient if she was okay. Patient 22 stated, "No, we were at the last five minutes of the movie."

d. At 11:18 AM, the director of nursing (DON) entered the unit. Surveyors explained the situation and asked the DON what was the next step. The DON stated "education for staff". It was several minutes before the patients were allowed to resume the movie at 11:22 AM.

e. At 11:58 AM, an interview was conducted with the RT. When asked why she did not allow the patients to finish the movie she stated again, "I can't compete with the TV. To be honest, you caught me on a bad day." She further stated she should have let the patients finish the movie and attend the activity when it was over.

2. Patient 12's medical record was reviewed during survey.

Patient 12 was admitted on 9/5/22, with a diagnosis of dementia with behaviors.

Patient 12's Observation Check Sheets for 15 minute checks from 9/5/22 through 9/19/22 were reviewed. Based on the key at the bottom of the form, the following documentation was revealed:

On 9/5/22, patient 12's brief was changed at 10:30 PM.

On 9/6/22, patient 12 was toileted at 5:00 AM, and his brief was changed at 9:45 PM.

On 9/7/22, patient 12's brief was changed at 1:15 AM, 5:15 AM, and 9:15 PM.

On 9/8/22, patient 12 was toileted at 8:30 PM.

On 9/9/22, patient 12's brief was changed at 4:30 AM, 9:45 AM, then toileted at 8:00 PM.

On 9/10/22, patient 12's brief was changed at 2:45 AM, 5:00 AM, 10:15 AM, and 2:15 PM.

On 9/11/22, patient 12's brief was changed at 4:15 PM and 8:45 PM.

On 9/12/22, patient 12's brief was changed at 5:00 PM and 9:15 PM.

On 9/13/22, patient 12's brief was changed at 5:15 AM.

On 9/14/22, patient 12's brief was changed at 12:45 AM, 5:15 AM, 5:00 PM, and 7:30 PM.

On 9/15/22, patient 12's brief was changed at 1:00 AM, 4:45 PM, and 7:45 PM.

On 9/16/22, patient 12's brief was changed at 5:15 AM, 10:30 AM, 3:45 PM, and 6:30 PM.

On 9/17/22, patient 12's brief was changed at 4:30 AM, 6:45 AM, 4:30 PM, and 9:45 PM.

On 9/18/22, patient 12's brief was changed at 5:00 AM, 8:00 PM, and 11:45 PM.

On 9/19/22, the documentation for brief changes had been altered.

In summary, according to the above documentation, patient 12 went without brief changes for extended periods of time as follows:

On 9/6/22, patient 12's brief had not been changed for nearly 17 hours.

Between 9/7/22 and 9/8/22, patient 12's brief had not been changed for nearly 24 hours.

Between 9/10/22 and 9/11/22, patient 12's brief had not been changed for 22 hours.

Between 9/16/22 and 9/17/22, patient 12's brief had not been changed for 22 hours.

3. Patient 3 was admitted on 8/10/22, with a diagnosis of dementia with behavioral disturbances.

a. On 9/19/22 at 8:03 AM, the following continuous observations of patient 3 were made:

8:52 AM - Patient 3 was observed wandering in other patients' rooms.

8:59 AM - Patient 3 was observed to grab the front of his crotch then went into the bathroom. RN 1 observed patient 3 entering the bathroom and asked if he was okay but did not offer toileting assistance.

9:23 AM - Patient 3 was observed grabbing his pants again. His brief appeared to be bulging.

11:48 AM - RN 1 told patient 3 his lunch was there; by observation the brief still had not been changed.

12:15 PM - Surveyors notified RN 1 that patient 3's brief had not been changed since before 8:03 AM.

12:21 PM - Patient 3 was observed wandering in other patients' rooms; the brief still had not been changed.

12:25 PM - RN 1 informed the aides that patient 3's brief needed to be changed.

12:34 PM - RN 1 was observed to go to lunch; patient 3's brief still had not been changed.

12:53 PM - CNA 3 and RN 1 changed patient 3's brief in another patient's bathroom. Very little peri care was observed. The surveyor did not have a clear view to determine if there was any skin breakdown or redness to the peri area.

b. On 9/19/22 at 1:49 PM, an interview was conducted with the DON. The DON stated she did not know why the staff changed patient 3's brief in another patient bathroom. The DON further stated the CNAs should have changed patient 3 sooner than they did.

c. On 9/19/22, a review of the 15 minutes checks for patient 3 was completed. The CNA's had documented patient 3 had a brief change at 4:45 AM and 6:15 AM that morning. Patient 3 had gone approximate 6 and a half hours without a brief change.

d. On 9/19/22 at 12:14 PM, an interview was conducted with RN 1. RN 1 stated when a patient was incontinent, they try to change them a minimum of every two hours. RN 1 stated patient 3 was incontinent and could not tell staff that he needed to be changed so they would assess his needs and change his brief at least every 2 hours. RN 1 stated they changed him whether he needed it or not. RN 1 stated patient 3 wore a "onesie" (loosely fit bodysuit) because he kept taking his clothes off. He further stated, he was not aware that patient 3 needed his brief changed that bad.

e. On 9/22/22, patient 3's medical record was reviewed. A review of the every 15 minute checks documentation and the nursing notes revealed no documentation of brief changes on 8/14/22, 8/16/22, 8/23/22 and 9/5/22. Brief changes were documented as being done one time in 24 hours on 25 days of his 43 day stay. Brief changes were documented twice in 24 hours on 11 days of his 43 day stay. Six days of patient 3's 43-day hospital stay had documentation of brief changes at least 3 or more times in a 24-hour period.

f. A review of a progress note dated 9/12/22 and timed 1:42 PM, revealed the following entry by the social worker (SW) regarding patient 3:

"SW met with APS (adult protective services) investigator (name) to provide information regarding an open investigation of an allegation of pt (patient) being neglected by lack of changing his briefs. It was explained due to patient's aggressive behaviors, looking at timing of his medications may help lessen incidence of harm to caregiving staff based on pt's past behavioral disturbances of harming staff during cares."

On 9/26/22 at 9:07 AM, a follow up interview was conducted with RN 1. RN 1 stated if a patient was continent and capable then the patient would toilet themselves. If the patient was not capable of toileting themselves then the CNAs were to toilet the patient a minimum of every 2 hours and as needed. The CNAs were to document the brief change or toileting on the every 15 minute checklist, mark behaviors and where the patient was located.

No documented evidence was provided to indicate the hospital had investigated the allegation or had implemented any interventions to ensure patient 3's brief was changed more frequently.

g. Further review of patient 3's medical record revealed the following incidents:

aa. 8/20/22 - 11:14 PM, Patient 3 wandered in another patient's room. A physical altercation almost occurred as the other man woke up yelling and upset. Patient 3 walked off upset and tried to punch the couch and he swung his fist which caused him to fall.

bb. 8/21/22 - 6:43 AM, Patient 3 had a fall today. The circumstances surrounding the fall was reported to the RN.

cc. 8/27/22 - 5:02 PM, Patient 3 was aggressive towards another patient as he held the patient's head down on the breakfast table this morning. He has been sexually inappropriate. (Note: This was documented in a progress note written by the nurse practitioner.)

dd. 8/28/22 - 12:43 PM, Patient 3 became agitated swung his arms and hit another patient.

ee. 9/2/22 - 12:29 PM, Patient 3 got into a yelling match with another patient and ended up hitting the patient in the jaw.

ff. 9/4/22 - 4:30 PM, patient 3 had a witnessed fall. Patient 3 tried to sit down in a dining room chair, and it fell backward.

gg. A review of the nursing notes revealed the following entry by the SW dated 9/12/22 at 1:42 PM:

hh. 9/16/22 - 11:12 PM, At the beginning of the shift, there was an altercation with another female patient in the day room. Staff heard a commotion and apparently, he slapped a female patient on the left side of her head. Staff are not sure what triggered the altercation. During the altercation the female slapped him on the left side of his face, causing redness and a small laceration to his left ear. Patient 3 also threw his water mug at the CNA.

ii. 9/17/22 - 6:32 PM, Patient 3 had a fall today. The circumstances surrounding the fall was reported to the RN.

jj. 9/20/22 - 12:36 PM, At approximately noon patient 3 became agitated and swung his arm and hit a staff member.

The incident logs for August and September were reviewed. The only incidents documented on the logs were incidents ee and ff. No documented evidence was provided to indicate the rest of the incidents had been logged and investigated and interventions initiated to prevent further incidents.

An email was sent by the DON on 9/29/22 at 2:20 PM, concerning the incident log for September 2022. The DON indicated that she had no more documented incidents after 9/15/22. Any incidents that had occurred were documented on the log.

5. Patient 1 was admitted on 9/9/22, with an admitting diagnosis of Parkinson's dementia.

a. On 9/19/22, observations were made of patient 1. Patient 1 was observed to wander about the common room. He was observed to have sagging briefs. At 12:41 PM patient 1 was escorted to his room by two CNAs. The brief was observed by the surveyor to be soiled with feces and urine. The buttock was observed to have a rash. CNA 3 stated the rash was new that day.

b. A review of patient's medical record revealed patient 1 had a brief change on 9/19/22 at 2:45 AM. There was no documented evidence he had another brief change until 12:41 PM, which was 10 hours from the last brief change. Further record review revealed the following brief change documentation:

9/18/22 - brief changes at 4:45 AM and 4:45 PM; 12 hours apart.

9/16/22 - brief changes at 5:45 AM and 7:45 PM; 11.5 hours apart.

9/14/22 - brief changes at 5:00 AM and 10:15 PM; 17 hours apart.

9/13/22 - brief changes at 5:00 AM and 10:15 PM; over 17 hours apart.

9/12/22 - brief changes at 3:30 AM and 3:00 PM; 12.5 hours apart, then again at 10:00 PM; 7 hours apart.

Between 9/11/22 and 9/12/22 he went 17 hours without a brief change.

9/11/22 - brief changes at 3:00 PM and 10:45 PM; approximately 8 hours apart.

9/10/22 - brief changes at 4:45 AM and 4:00 PM; approximately 11 hours apart.

c. No documented evidence was provided to indicate that patient 1 had his brief checked/changed every two hours as per hospital policy.

6. Patient 6 was admitted to the facility on 8/19/22.

Patient 6's medical record was reviewed throughout the survey and revealed the following:

In a Nursing Note dated 8/31/22 and timed 2:10 AM it was documented, "Pt was getting up from the toilet, and slid against the wall. She received a skin tear on her left upper arm, as well as a a (sic) small laceration on her left wrist. The wounds were cleaned and dressed. The provider was notified."

In a Client Support Note dated 8/31/22 and timed 5:14 AM, a CNA documented, "[name] had a fall today. The circumstances surrounding the fall was (sic) reported to the RN..."

In a Progress Note dated 8/31/22 and timed 7:59 AM, physician assistant 1 documented, "...No significant events were reported in the past 24 hours..."

In a Progress Note dated 8/31/22 and timed 3:37 PM, physician assistant 2 documented, "Had a skin tear on hand. Steri-Strips holding him. (sic)..." (Note: The provider did not mention the second skin tear on left upper arm.)

a. The incident log for August 2022 was reviewed. There was no documented evidence that patient 6's fall had been reported or investigated.

b. On 9/19/22 at 8:58 AM, an interview was conducted with the DON. The DON stated that incidents should be reported immediately and added to the incident log.



19354

7. On 9/19/22, surveyors requested to review the hospital's last three abuse investigations. The administrator stated there had only been one report of abuse investigated in the last several years and provided the survey staff a copy of the investigation. The abuse allegation was dated 8/22/22, and involved patient 11.

a. Patient 11 was admitted to the hospital on 8/7/22, with a diagnosis of lewy body dementia with behavioral disturbances.

Patient 11's medical record was reviewed from 9/15/22 through 10/3/22.

On 8/25/22, CNA 6 reported to the DON she had witnessed CNA 5 throwing a chair at patient 11 on 8/22/22, at 2:00 AM. The DON completed an investigation and determined the incident did not occur. However, the DON and Administrator did not identify that the allegation was not immediately reported to the charge nurse on 8/22/22. Additionally, there was no documentation of the allegation of abuse in patient 11's medical record.

On 9/12/22 at 1:46 PM, there was a case manager note completed by the social worker (SW). It was documented that an APS investigator reported to the SW and RN 1 that he had received an allegation of physical abuse by CNA 7. The SW documented that it was reported patient 11 kicked/pushed a chair towards CNA 7 who then pushed the chair back at the patient which hit patient 11 in the shins. The SW and RN 1 provided the APS investigator with, "Information was provided that the pt had behavioral disturbances to staff members since his admission to the Marian Center. It was also reported by SW that pt has been moved from his previous facilities due to aggressive behaviors towards staff along with providing pt's current disposition of dementia with behavioral disturbances." The allegation of physical abuse was not immediately reported to the DON or the Administrator.

b. The hospital's abuse policy and procedure was reviewed and revealed the following:

"The Marian Center clinical staff will assess every admission for abuse and neglect and appropriately handle such cases.

...2. A report of neglect or abuse of a patient while in the Marian Center is to be made immediately by any person suspecting, witnessing, or hearing about any such concern to the immediate supervisor.

3. The Marian Center Director or Compliance Team is to be notified immediately. The Director may be notified by phone and a description of the incident documented and given to Director. Director will investigate every instance of documented complaint of neglect or abuse. After the investigation, if the abuse is substantiated, it will be reported to the compliance officer. The compliance officer will report the abuse to adult protective services Utah law (62A-3-305) and to the patient's legal guardian (if applicable). Any employee can also report any compliance concerns or abuse to the compliance hotline 1-866-256-0955. All concerns can be reported anonymously and without fear of retaliation.

4. Confidentiality shall be ensured when the patient and/or guardian is informed of the reporting obligation prior to making the report. A release of information is not necessary to make the report. Documentation of the reporting must be made in the patient's record by the mental health professional who files the reported abuse.

5. Documentation in the medical record shall include the following reportable information:

a. Notification to patient and guardian of obligation to report the information.
b. Time and place of alleged incidents.
c. Persons involved (names/addresses).
d. Supporting evidence.
e. Detailed description of the incident.
f. Detailed description of who was notified when."


30334

Based on interview and medical record review, it was determined the hospital did not ensure that alternative or other less restrictive interventions were attempted prior to administering psychotropic medications for 1 of 20 sampled patients. (Patient identifier: 11)

Findings include:

Patient 11 was admitted to the hospital on 8/7/22, with a diagnosis of Lewy Body dementia with behavioral disturbances.

Patient 11's medical record was reviewed from 9/16/22 through 10/5/22 and revealed the following:

On 8/7/22 at 6:23 AM, there was an order for Haldol 2 mg (milligram) IM (intramuscularly) every 6 hours prn (as needed) for agitation or aggression.

On 8/7/22 at 9:39 PM, a registered nurse (RN) documented, "Pt (patient) required a prn injection for aggression, medication had minimal effect ..." The nurse documented that patient 11 was refusing to take his medications and that he was picking fights with staff and peers. The nurse documented that staff were unable to de-escalate patient 11's behaviors but did not document what interventions were attempted prior to the administration of Haldol 2 mg IM.

On 8/8/22 at 4:26 PM, the director of nursing (DON) documented that an order was received to administer Seroquel 25 mg by mouth at bedtime and to discontinue the use of Haldol 2 mg IM.

On 8/8/22 at 9:01 PM, an order was received to administer Ativan 1 mg PO (orally)/IM every four hours as needed, as well as Geodon 10 mg IM every 4 hours as needed for "aggression".

On 8/8/22 at 9:38 PM, a RN documented, "A prn was used today and was described as minimally effective. More angry outbursts are occurring. Impulsive behaviors continued to be displayed."

On 8/8/22 at 10:50 PM, a RN documented that Geodon 10 mg IM was administered for aggression. The RN documented, "Pt (patient) is combative toward peers and staff, throwing several pts water mugs, trying to punch staff, intrusive toward female pt's making one cry. Unable to deescalate."

On 8/9/22 at 6:06 AM, a RN documented, "He received one prn injection for aggression. The medication was effective for calming him down."

There was no documented evidence in the medical record of alternative or less restrictive interventions being attempted prior to the psychotropic medications being administered.

On 9/28/22 at 10:54 AM, an interview was conducted with the DON. When asked about alternative or less restrictive interventions being attempted prior to the psychotropic medications, the DON stated there are several interventions that staff should attempt first. She stated that prn medications should be the last resort. The DON further stated that any interventions attempted should be recorded in the nursing note.

Based on interview and record review, it was determined that the hospital did not ensure that all staff providing care to patients had been trained and demonstrated competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion. Specifically, no evidence was provided for 2 of 9 direct patient care employees to demonstrate that they had taken the required CPI (nonviolent crisis prevention and restraint training) recertification. (Employee identifiers: 1 and 8)

Findings include:

On 10/3/2022, a review of the hospital "Behavior Management and Restraint Policy" was reviewed. The policy indicated that all nursing and clinical staff were to received training in CPI.

On 10/3/2022, the CPI training records for hospital employees were reviewed. A review of the records revealed employee 1's CPI training had expired on 7/21/2020 and employee 8's CPI training had expired on 7/24/2022.

On 10/3/2022 at 4:00 PM, an interview was conducted with the hospital administrator and the director of nursing. They both indicated that all staff who provided hands on care to the patients were required to complete and maintain CPI training.

Based on observation, interview, and record review, it was determined that the hospital failed to develop and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program.

Findings include:

1. The hospital failed to ensure patient rights were protected. Refer to tag 0115.

2. The hospital failed to provide nursing services in a safe manner that met the needs of the patients. Refer to tag 0385.

3. The hospital failed to maintain accurate medical records for all patients. Refer to tag 0431.

4. The hospital failed to provide pharmaceutical services in a safe manner that met the needs of the patients. Refer to tag 0489.

5. The psychiatric hospital failed to meet the Conditions of Participation for hospitals. Refer to tag 1600.

6. The hospital failed to maintain medical records that determined the degree and intensity of the treatment provided to patients who were provided services in the hospital. Refer to tag 1620.

7. On 10/5/22 at 9:15 AM, an interview was conducted with the hospital administrator (ADM). The ADM stated the hospital did specific audits to ensure compliance with the hospital regulations. They audited the medication administration records and audited patient medical records to ensure each patients specific needs were being met. The ADM stated the director of nursing did the audits. The results of the audits are taken to the quality committee. The ADM stated if there were concerns, they would make immediate changes. If there continued to be a problem then they would do a process improvement project to make the necessary changes and work toward improvement.

8. A review of the quality documentation provided by the hospital revealed the hospital had not identified the concerns found during the survey process.

Based on observation, interview, and record review, it was determined the hospital failed to provide nursing services in a safe manner that met the needs of the patients. (Patient identifiers: 1, 2, 3, 4, 8, 9, 11, 12 and 14)

On 9/26/22 a finding of Immediate Jeopardy (IJ) was identified in the area of Nursing Services. The hospital was notified of this finding verbally and in writing on 9/26/22 at 3:20 PM. The Hospital submitted an IJ removal/abatement plan on 9/27/22 at 12:31 PM, via email, alleging removal as of 9/30/22 at 2:00 PM. The plan was accepted, and the hospital was notified on 9/28/22 at 8:26 AM. Surveyors were on site and reviewed for IJ removal. It was determined that IJ had been removed on 9/30/22 based on the steps the hospital had taken. The hospital was notified of this finding at 2:30 PM on 9/30/22.

Findings include:

1. The hospital failed to ensure drugs were administered in accordance with accepted standards of practice. Refer to tag 0405.

2. On 9/19/22, constant observations were conducted on the unit from 8:03 AM through 2:00 PM.

Patient 1 was observed to be wandering around the unit throughout the morning and early afternoon. Patient 1 was not toileted from the time surveyors entered the unit until surveyors asked about toileting him. At 12:41 PM, two certified nursing assistants (CNA) took patient 1 into his bathroom. Patient 1 was observed to be in a brief that was soiled with feces and urine. Patient 1's buttocks were observed to have a rash. CNA 3 stated to surveyors that the patient did not have a rash that morning and that the rash was new.

3. Patient 12's medical record was reviewed during survey.

Patient 12's Observation Check Sheets for 15 minute checks from 9/5/22 through 9/19/22 were reviewed. Based on documentation by the CNA's, patient 12's brief was not changed for several hours on multiple occasions.

The following examples demonstrate the longest time periods without brief changes:

On 9/6/22, patient 12's brief had not been changed for nearly 17 hours.

Between 9/7/22 and 9/8/22, patient 12's brief had not been changed for nearly 24 hours.

Between 9/10/22 and 9/11/22, patient 12's brief had not been changed for 22 hours.

Between 9/16/22 and 9/17/22, patient 12's brief had not been changed for 22 hours.

4. Review of 20 patients medical record revealed similar documentation regarding toileting and brief changes. (Patient identifiers: 1, 2, 3, 4, 8, 9, 11, and 14.)

.

Based on interview and record review, it was determined the hospital did not ensure drugs were administered in accordance with accepted standards of practice. Specifically, nursing assistants were administering medications to patients. (Patient identifier: 3)

Findings include:

1. Patient 3 was admitted on 8/10/22, with a diagnosis of dementia with behavioral disturbances.

On 9/22/22, patient 3's medical record was reviewed. Review of a progress note from the nurse practitioner dated 8/19/22 at 4:02 PM, indicated the following:

"(Patient 3) received the wrong medications today. They included haloperidol, amaryl, Eliquis, Glucophage, piolitazone, and levothyroxine. Medications are crushed in a cup. He took a third of the cup before it was caught as an air (sic). Punctures (sic) up to what medications are concerned. No adverse transient side efforts noted. Metformin, Eliquis are duplicates that are normally on his list."

There was no further documentation regarding the medication error in patient 3's medical record.


35223


2. During survey the hospital's medication error log, nursing assistant orientation checklist, and the policy and procedure for medication administration were reviewed.

On a Medication Error Data Entry Form, it was documented, "On 8/19/2022, while passing medications in the morning the writer [name] was putting crushed medications in the food of 4 patients...The medications for [name] was placed in some food and then put back on his food tray...and told the aides that [name] was ready and then started preparing the next patients tray...A few moments later Nurse [name] looked out to make sure things were going well and noticed that [name] (nursing assistant) was feeding the medications of [name] to the patient [name] who goes by [name]. [name] (Nurse) immediately stopped [name] (nursing assistant) and asked how much had been given..." (Note: The nurse documented preparing 4 patient's medications at the same time.)

It was further documented, "No changes made to level of patient care as a result of medication error. Patient was monitored throughout shift, BG (blood glucose) checks at noon higher, returned to baseline. (sic)".

The root cause analysis section of the form was blank.
The action taken details section was blank.

At the bottom of the form there was a section for signatures as follows:

Director/Manager Review: Date/Time:
Pharmacy Review: Date/Time:
Performance Improvement Committee Review: Date/Time:

All three signatures spaces were blank.

3. In the nursing assistant orientation checklist on a document titled Two Patient Identifier, it was documented, "The patients name band must be compared to the two patient identifier cards for all: ...3. Medication Administration". The nursing assistant name/title and signature were at the bottom of the document.

4. In the hospitals policy and procedure titled Medication Administration - General Guidelines, it was documented, "1. Medications are administered only by a licensed nurse... 3. Medications are administered at the time they are prepared. Medications are not pre-poured... 4. The person who prepares the dose of administration is the person who administers the dose".

On 9/28/22 at 10:40 AM, an interview was conducted with nursing assistants 1 and 2. When asked if they were allowed to administer medications to the patients, they both stated they were not allowed to handle or administer medications.

On 9/28/22 at 10:44 AM, an interview was conducted with registered nurse (RN) 2. RN 2 stated that only RN's administer medications. (Note: RN 2 was the RN involved in the medication error on 8/19/22, involving patient 3 and the nursing assistant.)

On 9/28/22 at 10:56 AM, an interview was conducted with the director of nursing (DON). The DON stated that it was the hospital's "protocol" that if a nurse is standing there, a nursing assistant can feed medications to patients but the nurse is "supposed to be watching".

There was no documented evidence that the hospital had investigated the medication error nor implemented procedures to prevent further medication errors.

Based on observation, interview, and medical record review, it was determined the hospital failed to maintain accurate medical records for all patients. Specifically, all sampled patient medical records were contradictory, incomplete, confusing, and inaccurate. Based on a sample of 20 medical records, it was determined that surveyors were unable to conduct a complete and accurate medical record review for 20 of 20 patients. (Patient identifiers: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, and 20)

Findings include:

Patient 12's medical record was reviewed during survey. A summary of findings follows:

Patient 12 was admitted on 9/5/22, with a diagnosis of dementia with behaviors.

1. In client support notes dated 9/5/22, 9/6/22, 9/7/22, 9/12/22, 9/13/22, 9/14/22, and 9/20/22, incorrect patient names were documented in patient 12's medical record. A total of four other patient names were identified. These client support notes recorded the patient's food and fluid intake for the day. There was no way to identify if the documentation was regarding patient 12 or the other patients that were named.

2. In a nursing note dated 9/7/22, patient 12's name and another patient's name were documented. In this same nursing note under the section titled BEHAVIOR, it was documented that, "Good medication compliance is noted ... He generally complies with rules. No prns (as needed) have been necessary today. Anger has been well controlled. Impulsive behaviors are not reported ..." Upon review of patient 12's medication administration record it was documented that a 1 mg dose of PRN Ativan had been administered on 9/7/22. No further documentation regarding the indication or effectiveness of the Ativan dose could be located.

3. In a social work note dated 9/8/22, under the section titled Strengths/Assets, it was documented, "*Ambulatory without assistance". In the same note under the section titled Assistive Devices, it was documented, "Mr. [name] uses a wheel chair (sic)."

4. In a group therapy note dated 9/13/22, under the section titled Participation, it was documented, "Mr. [name] did not attend group today." Under the section titled Behavior, it was documented, "Posture and body language was today suggestive of underlying anxiety. Mr. [name] was irritable and easily angered today."

a. In a group therapy note dated 9/14/22, under the section titled Participation it was documented, "Mr. [name] did not attend group today." Under the section titled Behavior it was documented, "Posture and body language was today suggestive of underlying anxiety. Fidgety, restless behavior was exhibited by Mr. [name] in group today."

5. On 9/19/22, surveyors conducted constant observations of the patients from 8:03 AM through 2:00 PM. Surveyors obtained a copy of the Observation Check Sheet for 15 minute Checks/Line of Sight/1:1 for patient 12. The observation sheet had 15 minute checks documented from midnight through 11:00 AM. At 8:00 AM, it was documented that patient 12 was in the dining room eating. At 10:00 AM, it was documented that patient 12 was in his bedroom sleeping.

a. On 9/22/22, the hospital provided a copy of this same document that had documentation completed on 9/19/22, from midnight through 11:45 PM. On this copy at 8:00 AM and 10:00 AM, the documentation had been changed to in the bedroom getting a brief change. Surveyors observed patient 12 from 8:03 AM through 2:00 PM. Patient 12 was observed to remain in the common area and was not in his room at 8:03 AM nor taken into his room at 10:00 AM for a brief change.

6. In a nursing note dated 9/13/22, it was documented, "Nurse very concerned that patient has a "mass" in his groin ...". Patient 12 was not evaluated by a physician for the mass until 9/18/22, when an ultrasound was ordered.

7. Clinical notes dated 9/7/22, 9/13/22, 9/15/22, and 9/16/22, revealed laboratory test results were reviewed. The laboratory results were reviewed and signed by a non-clinical employee.

8. Between 9/10/22 and 9/19/22, six clinician notes were not signed by the clinicians.

9. On a Treatment Plan dated 9/9/22, it was documented under the section titled Short Terms Goal(s) & Interventions:

a. "...Therapist/Counselor will conduct individual therapy...1-3 times per week ..."

b. There was no documented evidence in patient 12's medical record of individual therapy being conducted.

10. In a nursing note dated 9/14/22, it was documented, "...he was placed into his wheelchair and didn't move of his own accord afterward. He sat in the dining area with his head down until moved to a different area ..."

In a group therapy note dated 9/14/22, it was documented, "Mr. [name] was active today and participated fully in discussions today. (sic) " In this same group therapy note under the Date/Time section it was documented, "9/14/22, 12:50 PM". In the body of the note it was documented, "Session start: 2:30 PM. Session end 3:30 PM." At the bottom of the note, it was documented "Electronically Signed On: 9/15/2022 12:50:13 PM".

11. In a nursing note dated 9/13/22 and timed 3:26 PM, it was documented, "...He has been socially isolating today, not looking up to see what was around him..."

a. In a group therapy note dated 9/13/22, it was documented in the body of the note, "Session start: 2:30 PM, Session end: 2:30 (sic) PM". Under the Participation section it was documented, "Mr. [name] was active today and participated fully in discussions today (sic). He stayed the entire session."

12. On 9/28/22 at 10:54 AM, an interview was conducted with the director of nursing (DON). The DON stated she reviewed every chart for completeness and accuracy when the patient was discharged. She further stated that the provider and another staff member would review the charts for completeness and accuracy also.

13. On 10/3/22 at 11:00 AM, an interview was conducted with physician assistant (PA) 1. PA 1 stated the electronic medical record they used is mostly clicking boxes and that it provides prompts for where to click next.

14. On 10/5/22 at 9:15 AM, an interview was conducted with the hospital administrator (ADM). The ADM stated the hospital did specific audits to ensure compliance with the hospital regulations. They audited the medication administration records and audited patient medical records to ensure each patients specific needs were being met. The ADM stated the director of nursing did the audits. The results of the audits were taken to the quality committee. The ADM stated if there were concerns, they would make immediate changes. If there continued to be a problem then they would do a process improvement project to make the necessary changes and work toward improvement.

15. The 19 other sampled medical records had similar results/issues/concerns. Due to the confusion and inaccuracy of the medical records, surveyors were not able to conduct a complete and accurate medical record review therefore compliance could not be determined in standards 0432, 0438, 0449, 0450, 0454, 0458, 0461, 0462, 0464, 0465, 0466, 0467, and 0468 under this condition.

Based on observation, interview, and record review, it was determined the hospital failed to provide pharmaceutical services in a safe manner that met the needs of the patients. Specifically, the hospital failed to ensure medications were administered by licensed professionals; failed to investigate medication errors; and failed to assess patients for adverse drug reactions. (Patient identifier: 12)

On 9/26/2022 a finding of Immediate Jeopardy (IJ) was identified in the area of Pharmaceutical Services. The hospital was notified of this finding verbally and in writing on 9/26/2022 at 3:20 PM. The Hospital submitted an IJ removal/abatement plan on 9/27/22 at 12:31 PM, via email, alleging removal as of 9/30/2022 at 2:00 PM. The plan was accepted, and the hospital was notified on 9/28/2022 at 8:26 AM. Surveyors were on site and reviewed for IJ removal. It was determined that IJ had been removed on 9/30/2022 based on the steps the hospital had taken. The hospital was notified of this finding at 2:30 PM on 9/30/2022.

Findings include:

1. The hospital failed to ensure drugs were administered in accordance with accepted standards of practice. Specifically, nursing assistants were administering medications to patients. Refer to tag 0405.

2. Patient 12 was admitted on 9/5/22.

Patient 12's medical record was reviewed throughout the survey and revealed the following:

In a Complete Evaluation/Inpatient note dated 9/6/22 and timed 8:54 AM, it was documented that patient 12 had normal muscle strength and tone. It was further documented that his gait was normal.

In a Nursing Note dated 9/5/22 and timed 11:24 PM, it was documented that patient 12 was a low fall risk.

In a Group Therapy Note dated 9/6/22 and timed 12:35 PM, it was documented that patient 12 was active and participated fully in discussions.

In a Nursing Note dated 9/6/22 and timed 2:42 PM, it was documented that patient 12 had been eating and drinking well with normal food and fluid intake, was participating regularly in activities, and was engaged in conversations.

In a Complete Evaluation/Inpatient note dated 9/6/22 and timed 6:13 PM, it was documented that patient 12 was sitting up in a wheelchair, confused but "very cooperative". Under the physical exam portion of the note it was documented, "I - Olfactory: smells alcohol swab and said: "that is very strong smell and cleaned my ...and then pointed to his nose"." It was further documented that he could ambulate without assistance.

In a Nursing Note dated 9/7/22 and timed 12:09 PM, it was documented that patient 12 spent the morning socializing with his peers and had taken his medications whole with water.

In a Treatment Plan dated 9/9/22 and timed 9:32 AM, it was documented that patient 12 could make his needs known.

Beginning on 9/10/22, nursing staff began noting that patient 12's food and fluid intake was decreasing and that he needed to be coaxed to eat and drink. On 9/13/22, 9/17/22, and 9/18/22, it was documented that patient 12 only ate 25% of one meal on each day.

In a Nursing Note dated 9/12/22 and timed 12:40 PM, it was documented that patient 12, "...had been tired today staing (sic) in his bed most of the day, occasionally trying to stand but has been unsuccessful so far..."

In a Nursing Note dated 9/12/22 and timed 10:22 PM, it was documented that patient 12 spent the evening resting in the common area, was compliant with medications and was minimally communicative.

In a Dietician Note dated 9/13/22 and timed 9:06 AM, it was documented that patient 12 was having a hard time feeding himself with utensils and he needed finger foods. It was further documented that his food and fluid intake trend was at 0-50%.

In a Nursing Note dated 9/13/22 and timed 3:26 PM, it was documented, "...he would not or could not feed himself today and was fed for each meal. He has been socially isolated today, not looking up to see what was around him ...".

In a Nursing Note dated 9/14/22 and timed 12:15 PM, it was documented, "...he was placed into his wheelchair and didn't move of his own accord afterward. He sat in the dining area with his head down until moved to a different area. he (sic) has been quite and withdrawn." It was further documented that he had diminished food and fluid intake and needed to be fed.

In a Progress Note dated 9/15/22 and timed 8:46 AM, it was documented that, "...Side effects to medications cannot be ruled out at this time..."

In a Nursing Note dated 9/15/22 and timed 4:06 PM, it was documented, "...He sleeps most of the time whether in bed or a wheelchair...". It was further documented that patient 12 presented as drowsy and his fall risk had been changed from low to high.

In a Nursing Note dated 9/18/22 and timed 12:22 PM, it was documented, "...he has been sleeping most of the day, and calling out when cares are performed. Pt (patient) oral intake has been minimal today. An IV of NS (normal saline) was prescribed and given today due to low intake."

Patient 12's medication administration record was reviewed and revealed the following:

Patient 12 had received 1 milligram (mg) as needed (PRN) doses of Ativan on 9/5/22, 9/6/22, 9/7/22, 9/9/22, 9/10/22, 9/11/22, and 9/13/22.

Patient 12 received 50 mg doses of scheduled Trazadone every night from 9/5/22 through 9/9/22. On 9/10/22, the Trazadone dose was increased to 100 mg nightly which he received from 9/10/22 through 9/20/22.

On 9/10/22, patient 12 was started on Abilify 5 mg daily which he received from 9/10/22 through 9/12/22. On 9/13/22 the dose was increased to 10 mg, then on 9/14/22 the dose was increased again to 15 mg daily which he received from 9/14/22 through 9/21/22.

On 9/15/22, patient 12 was started on scheduled Clonazepam 0.5 mg twice a day. He received 0.5 mg on 9/15/22. On 9/16/22 he received 0.5 mg in the morning then the dose was increased to 1 mg twice a day. He received a total of 1.5 mg on 9/16/22. On 9/17/22, he received a total of 2 mg. On 9/18/22, he received a total of 1 mg.

(Note: All four of these medications have drowsiness/tiredness as a side effect.)

(Note: Patient 12's increased drowsiness and decreased food/fluid intake coincided with the increased doses of medications and the addition of more psychotropic medications.)

On 9/19/22 Between 8:03 AM and 2:00 PM, patient 12 was observed on the unit. From 8:03 AM through 10:00 AM, patient 12 was sitting in a wheelchair at a dining table with his head laying on the tabletop. At 9:14 AM, registered nurse (RN) 1 was observed attempting to give patient 12 some medications that had been crushed and mixed with food. RN 1 pulled patient 12's head up from the table by his forehead. Patient 12's eyes were closed and his mouth was hanging open. There was a large patch of moisture on patient 12's shirt front from him drooling. RN 1 put some of the crushed medications into patient 12's mouth. Some of the medications ran out of patient 12's mouth. RN 1 attempted again to put the medications into patient 12's mouth. Patient 12 appeared not to respond, and he did not open his eyes. RN 1 then put patient 12's head back on the table and left.

3. On 9/19/22 at 12:19 PM, an interview was conducted with the director of nursing. When asked about patient 12 appearing unable to respond and not opening his eyes when addressed by the RN, she stated that there is a "fine line" between treatment and sedation.

Based on interview and record review, it was determined the hospital did not make adequate provisions for dietary consultation that met the needs of the patients for 1 of 20 sampled patients. (Patient identifier: 3)

Findings include:

1. On 9/28/2022 @ approximately 9:50 AM, the dietary manager (DM) was interviewed. The DM stated she worked for the assisted living center (ALC) that is next to the hospital but was contracted with the Marian Center. The DM stated that the ALC kitchen provided the hospital with food and snacks. Other than that, she stated she was not involved in the care or services provided to the patients in the hospital.

2. On 9/28/2022 at approximately 10:00 AM, a telephone interview was conducted with the registered dietitian (RD). The RD stated that she was contracted by the hospital to do nutritional assessments on the patients and monitor dietary needs and consult with hospital staff to meet the needs of the patients. The RD stated she came in once a week to do the assessments. If a patient had been admitted and discharge before she came each week then she would not be involved in their care. The RD stated based on her evaluation, if she noticed they were skipping meals, she would write an order for boost (nutritional protein drink) or offer snacks. If they don't eat, they get offered a boost or any other supplement.

3. Patient 3 was admitted on 8/10/2022, with a diagnosis of dementia with behavioral disturbances.
A review of patient 3's medical record revealed patient 3 was diabetic and was ordered a diabetic diet by the admitting physician.

Further review revealed patient 3 did not receive a dietary consultation and assessment until 8/23/2022 at 8:49 AM (13 days after admission). A review of progress notes revealed a steady decline in food and fluid intake.

A progress note dated 9/8/2022, indicated patient 3 had a decrease in food and fluid intake and needed to be coaxed to eat and drink.

On 9/19/2022 at 12:03 PM, a nurse practitioner progress note indicated patient 3's caloric and fluid intake were likely not sufficient for adequate health in his frail condition.

On 9/20/2022, a progress note indicated patient 3 had a decline in food and fluid intake.

On 9/22/2022, patient 3 was discharged to a skilled nursing facility.

No documented evidence was provided to indicate the dietician had done a follow up assessment on patient 3 or had ordered a nutrition supplement such as boost or another supplement.

Based on interview and record review, it was determined the hospital did not ensure individual patient nutrition needs were met. Specifically, the hospital did not ensure the appropriate diet was ordered for 2 of 20 patients. (Patient identifiers: 3 and 4)

Findings include:

1. Patient 3 was admitted on 8/10/2022, with a diagnosis of dementia with behavioral disturbances.
A review of patient 3's medical record revealed patient 3 was diabetic and was ordered a diabetic diet by the admitting physician.

Further review revealed patient 3 did not receive a dietary consultation and assessment until 8/23/2022 at 8:49 AM (13 days after admission). A review of progress notes revealed a steady decline in food and fluid intake.

A progress note dated 9/8/2022 indicated patient 3 had a decrease in food and fluid intake and needed to be coaxed to eat and drink.

On 9/19/2022 at 12:03 PM a nurse practitioner progress note indicated patient 3's caloric and fluid intake were likely not sufficient for adequate health in his frail condition.

On 2/20/2022, a progress note indicated patient 3 had a decline in food and fluid intake.
On 2/22/2022, patient 3 was discharged to a skilled nursing facility.

No documented evidence was provided to indicate the dietician had done a follow up assessment on patient 3 or had ordered a nutrition supplement such as boost or another supplement.

2. Patient 4 was admitted on 9/14/2022, with a diagnosis of psychosis.

A review of patient 4's medical record revealed an order dated 9/14/2022 for a regular diet.

Further review of the medical record revealed a dietitian consult note dated 9/20/2022. The dietitian documentation indicated patient 4 had told her that he had a gluten allergy but could tolerate some gluten. He stated he would like to have gluten free bread with meals, and he would manage other items as he desired at each meal.

A gluten free diet was ordered on 9/23/2022. (Note: Patient 4 was discharged on 9/23/22 at approximately 1:00 PM.)

On 10/5/2022 at approximately 9:20 AM, an interview was conducted with the administrator. He stated he would have to talk with the director of nursing concerning patient 4's diet requirements.

On 10/5/2022 at 10:30 AM, the director of nursing indicated they had no further information regarding patient 4's dietary requirement other than what had been documented in the medical record. No documented evidence was provided to indicate the hospital had met the nutritional needs for patient 4.

Based on observation and interview, it was determined the hospital failed to have an active hospital-wide program for the surveillance, prevention, and control of HAIs (hospital acquired infections) and other infectious diseases.

Findings include:

The hospital did not employ methods for preventing and controlling the transmission of infections within the hospital. Refer to tag 0749.

Based on observation and interview, it was determined the hospital did not employ methods for preventing and controlling the transmission of infections within the hospital. (Patient identifiers: 2, 3, 4, 12, 15, and 22)

Findings include:

1. On 9/15/22 at 9:15 AM, surveyors began observations on the unit. At 9:52 AM, patient 3 was observed drinking out of patient 15's water mug. At 9:54 AM, certified nursing assistant (CNA) 2 was observed taking patient 15's water mug and setting it on the floor next to a recliner with a different patient sitting in it. The water mug had not been cleaned.

2. On 9/19/22 observations began at 8:03 AM. At 8:30 AM, patient 4 was observed touching patient 2's water mug. At 9:02 AM, patient 3 was observed drinking out of patient 4's water mug. At 12:11 PM, CNA 3 was observed giving patient 22's water mug to patient 4. Patient 4 drank from the mug. At 12:41 PM, patient 22 was observed to have her water mug again.


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3. On 9/19/22 at 8:10 AM, CNA 3 was observed exiting room 3108 with bed linens held up against her scrubs. The bed linens were not placed in a bag to prevent her scrubs from coming in contact with potential human waste.

4. On 9/19/22 at 11:28 AM, CNA 4 was observed while checking the blood glucose of three patients who had been diagnosed with diabetes. CNA 4 was observed to check each patient with the same glucometer without sanitizing it between patients. She was further observed to wear the same pair of gloves for all three patients.

a. On 9/19/22 at 11:32 AM, the director of nursing (DON) was interviewed. The DON stated that patients should be taken into their room to check blood glucose. She further stated that the glucometer should be cleaned and gloves should be changed between patients.

5. On 9/19/22 at 11:39 AM, CNA 4 was observed pushing patient 12 in his wheelchair. CNA 4 was wearing gloves. CNA 4 was asked if she had changed patient 12's brief and if she had performed peri-care. CNA 4 stated yes, she had. CNA 4 was then asked if she had changed her gloves after performing peri-care and before pushing the wheelchair. CNA 4 stated No. When asked if she should have changed her gloves, CNA 4 nodded her head yes.

Based on observation, interview, and record review, the psychiatric hospital failed to meet the Conditions of Participation for hospitals. Specifically, the hospital failed to meet the conditions of participation which resulted in Immediate Jeopardy in the areas of 482.13 Patient Rights, 482.23 Nursing Services, and 482.25 Pharmaceutical Services. In addition, the hospital failed to meet the Conditions of Participation in the areas of 482.12 Governing Body, 482.21 Quality Assurance and Performance Improvement, 482.24 Medical Records, and 482.42 Infection Control.

Findings include:

1. The hospital failed to provide appropriate oversight and overall management of its operations. Refer to tag 0043.

2. The hospital failed to ensure patient rights were protected. Refer to tag 0115.

3. The hospital failed to develop and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance program. Refer to tag 0263.

4. The hospital failed to provide nursing services in a safe manner that met the needs of the patients. Refer to tag 0385.

5. The hospital failed to maintain accurate medical records for all patients. Refer to tag 0431.

6. The hospital failed to provide pharmaceutical services in a safe manner that met the needs of the patients. Refer to tag 0489.

7. The hospital failed to employ methods for preventing and controlling the transmission of infections within the hospital. Refer to tag 0749.

Based on interview and record review, the psychiatric hospital failed to maintain medical records that determined the degree and intensity of the treatment provided to patients who were provided services in the hospital.

Findings include:

1. The psychiatric hospital failed to ensure each patient had an individualized comprehensive treatment plan. Refer to tag 1640.

2. The psychiatric hospital failed to ensure specific treatment modalities were utilized to meet the needs of the individual patient and were provided by all disciplines. Refer to tag 1643.

Based on observation, interview, and record review, the psychiatric hospital did not ensure each patient had an individualized comprehensive treatment plan for 20 of 20 patients. (Patient identifiers: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, and 20)

Findings include:

1. Patient 3 was admitted to the hospital on 8/10/2022, with an admitting diagnosis of dementia with behavioral disturbances. Secondary diagnoses included diabetes, obstructive sleep apnea, hypertension, bipolar disorder, long term use of anticoagulants, and gastro-esophageal reflux disease.

2. On 9/22/2022, patient 3's medical record was reviewed.

A review of the treatment plan revealed the following:
PROBLEM / NEEDS:
Problem / Need # 1: Fall Risk
Problem / Need # 2: GERD
Problem / Need # 3: Diabetes
Problem / Need # 4: Sleep Problems
Problem / Need # 5: Coumadin Therapy
Problem / Need # 6: Hypertension
Problem / Need # 7: Cognitive Impairment
Problem / Need # 8: Anxiety
Problem / Need # 9: Discharge Plan

A review of patient 3's medical history revealed patient 3 was not on Coumadin therapy. Patient 3 was taking Eliquis which is an anti-coagulant, but the monitoring and treatment is different than Coumadin. The care plan was for Coumadin Therapy.

A review of the sleep problems plan revealed the problem was evidenced by, "awakening with Worried Ruminating". There was no mention of treatment for his obstructive sleep apnea in the treatment plan.

3. All other problems, 1, 2, 6, 7, 8 and 9, were worded generically and were the exact same wording for all other patients with the same problem listed on their treatment plan.

a. As an example patient 3's cognitive plan indicated that he had an active problem that required treatment that was primarily evidenced by reduced awareness of environment, cognitive and functional disturbance and cannot negotiate milieu.

Patient 1's cognitive plan indicated that he had an active problem that required treatment that was primarily evidenced by needing careful supervision and required psychiatric intervention.

The short term goals and interventions for both patient 1 and patient 3 were exactly the same which were as follows:

"Intervention: Prescriber will prescribe medications to patient, monitor side effects, and adjust dosage to treat symptoms and behaviors associated with the cognitive impairment. Progress will be monitored and documented.

Frequency: once per day, Duration: 15 minutes, Clinician: Physician Assistant

Intervention: Case manager will maintain family contact to apprise them of patient treatment response and to encourage their ongoing treatment involvement. Progress will be monitored and documented.

Frequency: 1-3 times per week, Duration: 20 minutes, Clinician: Case manager

Intervention: OT/PT/REC (occupational therapy/physical therapy/recreational therapy) will provide patient with cognitive and intellectual stimulation. Progress will be monitored and documented.

Frequency: 1-3 times per day, Duration: one hour, Clinician: Recreation Therapist

Intervention: Nurse will administer medication and other treatments to patient, monitor and document compliance, effectiveness, and side effects. Progress will be monitored and documented.

Frequency: 1-3 times per day, Duration: 10 minutes, Clinician: DON (director of nursing)

Intervention: Therapist/Counselor will encourage patient to cooperate and complete all testing and evaluations. Progress will be monitored and documented.

Frequency: 1-3 times per week, Duration: 20 minutes, Clinician: LCSW (licensed clinical social worker)"

b. Another example was the discharge treatment plan which is worded exactly the same for 20 out of 20 patients in which record review was completed.

Documentation of the discharge plan:

"Problem: Discharge Plan

(Patient name) discharge plan is an active need that affects his recovery environment and requires intervention. It is primarily manifested by:

Discharge date approaches: Details are as follows:

Ready for discharge when medications are stable and 24 hr (hour) nursing care is no longer required.

(Patient name) appropriate level of care is facilitated prior to discharge.
Target Date: (date they anticipated discharge)

Short Term Goal Objective:

(Patient name) will accept social services help. Frequency: once per day Duration: 10 minutes
Intervention:

Case Manager will schedule follow up appointments, refer to community agencies as needed, and arrange for transportation, prior to discharge.

Frequency: once per stay, Duration: 20 minutes, Clinician: case manager"

4. On 9/26/2022 at approximately 1:30 PM, an interview was conducted with the DON. The DON stated she knew patient 3 was not on Coumadin therapy but was taking another anticoagulant. The DON stated the physicians never addressed the sleep apnea for patient 3 so she did not document it on the treatment plan.

The DON further stated she could not change the information in the electronic treatment plan. She stated the program prompted her to click on certain areas and then it would auto populate the treatment plan. The DON stated that she could not free text in the program or make changes.
The surveyor asked the DON about providing OT and PT therapy. The DON stated they did not provide PT therapy because the patients were not there for physical therapy. The DON stated they have at times provided OT, but it was not often.

No documented evidence was provided to indicate the hospital had developed an individualized patient specific treatment plan that included individualized goals and interventions for patient's 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19 and 20.

Based on observation, interview, and record review, it was determined the psychiatric hospital did not ensure the specific treatment modalities were utilized to meet the needs of the individual patient and were provided by all disciplines. (Patient identifiers:1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, and 20)

Findings include:

1. Observations were made throughout the survey process of the patients and activities.

a. On 9/24/2022 at approximately 10:30 AM, observations were made of a group activity. Patient's 2, 19, 21 and 22 were observed sitting outside on the sidewalk in the shade. All four patients were wrapped in blankets. (The temperature at that time was in the low 60's in the sun with a slight breeze.) Certified nursing assistant (CNA) 1 was observed to be sitting under the covered patio next to the door to the common room watching the patients. There was no organized activity occurring at the time. The patients were observed to be just sitting wrapped in blankets. Patient's 21 and 22 repeatedly requested to go back into the commons room because they were "freezing to death". CNA 1 stated that it was not time to go back inside just yet.

At approximately 10:45 AM, CNA 1 asked if the patients would like a cookie. Patient 21 stated yes if it meant they could go back into the building. CNA 1 brought out cookies for them to eat. At 10:55 AM, CNA 1 allowed the patients to re-enter the building. At that time patient 22 stated she was so cold she did not think she could move.

Patient 1 was observed to wander aimlessly around at approximately 10:30 AM. Patient 1 was fidgeting with the doorknobs frequently during that time. Two other patients were observed to be sitting with their eyes closed during the same time frame.Two CNAs were observed to stand around throughout the observations. There was very little interaction observed between the staff and the patients.

On 9/24/2022 at approximately 11:00 AM, patient 21 asked for something to do. CNA 1 brought patient 21 a crossword puzzle to do. Patient 21 looked at the puzzle and stated that she had already done that puzzle and asked was there something else to do? CNA 1 brought over a deck of cards for patients 21 and 22 to use.

At approximately 11:30 AM, CNA 1 asked patients 21 and 22 who was winning the game. Patient 22 stated that had played the games so many times that they did not keep track anymore.

Patient 1 was observed to wander around the common room while two other patients sat with their heads down and eyes closed. Patient 1 continued to wander and fidget with the doorknobs. No organized activities were observed from 10:30 AM until the noon meal was delivered.

b. Observations were made on 9/26/2022 from 8:35 AM to 12:45 PM.

At 8:45 AM patient 21 commented, "It is almost 9:00 and we haven't done anything. But I am sure enjoying the change in music."

At 9:30 AM, CNA 3 handed out word search puzzles for the patients to do. Patient 21 and 22 both stated that it was not a new one. They had done that one before.

At 10:30 AM, the recreational therapist (RT) started a Pictionary game out on the patio. The temperature outdoors was 67 degrees. Patients 21, 22 and 2 participated.

Lunch was delivered at 11:45 AM.

No other organized activities or therapy was observed during that time.

c. On 9/27/22 at 9:15 AM, a morning interdisciplinary meeting was observed. The licensed clinical social worker (LCSW) mentioned there was a social work (SW) group for the patients.

Observations were made of the white board in the common room. Written on the board was the daily schedule which indicated a SW group was to be held at 12:30 PM that day. Surveyors observed until 1:00 PM. No SW group was held during that time. A review of the white board noted the SW group for that day had been erased.

The director of nursing (DON) was interviewed at 1:20 PM. The DON stated "Yes" they do SW groups. They just started them.

d. Observations were made of group therapy 9/29/2022 at 10:30 AM. Four patients attended. The activity was guessing what decade an event occurred. Patient 21 stood up and started wandering around the group therapy room at approximately 10:40 AM. The activity ended at 11:26 AM. Patient 21 walked out of the room and commented the activity dragged on forever. She stated it was fun for a few minutes, but it got boring quickly. Patient 22 stated that she agreed.

Other patients were observed just wandering or sitting in the common room while soft music was playing on the television.

2. Patient medical records were reviewed during the survey.

a. Patient 1 was admitted on 9/9/2022, with an admitting diagnosis of Parkinson's dementia.

A review of the group notes revealed the following:

aa. Group Therapy Note dated 9/14/2022 at 1:01 PM, the session started at 10:30 AM and ended at 11:30 AM.

"Group Type: Shake Loose a Memory

Activity Therapy: Activity Therapy includes a variety of activities designed to help the group members learn more about themselves, problem solve, express feelings in appropriate ways, reduce stress and improve relationships with others. They may participate in art, music, exercise, sports, games and other activities.

Individual Remarks: blank

Participation:
[Patient 1] was relatively inactive today and did not fully participate in discussions. He stayed the entire session."
The note was signed by the RT.

bb. Group Therapy Note dated 9/18/22 at 1:15 PM. The session started at 11:00 AM and ended at 12:00 PM.

"Session Remarks: Participation

Naturescape: Participation: Participant wandered in and out of activity and did not fully engaged (sic). Client was becoming self with no social worker (sic)."

Individual Remarks: Participation

Group therapy note was signed by the social worker.

cc. Group Therapy Note dated 9/19/2022 at 12:33 PM, The session started at 10:00 AM and ended at 11:45 AM." (Note: This was the day the RT came in late and started group at 11:15 AM)

"Group Type: German Jeopardy

Activity Therapy: Activity Therapy includes a variety of activities designed to help the group members learn more about themselves, problem solve, express feelings in appropriate ways, reduce stress and improve relationships with others. They may participate in art, music, exercise, sports, games and other activities.

Individual remarks:
Participation: (Patient 1) was active today and participated fully in discussions today. He stayed the entire time."
The note was signed by the RT.

3. Patient 3 was admitted to the hospital on 8/10/2022, with an admitting diagnosis of dementia with behavioral disturbances.

A review of his medical record revealed the following documentation:

aa. Psychotherapy Group Note dated 8/21/2022 at 2:37 PM. The session started at 12:30 PM and ended at 2:30 PM

"Session Remarks:

Therapy Type: Client Centered - Naturescape to enjoy the outdoor scenery and discuss old memories among themselves and outlook on their future.

Participation: (Patient 3) was relatively inactive today and did not fully participate in discussions. He presented as restless, fidgety and hyperactive in today's session."

The note was signed by the LCSW. (Note: This was 1 of 2 documented SW therapy sessions for patient 3 during his 43 day stay in the hospital.)

bb. Group Therapy Note dated 9/16/22 at 12:41 PM. The session started at 10:30 AM and ended at 11:30 AM.

"Group Type: Picture Story

Activity Therapy: Activity Therapy includes a variety of activities designed to help the group members learn more about themselves, problem solve, express feelings in appropriate ways, reduce stress and improve relationships with others. They may participate in art, music, exercise, sports, games and other activities.

Individual Remarks: Blank

Participation: (Patient 3) did not attend group today."
The noted was signed by the RT.

cc. Group therapy note dated 9/16/2022 at 8:37 PM.

"Session Remarks: Blank

Individual Remarks: Blank

Participation: He (patient 3) was verbally aggressive in today's session.
Behavior: (Patient 3) was focused and attentive in group today.
(Patient 3) had a snack in his room instead."

The note was signed by CNA 8.

dd. Group Therapy Note dated 9/18/22 at 1:15 PM. The session started at 11:00 AM and ended at 12:00 PM.

"Session Remarks: Participation

Naturescape: Participation: Participant wandered in and out of activity and did not fully engaged (sic). Client was becoming self with no social worker. (sic)"

Individual Remarks: Participation
Naturescape: Participation: Participant wandered in and out of activity and did not fully engaged (sic). Client was becoming self with no social worker. (sic)"

Group therapy note was signed by the social worker.

4. Patient 5's medical record was reviewed. Patient 5 was admitted on 8/30/2022.

aa. Group Therapy Note dated 9/13/22 at 5:34 PM. The session started at 2:30 PM and ended at 2:30 PM. (sic)
"Group Type: Snow Cones

Activity Therapy: Activity Therapy includes a variety of activities designed to help the group members learn more about themselves, problem solve, express feelings in appropriate ways, reduce stress and improve relationships with others. They may participate in art, music, exercise, sports, games and other activities.

Individual remarks:
Participation: (Patient 5) was active today and participated fully in discussions today. She stayed the entire session."

The group therapy note was signed by the RT.

bb. Group Therapy Note dated 9/16/22 at 12:41 PM. The session started at 10:30 AM and ended at 11:30 AM.

"Group Type: Picture Story

Activity Therapy: Activity Therapy includes a variety of activities designed to help the group members learn more about themselves, problem solve, express feelings in appropriate ways, reduce stress and improve relationships with others. They may participate in art, music, exercise, sports, games and other activities.

Individual Remarks: Blank

Participation: (Patient 5) was active today and participated fully in discussions today. She stayed the entire session."

The note was signed by the RT.

5. Review of the medical records for 1, 2, 3, 4, 5, 6, 7, 8, 9, 10,11, 12, 13, 14, 15, 16, 17, 18 ,19, and 20 revealed the same generic documentation for the group therapy notes for each patient.

6. On 10/4/2022 at 2:00 PM, an interview was conducted with CNA 3. CNA 3 stated the SW was responsible to do the group activities on the weekends. CNA 3 stated it really was not scheduled though. At times the CNAs try to provide them with things they would like to do.

7. On 10/4/2022 at 2:35 PM, an interview was conducted with CNA 4. CNA 4 stated she thought the CNAs planned the activities on the weekends, but she was not sure since she did not work weekends anymore. She stated there may be a paper telling the CNAs what they were supposed to do. CNA 4 stated the RT planned and supervised the group activities Monday through Friday. CNA 4 stated they were scheduled for 10:30 AM and 2:30 PM during the week. CNA 4 stated the aides were to offer books to read and puzzles to do during other times of the day to keep the patients busy.

No documented evidence was provided to indicate the hospital provided individualized active treatment with appropriate treatment measures to meet needs of 20 of 20 sampled patients.