HospitalInspections.org

Based on observation and interview, the facility failed to ensure that the care of its patients was conducted in a safe setting as relates to the lack of proper functioning of patient call lights on the adult unit and delay in responding to a call light on the geriatric unit.

Findings:
1. While on tour of the adult unit on 1/22/15 at 2:10 PM, in the company of staff member #44, the chief nursing officer, it was observed that:
a. The call light in room #108 was activated and lighted up, but when returning to the nursing station could not be heard to be sounding.
b. It was found that the call light "box" at the nurses' station had been turned off so that call lights could not be heard.
c. Room 109 was occupied with patients, but had no call lights available.

2. Interview with staff member #43, the plant operations manager, at 2:20 PM on 1/22/15 indicated:
a. Call lights were removed by nursing, on 1/21/15, from at least one patient room for precautions due to patient suicidal tendencies.
b. When the call lights are removed from the wall unit, the call box at the nursing station sounds continuously and cannot be deactivated, so it was turned off.
c. There should be some type of "plug" that can be placed in the wall unit after removing the call light cords so that the call box won't sound continuously.

3. Interview with staff member #43, the plant operations manager, on 1/23/15, in the company of staff member #42, the director of performance improvement and risk, indicated:
a. The nurse call system was new the first of January and the "bugs" are still being worked out. (Purchase order signed by #43 on 1/3/15.)
b. The system representative arrived the evening of 1/22/15 and worked on the adult unit nurse call system.

4. A return tour of the adult unit at 11:55 AM on 1/23/15 indicated:
a. The nurse call "box" at the nurses' station had once again been turned off.
b. Once the call box was turned back on, the call light in room 111 was activated.
c. Staff member #56 at the nurses' station did not know how to cancel the call light's "sounding".
d. The call light could not be "canceled" at the bedside, when the "cancel" button was pushed.
e. It is unclear when the adult unit nurse call system will be installed and functioning correctly, so that patients can be assured that when they activate their call buttons for help, a nursing staff member will respond.

5. At 11:00 AM on 1/23/15, while on tour of the geriatric unit in the company of staff member #44, the chief nursing officer, it was observed that:
a. The call light in room 313 was activated.
b. The nurse call "box" at the nursing station had a light sounding alert.
c. Staff in the day room had music turned up too loud to hear the sound of the call light alert.
d. Staff member #44 asked staff to decrease the music level, but staff still did not hear, or did not respond, to the alerting call of a call light.
e. Two nurses were in and out of the nursing station and did not respond to the call light.
f. At about 11:05 AM, one of the nurses happened to be at the end of the corridor, looked up and saw that the call light for room 313 was on, entered the room, and deactivated the call light.

Based on policy and procedure review, medical record review and interview, the facility failed to ensure that a physician order was received for 2 restraint events for 1 of 3 patients who had ESIs (emergency safety interventions) documented (Pt. #20) and failed to ensure
that a physician order for restraint specified the type of restraint to be utilized to ensure that the least restrictive intervention was used in the restraint event for 3 of 3 patients who had ESIs (emergency safety interventions) documented (Pts. #20, #31, and #32).

Findings:
1. Review of the policy "Seclusion and Restraint for Inpatient Acute Programs", policy number CTS 11.13, last reviewed on 4/8/2014, indicated:
a. On page 5 under section "II. Restraint Procedure", it reads: "..., a clinical order must be obtained...".
b. On page 5 under section "II. Restraint Procedure", it reads: "...Objectives for Utilization The only reason for utilizing a restraint is to protect the patient from harming him/herself or others. This level of intervention should NEVER be employed as follows:...(4) Without written or verbal consent from the licensed independent practitioner designated...to order restraint;...".
c. On page 6 under "Restraint Process", it reads: "...(1) Any restraint requires a clinical order from a licensed independent practitioner...".

2. Review of medical records of patients having restraint events indicated Pt. #20 was admitted on 1/9/15 and had:
a. A 1/21/15 "Emergency Safety Intervention Report" packet completed that was "Time initiated" at 2050 hours, (for a "CPI [Crisis Prevention Intervention/Hold]")- but lacked a physician order for the hold/restraint. (An order was noted at 2230 hours with the order date absent, but signed by the nurse on 1/19/15, indicating this was most likely not the order for the 1/21/15 intervention.)
b. The second page of the packet, in the section "II. ORDERS" was blank in the area: "Order obtained from __________ Time__________ and Order received by______________ Time__________".
c. A 1/22/15 ESI packet was initiated at 2230 hours (time ended 2245 hours) for a "CPI Hold", but lacked an order written on the "Physicians Orders" form.

3. At 10:30 AM on 1/23/15, interview with staff nurse #54, indicated there were no orders on the physician's order forms for the restraints/holds of 1/21/15 and 1/22/15, as listed in 2. above.

4. Review of the policy "Seclusion and Restraint for Inpatient Acute Programs", policy number CTS 11.13, last reviewed on 4/8/2014, indicated there is nothing in the document that indicates the specific type of restraint must be ordered.

5. Review of the training documents used for CPI (non-violent crisis prevention/intervention) indicated the types of holds included, but were not limited to:
a. "CPI Children's Control Position".
b. "CPI Team Control Position".
c. "CPI Transport Position".

6. Review of medical records indicated:
a. Pt. #20, a 14 year old, had no orders for restraint, and therefore, no specific type of restraint ordered for the two restraints conducted on 1/21/15 and 1/22/15.
b. Pt. #31, a 15 year old, had an order for an ESI ("hold") on 11/21/14, but lacked an order for the type of restraint to use.
c. Pt. #32, a 12 year old, had an order on 10/16/14 for a "...CPI hold for physical aggression...", but lacked an order for the type of restraint to use.

Based on policy and procedure review, medical record review, and interview, the facility failed to ensure that physician orders for restraint/hold were given/written with a time limit for 1 of 3 patients who had ESIs (emergency safety interventions) documented (Pts. #32).

Findings:
1. Review of the policy "Seclusion and Restraint for Inpatient Acute Programs", policy number CTS 11.13, last reviewed on 4/8/2014, indicated:
a. On page 7 under "Restraint Process", it reads: "...(3) All restraint orders must be time-limited as follows: Up to 4 hours for adults ages 21 and older Up to 2 hours for adolescents ages 9 to 17...".

2. Review of medical records indicated Pt. #32, a 12 year old, had an order on 10/16/14 for a "...CPI hold for physical aggression...", but lacked a time-limited order for restraint used on 10/16/14.

3. At 10:30 AM on 1/23/15, interview with staff nurse #54, indicated there were no time-limited order on the physician's order forms for the restraints/holds of 10/16/14, 1/21/15 and 1/22/15.

Based on document review, medical record review, and interview, the facility failed to ensure that a physician conducted a clinical assessment of the patients within an hour of the order for restraint for 3 of 3 patients restrained (Pts. #20, #31, and #32).

Findings:
1. Review of the "Medical Staff Rules and Regulations", last approved on May 28, 2014, indicated:
a. On page 11, under section "9.0 Seclusion/Restraint", it reads: "9.1 The use of seclusion and/or restraint to assist the patient to regain behavioral control must be authorized by the patient's physician. The physician shall conduct a clinical assessment of the patient in person within ONE hour of the order...".

2. Review of patient medical records indicated:
a. Pt. #20 had ESIs (emergency safety interventions) on 1/21/15 (no order) from 2050 hours to 2055 hours and on 1/22/15 (no order) from 2230 hours to 2245 hours that had RN (registered nurse) assessments, but lacked a physician assessment within ONE hour of the order, as required by medical staff rules and regulations.
b. Pt. #31 had an ESI ("hold") on 11/21/14 (order written at 1530 on 11/21/14) from 1504 hours to 1506 hours that had RN assessments, but lacked a physician assessment
within ONE hour of the order, as required by medical staff rules and regulations.
c. Pt. #32 had an ESI ("hold") on 10/16/14 (order written at 1822 hours on 10/16/14) from 1820 hours to 1830 hours that had RN assessments, but lacked a physician assessment within ONE hour of the order, as required by medical staff rules and regulations.

3. It was confirmed at 10:30 AM on 1/23/15 with staff RN #54, that only FNPs round and write progress notes on the adolescent unit, thus a physician is not completing an assessment within one hour of a restraint/seclusion event.

Based on document review and interview, the hospital did not include in its Quality Assurance/Performance Improvement (QAPI) program 2 services (alcohol detoxification and housekeeping) provided by the facility.

Findings:

1. Review of the facility's QAPI program indicated it did not include the services of alcohol detoxification and housekeeping.

2. In interview, on 1-23-15 at 12:45 pm, employee #A4, Performance Improvement/Risk Manager, confirmed the above and no other documentation was provided prior to exit.

Based on review of the medical staff by-laws, medical staff rules and regulations review, review of policy and procedure, medical record review, and interview, the medical staff failed to implement their by-laws related to at least six days weekly patient assessment for 5 of 32 patients (Pts. #5, 14, 20, 25, and 31).

Findings:
1. Review of the Medical Staff Bylaws, with unknown approval date, indicated:
a. In Article V. "Allied Health Professionals (Health Professional Affiliates)", it reads: "...AHPs may be granted permission to participate in the provision of certain patient care services within the Hospital, but such permission shall not be construed to afford AHPs the rights of Medical Staff membership...".

2. Review of the Medical Staff Rules and Regulations, approved on May 28, 2014, indicated on page 3., in section 1.25. that "Every inpatient shall be assessed by a physician, or other qualified member of the medical staff, at least six days weekly...".

3. Review of medical records indicated:
a. Pt. #5 had daily "Physician Progress Note" documentation by a NP (nurse practitioner), rather than a physician, on 11/25/14, 11/26/14, 11/27/14, 11/28/14, and 11/29/14. No physician assessment documentation.
b. Pt. #14 had daily "Physician Progress Note" documentation by a NP on 12/19/14, and 12/21/14. No physician assessment documentation.
c. Pt. #20 had daily "Physician Progress Note" documentation by a NP on 1/12/15, 1/13/15, 1/14/15, 1/15/15, 1/16/15, 1/19/15, 1/20/15, and 1/22/15. No physician assessment documentation.
d. Pt. #25 had daily "Physician Progress Note" documentation by a NP on 12/8/14, 12/9/14, and 12/10/14. No physician assessment documentation.
e. Pt. #31 had daily "Physician Progress Note" documentation by a NP on 11/19/14, 11/20/14, and 11/21/14. No physician assessment documentation.

4. Interview with the chief executive officer, staff member #40, at 1:00 PM on 1/23/15, indicated:
a. Per the medical staff by-laws, nurse practitioners are not considered part of the medical staff, so that daily patient assessments and progress notes are not to be completed by the nurse practitioners.

Based on policy and procedure review, medical record review, and staff interview, the nursing director failed to ensure that nursing staff: completed vital signs, per physician orders, for 9 of 32 patients (pts. #1, 2, 3, 5, 9, 10, 16, 18, and #32); failed to document the contact of the RD (registered dietician) when a patient scored high enough for a consult, for 3 of 5 patients who scored at 5 or above (pts. #1, 3, and 9); failed to ensure the completion of the flowsheet for the percent eaten at each meal, the amount of liquid intake at each meal, and whether hygiene occurred each day for 5 of 16 adult and geriatric patient records reviewed (Patients #3, 9, 10, 16 and 18); and failed to implement the policy related to glucometer calibration on a daily basis.

Findings:
1. Review of patient medical records indicated:
a. Patient #1 had admission orders at 1935 hours on 12/29/14 for VS (vital signs) daily, but lacked documentation of having VS taken on 1/1/15.
b. Patient #2 had admission orders on 12/26/14 at 2300 hours for VS BID (two times/day) X 24 hours, then daily, but lacked a second set of VS on 12/27/14.
c. Patient #3 had admission orders on 12/1/14 at 2025 hours for VS BID X 24 hours, then once daily. VS were taken once on 12/1/14 and once on 12/2/14.
d. Patient #5 had admission orders on 11/24/14 for daily VS with no VS documented on 11/27/14.
e. Patient #9 had admission orders on 12/12/14 for VS BID for 24 hours, then once daily but had no VS documented on the "Vitals Signs Flow Sheets" for 12/12/14 and only one set of VS noted at "1 PM" on 12/13/14.
f. Patient #10 had orders on admission at 10:30 PM 1/5/15 for VS TID (three times/day). VS were noted at 2045 hours and 2300 hours on 1/5/15 and then only once on 1/6/15. (Twice on 1/7/15 with discharge later that day.)
g. Patient #16 had orders written on 1/19/15 for VS BID and had only one set of VS documented (1430 hours) on 1/19/15 and one set (1000 hours) on 1/20/15.
h. Patient #18 had orders on 1/14/15 to "...Check B/P (blood pressure) TID (three times a day) X 48 hrs." and lacked VS (vital sign) checks a second time on 1/14/15 (first VS at 1800 hours, on admission) and lacked two sets of VS on 1/15/15.
i. Patient #32 had admission orders for VS BID X 24 hours, then once daily, but was admitted at 1300 hours on 10/16/14 and had the first VS noted on the VS flow sheet on 10/17/14 and then on 10/19/14, missing 10/18/14 and no BID VS the first 24 hours.

2. At 9:00 AM on 1/23/15, interview with staff member # 44, the chief nursing officer, indicated that VS were not taken per physician order, or at least not documented on the vital signs flow sheet, for the patients, as listed in 1. above.

3. Review of the policy and procedure "Nutritional Consults", with a revised date of 11/24/14 and a policy number of CTS - 242, indicated:
a. Under "Policy", it reads: "A nutritional consultation will be provided by the registered dietitian only upon assessment of a nurse...Any yes response of the Nutritional Screen of 5 or more will trigger a nutritional consultation...".
b. Under "Procedure", it reads: "... 3. Nurse documents the notifications of nutritional consultation on the nutritional assessment."

4. Review of medical records indicated:
a. Patient #1 was admitted on 12/29/14 and had a nutritional assessment that indicated a score of "9", with the form reading "If score 5 or more, a Nutritional Consult is called and documented by Nursing", but in the section "Date notified RD (registered dietician)", this was blank.
b. Pt. #3 had a nutritional score of 5 on 12/1/14, but failed to contact the RD until 12/8/14.
c. Pt. #9 had a nutritional assessment score of 9 on 12/12/14 and lacked notation by a nurse that the RD was notified.

5. At 9:00 AM on 1/23/15, interview with staff member #44, the chief nursing officer, indicated:
a. Patients #1 and 9 lacked documentation by nursing staff that the RD was notified to conduct a nutritional consult for patients scoring 5 or above on the nutritional assessment performed at the time of admission.
b. Pt. #3 had a 7 day delay in contacting the RD.

6. Review of the policy "Nursing Standards of Care", policy number NR 10.6, last reviewed on 1/24/14, indicated:
a. Under "Standard of Care", in the "Rationale" section, it reads: "Nurses and the mental health technicians are the primary health care providers who interact with the patient on a daily basis regarding activities of daily living (ADL)...".
b. Under the "Outcome Criteria" section, it reads: "...4..C.1.A Maintain adequate food and fluid intake. 4.C.1.B Maintain hygiene with minimal assistance...4.C.2.C Maintain adequate physical activity...".

7. Review of medical records indicated:
a. Pt. #3 lacked documentation of:
A. Any hygiene occurring on 12/3/14, 12/16/14, and on one page lacking a date.
B. Breakfast and fluids on 12/6/14, Lunch and fluids on 12/5/14 and 12/12/14, and Dinner and fluids on 12/4/14, 12/14/14 and 12/16/14.
b. Pt. #9 lacked documentation of Breakfast and fluids on two days, lunch and fluids on one day, and dinner and fluids on one day. (The dates at the tops of the pages were either blank [on two days] or unreadable after staff copied the form.)
c. Pt. #10 lacked documentation on 1/6/15 and 1/7/15 of the % of food intake and liquid intake amounts for lunch.
d. Pt. #16 lacked documentation of hygiene on 1/20/15 and 1/21/15. The record also lacked documentation of the % of dinner and fluids on 1/20/15.
e. Pt. #18 lacked documentation of food and liquid intake for Breakfast and lunch on 1/20/15

8. At 9:00 AM on 1/23/15, interview with staff member # 44, the chief nursing officer, indicated:
a. A training was done with nursing staff the end of December to remind them of the necessity of complete documentation on forms.
b. Patients #10, #16, and #18 were all admitted in January and should have more complete documentation on the flow sheets, as per education given to nursing staff.

9. Review of the policy "Glucometer Use and Quality Controls', policy number WT 15.3, last reviewed 1/20/14, indicated:
a. Under "Procedure", it reads: "...2.0 Licensed nursing staff will be responsible for glucometer calibration daily...".

10. While on tour of the Geriatric Unit on 1/23/15 at 11:10 AM, in the company of staff member #44, the chief nursing officer, it was observed that the glucometer log had not been completed on a daily basis and was lacking documentation of calibration on 1/9/15, 1/10/15, 1/12/15, 1/14/15, 1/15/15, and 1/16/15.

11. Interview with staff member #44 at 11:15 AM on 1/23/15 indicated:
a. Nursing staff are to calibrate the glucometer on a daily basis regardless of whether there no diabetic patients on the unit.
b. There were dates on the January "Glucometer Quality Control" log that indicated nursing staff failed to conduct a quality control check of the glucometer daily, as required by policy.

Based on policy and procedure review, medical record review, and staff interview, the facility failed to ensure that documentation for the administration of medications was per facility policy for 6 of 32 records reviewed (Pts. #3, #9, #13, #14, #16, and #18).

Findings:
1. Review of the policy and procedure "The Role Of Nursing In Medication Administration", policy number PHR - 140, last revised on 6/2013, indicated:
a. In section "1.0 Statement Of Purpose", it reads: "The intent of this policy is to provide needed medication in an efficient, safe manner, and to provide a complete and accurate up-to-date record of all medications a patient receives."
b. In section "4.0 Procedure", it reads:
A. "...4.3 MAR (medication administration record) Review: The Night Shift Registered Nurse is responsible for verifying the accuracy of daily Medication Administration Record entries...".
B. "...4.7 Missed or Late doses: When a medication is not administered at the scheduled time, the nurse will properly document the reason(s) on the MAR or patient record...".
C. "...4.11...Buccal and Sublingual Medications...Intramuscular Injections..." etc. all indicate in the last step of the procedure to "Document medication administration."

2. Review of both open and closed patient medical records indicated:
a. Patient #3 lacked documentation on 12/4/14 of the 2000 hours doses of: Aricept, Cordarone, Paxil 20 mg, Paxil 10 mg, Zocor, and Seroquel having been administered by nursing personnel.
b. Patient #9 lacked documentation on the MAR for the 12/17/14 doses of Duoneb nebulizer and Albuterol inhaler at 1600 hours, and the 0800 hours administration of Claritin on 12/18/14.
c. Patient #13 lacked documentation of administration on the MAR for the 2000 hours dose of Baclofen on 12/18/14.
d. Patient #14 lacked documentation of administration by nursing staff of the 0800 hours Norvasc and the 2000 hours of Riperdal on 12/18/14.
e. Patient #16 lacked nursing documentation on the MAR of the administration of Lopressor for the 2100 hours dose on 1/19/15.
f. Patient #18 lacked documentation by nursing that the 1/15/15 0900 hours and 1300 hours Seroquel was administered, and that the 2100 hours dose of Seroquel was given on 1/15/15. The medical record also lacked documentation by nursing on the MAR for Haldol administration for the 2100 hours dose on 1/16/15.

3. At 1:20 PM on 1/22/15 and 9:00 AM on 1/23/15, interview with staff member # 44, the chief nursing officer, indicated:
a. The MARs for patients #3, #9, #13, #14, #16, and #18 were lacking documentation by nursing staff of having given the meds, or documentation of patient refusal or other reason not given.
b. A new process was supposed to have been implemented in which the nurses, at the change of shifts, review the MARs for any missed documentation of medication administration.

4. At 3:50 PM on 1/22/15, interview with floor nurse #53, indicated agreement that the medical record for pt. #18 lacked documentation of Haldol being administered on 1/16/15.

Based on review of policy and procedure, medical record review and interview, the hospital failed to implement their policies related to medical staff responding to recommendations by the RD (registered dietician) for 2 of 2 patients with recommendations (Pts. #3 and #16), failed to ensure that the psychiatrist signed off on the master treatment plan for 3 of 32 (Pts. #5, #13, and #31) patients and failed to ensure that the psychiatrist performed the psychiatric evaluation for 6 of 11 adolescent patients (#5, 13, 21, 25, 31, and 32).

Findings:
1. Review of the policy "Nutritional Consults", policy number CTS - 242, last revised on 11/24/14, indicated:
a. Under "Policy", it reads: "...The findings of the dietitian are to be reviewed by the attending physician, with relevant findings and follow-up actions, as required, integrated into the treatment plan."

2. Review of patient medical records indicated:
a. Pt. #3 had recommendations written on 12/8/14 by the RD for: "...Vitamin D3 2000 international units daily." that was never followed up on by the attending physician by the day of discharge on 12/16/14.
b. Pt. #16 had recommendations written by the RD on 1/20/15 for a "Baseline A1C" for a diabetic patient, that had not been acted upon by the afternoon of 1/22/15 when the record was reviewed. (Recommendations form reads: "Physician Approval: Yes___ No__ or Alternative Order", with an area for the physician to sign and date.

3. At 3:20 PM on 1/20/15 and 3:50 PM on 1/22/15, interview with staff member #44, the chief nursing officer, indicated:
a. Pt. #3 is lacking the form that the physician completes either accepting the RD recommendation or documenting another alternative treatment.
b. It cannot be determined that the physician followed up on the RD recommendations for pt. #3 written on 12/8/14, prior to the patient's discharge on 12/16/14.
c. The medical doctor rounded on 1/21/15 and could have, should have, signed off on the RD recommendations of 1/20/15.

4. Review of the binder "Clinical, Treatment and Services Manual" for 2014, approved on 1/24/14, indicated:
a. On page 13, it reads: "...Master Treatment Plan for Inpatient... - The master treatment plan is formalized no later than three (3) days after admission for inpatient psychiatric units...and reflects the interdisciplinary input and collaboration of all team members...".

5. At 1:15 PM on 1/23/15, interview with the psychiatrist, staff member #55, indicated:
a. The psychiatrist ALWAYS signs off on the Master Treatment Plan.
b. Review by the psychiatrist of the medical records for pts. #5, (admitted on 12/1/14 and discharged on 12/16/14), patient #13 (admitted on 12/17/14 and discharged 12/19/14), and patient #31 (admitted 11/18/14 and discharged 11/23/14) indicated agreement that the treatment plans had not been signed by the psychiatrist, as required by the facility.

6. Review of the binder "Clinical, Treatment and Services Manual" for 2014, approved on 1/24/14, indicated:
a. On page 7, it reads: "5.3.1 Inpatient Psychiatric Treatment: Psychiatric Evaluation: Performed by the attending psychiatrist within 24 hours of admission...".

7. Review of adolescent medical records indicated that adolescent patients #5, 13, 21, 25, 31, and 32 had admission psychiatric evaluations performed by a nurse practitioner.

8. Interview with the chief executive officer, staff member #40, at 1:00 PM on 1/23/15, indicated:
a. Per the "Clinical, Treatment and Services Manual" for 2014, only a psychiatrist is to perform admission psychiatric evaluations, but the facility has been allowing nurse practitioners to perform these on the adolescent unit.

Based on document review, observation, and staff interview, it was determined that the hospital failed to have an organized dietary service that was directed and staffed by adequate qualified personnel and failed to provide therapeutic diets as ordered by a qualified practitioner. The facility failed to ensure the Dietary Department was organized to meet the basic sanitation practices for daily operation of the kitchen (see A619); failed to ensure the Dietary Supervisor was qualified by experience or training for the daily management of the Dietary Department (see A620); failed to ensure the kitchen staff were competent in the assigned responsibilities working in the kitchen(see A622); and failed to ensure patients received their diets as prescribed (see A630).

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

Based on document review, observation and staff interview, the hospital failed to ensure the Dietary Department was organized to meet the basic sanitation practices for daily operation of the kitchen.

Findings included:

1. Indiana Retail Food Establishment Sanitation Requirements, 410 IAC 7-24 (Effective November 13, 2004) indicated the retail food establishment shall require food employee applicants to whom a conditional offer of employment is made and food employees to report to the person-in-charge, information about their health and activities as they relate to diseases that are transmissible through food. The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris and shall be cleaned at a frequency necessary to preclude accumulation of soil residue. Food employees shall wash their hands least twenty (20) seconds in water having a temperature of at least one hundred (100) degrees Fahrenheit and thoroughly wash hands before placing gloves on hands. Hot dogs shall be cooked to 155 degrees Fahrenheit. A chemical sanitizer used in a sanitizing solution for a manual ware washing operation shall be used in accordance with the manufacturer's label use instructions. Wiping cloths that are in use for wiping food spills shall be stored in a chemical sanitizer used for food contact only. Single-service utensils shall be handled, displayed, and dispensed so that contamination of food-contact and lip-contact surfaces is prevented.

2. The chemical sanitizer used for ware washing was OASIS 146. The manufacturer's label use instructions specify the concentration for use in ware washing to be between 150 and 400 parts per million.

3. The chlorine solution (Bleach) the kitchen staff were using for wiping food-contact surfaces specified the concentration not to exceed 200 parts per million.

4. At 10:05 AM on 1/20/2015, staff members #AD6 (Dietary Supervisor), AD7 (Cook), AD8 (Cook) indicated they did not know diseases that are transmittable through food. The staff indicated they did not know to report any symptoms to the hospital that could exclude them from working in the kitchen.

5. At 10:15 AM on 1/20/2015, the kitchen was inspected. The exterior surface of the double-stacked industrial confectionary ovens were observed heavily caked with grease deposits, grime, and other soil residue. The industrial fryer was observed with a sheet pan covering the fryer that was filled with old dark black grease. There was accumulation of food deposits floating at the top of the grease within the fryer. There was heavy accumulation of caked on grease deposits and soil residue on the inside and outside surfaces of the fryer. On the shelves of the prep table adjacent to the fry station in the kitchen was observed with two sheet pans with torn aluminum foil covering each pan. The pans were observed heavily caked with black grime, loose soil residue on them. The sheet pans contained soiled utensils for cleaning the fryer stored on these sheet pans. Clean utensils were observed stored under the shelves that contained the heavily soiled sheet pans. Under the prep tables and the industrial ovens and grill was loose grease deposits, trash, and other soil residue. The walk-in freezer was observed with trash debris on the floor and ice build-up under one of the food storage racks. The dishwashing room's floor was observed with caked on white deposits and loose soil residue was observed throughout the room.

6. At 10:59 AM on 1/20/2015, the hand sink's water faucet behind the serving line ran for approximately 3 minutes and the maximum hot water
the water flow reached was 86 degrees Fahrenheit. The posted hand washing sign above the hand washing sink mandated 10 seconds and not the required 20 seconds for food service personnel.

7. At 11:10 AM on 1/20/2015, three kitchen staff members were observed taking off their single-use gloves then began to work with non-food contact activities. Then the staff members put on a new pair of single-use gloves without washing their hands first.

8. At 11:15 AM on 1/20/2015, hot dogs were observed removed from the industrial oven and placed on the serving line. The cook did not take any temperatures of the hot dogs after they were removed from the oven. The cafeteria staff member temperature tested the hot dogs at 122 degrees Fahrenheit and then moved on to the next item to temperature test. The staff member took no action to ensure the hot dogs were cooked to the proper temperature of 155 degrees Fahrenheit.

9. At 11:25 AM on 1/20/2015, a kitchen staff member was observed wash/rinse/sanitizing pots and pans in the three compartment sink; however, the sanitizing compartment was not registering any concentration of quaternary ammonia. After further investigation, the gallon container of quaternary ammonia was empty.

10. At 11:30 AM on 1/20/2015. two kitchen staff members were observed preparing two gallon wiping cloth containers with chlorine solution. After testing both containers, the concentration exceeded 200 parts per million chlorine concentration.

11. At 11:38 AM on 1/20/2015, wiping cloth rags were observed lying around the kitchen on two prep tables and the drain board of a two-compartment sink. Two staff members were observed rinsing out two of the rags in the faucet and then used them to wipe down counter tops. The kitchen did not have sanitizing buckets prepared to store the rags for food-contact surface between the use of the rags.

12. At 11:45 AM on 1/20/2015, the plastic single-use spoons stored on the serving line for patients to use were observed positioned in a way the patients had to handle the food-contact surface of other spoons while retrieving their spoon.

13. On 1/21/2014 at 12:05 PM, the serving trays on the serving line for patients and customers to use were inspected. The bottom side of the first six trays were observed with loose food residue on them which in turn was sticking to the top side of the plastic trays each one was stacked on.

14. At 2:30 PM on 1/21/2014, staff member #AD6 indicated that he/she does not have any set training curriculum on ensuring food sanitation are meeting the requirements. The staff member confirmed the observations during the tour of the Dietary Department. The staff member indicated the deficiencies noticed during the inspection were lack of kitchen sanitation training.

15. At 10:30 AM on 1/22/2015, staff member #AD5 (Plant Operations/Safety Director) indicated he/she was the Dietary Supervisor's boss. The staff member indicated he/she conducts tour of the sanitation; however, the focus of the inspection was on diets and visual look. The staff member indicated he/she does not have the knowledge of basic kitchen sanitation training to ensure the kitchen was maintained to meet the State and Federal requirements. The staff member confirmed the deficiencies during the tour of the kitchen.

Based on observation, documentation review, and staff interview, the hospital failed to ensure the Dietary Supervisor was qualified by experience or training for the daily management of the Dietary Department.

Findings included:

1. At 10:00 AM on 1/20/2015, the Dietary Department was inspected. During the inspection of the Dietary Department, a lack of basic sanitation practices was determined. This was evidenced by staff members #AD6 (Dietary Supervisor), AD7 (Cook), AD8 (Cook). They indicated they did not know diseases that are transmittable through food and they did not know to report any symptoms to the hospital that could exclude them from working in the kitchen. Three kitchen staff members were observed taking off their single-use gloves then beginning to work with non-food contact activities. Then the staff members put on a new pair of single-use gloves without washing their hands first. Two kitchen staff members were observed preparing two gallon wiping cloth containers with chlorine solution. After testing both containers, the concentration exceeded 200 parts per million chlorine concentration which exceeded the concentration required for sanitizing food-contact surfaces. Wiping cloth rags were observed lying around the kitchen on two prep tables and the drain board of a two-compartment sink. Two staff members were observed rinsing out two of the rags in the faucet and then used them to wipe down counter tops. The kitchen did not have sanitizing buckets prepared to store the rags for food-contact surfaces between the use of the rags. The bottom side of the first six trays that patients were reaching for were observed with loose food residue on them, which in turn was sticking to the top side of the plastic trays each one was stacked on. The confectionary oven, industrial fryer, prep tables were observed heavily caked with grease deposits, grime, and other soil residue on the inside and outside surfaces. The walk-in freezer was observed with trash and accumulation of ice-build up on the floor and the dishwashing room's floor was observed with caked on white deposits and loose soil residue throughout the room.

2. The Dietary Supervisor's personnel file was reviewed. The file lacked evidence of dietary competency and this was confirmed by staff member #AD15 (Human Resource Director).

3. At 1:05 PM on 1/21/2015, staff member #AD6 (Dietary Supervisor) indicated he/she was not trained by the hospital in basic kitchen sanitation guidelines and had no knowledge of the diseases that are transmittable through food. The staff member indicated between changing of gloves without washing his/her hands was acceptable; was unaware that hand washing was required between changing of gloves. The staff member had no idea there was a state food code, 410 IAC 7-24, Retail Food Establishment Sanitation Requirements on proper sanitation practices needed in operation of any kitchen establishment. The staff member indicated he/she did not have dietary knowledge before he/she was promoted to supervisor of the Dietary Department. The staff member indicated his/her staff are not trained on basic kitchen sanitation practices. The staff member #A6 indicated his/her director was #AD5, the Plant Operations/Safety Director and he/she has less knowledge of sanitation requirements then he/she has.

4. At 1:30 PM on 1/21/2015, staff member #AD9 (Contracted Dietician)indicated he/she has never trained or had class with the kitchen staff on proper sanitation practices in the kitchen and cafeteria.

5. At 10:45 AM on 1/22/2015, staff member #AD5 (Plant Operations/Safety Director) indicated he/she was not trained or has the basic knowledge of kitchen sanitation. The staff member indicated none of the Dietary Department were trained in kitchen sanitation. The training provided was a checklist and it dealt with diets and not kitchen sanitation practices.

6. At 2:00 PM on 1/22/1015, staff member #AD15 (Human Resource Director) indicated the food service staff annual competencies do not address basic sanitation practices while working in the kitchen. None of the kitchen staff were well knowledgeable in food service before they started to work in the kitchen.

Based on observation, documentation review, and staff interview, the hospital failed to ensure the kitchen staff were competent in the assigned responsibilities working in the kitchen.

Findings included:

1. Options Behavioral Health System Food Services policy #FS.023 (last reviewed 1/24/2014) was reviewed with staff member #AD6 (Dietary Supervisor) and staff member #AD5 (Plant Operations/Safety Director). Food Services policy #FS.023 stated, "It is the policy of Option's Behavioral Health for the Food Service Department to plan, prepare and serve nutritious, appetizing food for the clients and visitors. Additionally, nutritional treatment is provided weekly, including client and family counseling and education. Regular, balanced meals for clients and visitors; Menus planned and approved by a Registered and Licensed Dietitian; Modified diets, Nutrition and/or assessment; Nutrition Counseling; Unit pantry supplies; Special administration functions; Special food requests for units; and Instruction on drug-nutrient interaction." The policy did not address the sanitation guidelines that are to be followed by kitchen staff. The policy had defined the orientation and instruction for food service workers. The orientation guidelines failed to address the specifics of daily kitchen sanitation guidelines and infection control practices for food service staff that work in the Dietary Department.

2. At 10:00 AM on 1/20/2015, the Dietary Department was inspected. During the inspection of the Dietary Department, a lack of basic sanitation practices was determined. This was evidenced by staff members #AD6 (Dietary Supervisor), AD7 (Cook), AD8 (Cook). They indicated they did not know diseases that are transmittable through food and they did not know to report any symptoms to the hospital that could exclude them from working in the kitchen. Three kitchen staff members were observed taking off their single-use gloves then beginning to work with non-food contact activities. Then the staff members put on a new pair of single-use gloves without washing their hands first. Two kitchen staff members were observed preparing two gallon wiping cloth containers with chlorine solution. After testing both containers, the concentration exceeded 200 parts per million chlorine concentration which exceeded the concentration required for sanitizing food-contact surfaces. Wiping cloth rags were observed lying around the kitchen on two prep tables and the drain board of a two-compartment sink. Two staff members were observed rinsing out two of the rags in the faucet and then used them to wipe down counter tops. The kitchen did not have sanitizing buckets prepared to store the rags for food-contact surfaces between the use of the rags. The bottom side of the first six trays that patients were reaching for were observed with loose food residue on them, which in turn was sticking to the top side of the plastic trays each one was stacked on. The confectionary oven, industrial fryer, prep tables were observed heavily caked with grease deposits, grime, and other soil residue on the inside and outside surfaces. The walk-in freezer was observed with trash and accumulation of ice-build up on the floor and the dishwashing room's floor was observed with caked on white deposits and loose soil residue throughout the room.

3. The Dietary Supervisor's personnel file was reviewed. The file lacked evidence of dietary competency and this was confirmed by staff member #AD15 (Human Resource Director).

4. Staff Members #AD7 and #AD8 (Cooks) personnel files were reviewed. The files lacked evidence of specifics in daily operation and infection control practices in the Dietary Department and this was confirmed by staff member #AD15 (Human Resource Director).

5. At 2:00 PM on 1/22/1015, staff member #AD15 (Human Resource Director) indicated the food service staff annual competencies do not address basic sanitation practices while working in the kitchen. None of the kitchen staff were well knowledgeable in food service before they started to work in the kitchen.

Based on document review, observation, and staff interview, the hospital failed to ensure 7 (L1, L2, L3, L4, L5, L7 and L9) of 10 patients received their diet as prescribed by a qualified practitioner.

Findings included:

1. Week-2 lunch menu was reviewed. A regular meal consisted of 1 cup chili con carne, 1 tablespoon shredded cheese, 1 hot dog and bun,
10 french fries, 1/2 cup cole slaw and 8 ounces milk. A 1700-calorie diabetic diet included 1 tablespoon shredded cheese, 1 hot dog and bun, 5 french fries, 1/2 cup cole slaw and 8 ounces milk.

2. The Dietary Department documented in their Patient Diet Log book for Patient #L1 to receive a 1700 calorie diabetic diet; however, the patient's medical record dated 1/20/2015 had an order for the patient to receive a regular tray. On 1/20/2015, the patient received a 1700 calorie diabetic diet.

3. The Dietary Department documented in their Patient Diet Log book for Patient #L2 to receive a 1700 calorie diabetic diet; however, the patient's medical record did not document what diet the patient was to receive; therefore, the diet defaulted to a regular tray. On 1/20/2015, the patient received a 1700 calorie diabetic diet.

4. The Dietary Department documented in their Patient Diet Log book for Patient #L3 to receive a 1700 calorie diabetic diet; however, the patient's medical record dated 1/17/2015 had an order for the patient to receive a regular tray. On 1/20/2015, the patient received a 1700 calorie diabetic diet.

5. The Dietary Department documented in their Patient Diet Log book for Patient #L4 to receive a 1700 calorie diabetic diet; however, the patient's medical record dated 1/16/2015 had an order for the patient to receive a "No Concentrated Sweets" diet. The regular diet complied with the physician's diet order on 1/20/2015. However, the patient received a 1700 calorie diabetic diet.

6. The Dietary Department documented in their Patient Diet Log book for Patient #L5 to receive a Low Sodium diet; however, the patient's medical record did not document what diet the patient was to receive; therefore, the diet defaulted to a regular tray. On 1/20/2015, the patient received a Low Sodium diet.

7. The Dietary Department documented in their Patient Diet Log book for Patient #L7 to receive a 1700 calorie diabetic diet and was also lactose intolerance; however, the patient's medical record did not document what diet the patient was to receive; therefore, the diet defaulted to a regular tray. The medical record failed to identify the patient as lactose intolerance. On 1/20/2015, the patient received a 1700 calorie diabetic diet and was given water instead of milk.

8. The Dietary Department documented in their Patient Diet Log book for Patient #L9 to receive a 1700 calorie diabetic diet; however, the patient's medical record dated 1/12/2015 had an order for the patient to receive a regular tray. On 1/20/2015, the patient received a 1700 calorie diabetic diet.

9. At 1:15 PM on 1/22/2015, staff member #AD6 (Dietary Supervisor) confirmed patients that were ordered a diabetic diet did not receive their diet and therapeutic diets were given to patients that were on a regular diet, that the patients were actually receiving the diet recorded in the Patient Diet Log book.

10. At 2:00 PM on 1/22/2015, staff member #AD9 (Dietician) indicated the hospital provides meals for 3 units: adolescent, geriatric and adult. The Dietary Department provides a menu on a four week cycle to these three units. The Dietician indicated the 4-week menu cycle was approved by him/her. The diets that were approved by the Dietician were a Regular diet, Children (adolescent), Consistent Carbohydrate diet and 1700 calorie diabetic diet. The Dietician indicated the physicians tried to write a diet order for all patients even if they were to receive a regular tray. However, if a physician did not order a diet for a patient, the patient would receive a regular tray.

Based on document review and interview, the Utilization Review Committee (Medical Executive Committee) failed to follow its policy to report at least quarterly, to Medical Executive Committee for 2 of 4 quarters in calendar year 2014.

Findings:

1. Review of hospital Policy No. CTS-122, entitled Utilization Management Plan, approved 1-24-2014, indicated the results of routine utilization management activities will be reported at least quarterly to the Medical Executive Committee.

2. Review of the Medical Executive committee minutes for calendar year 2014, indicated the review of routine utilization management activities:

January 22 - review
February 26- review
March 26 - no review
April 23 - no review
May 28 - review
June 25 - review
July 23 - no review
August 27 - no review
September 25 - no review
October 23 - no review
November 20 - no review
December 18 - no review

Based on document review and interview, the utilization review process failed to review the professional services of laboratory, radiology and pharmacy personnel to the determine medical necessity of services provided to patients.

Findings:

1. On 1-20-15 at 9:30 am, employee #A3, Chief Executive Officer, was requested to provide documentation of review of professional services as part of Utilization Review process.

2. In interview, on 1-23-15 at 11:55 am, employee #A3 indicated there was no documentation of review of the professional services of laboratory, radiology and pharmacy personnel to the determine medical necessity of services provided to patients as part of the utilization review process and no other documentation was provided prior to exit.

Based on policy and procedure review, observation, and interview, the plant operations manager failed to ensure the cleanliness of pantry refrigerators.

Findings:
1. Review of the policy "Refrigerators-Cleaning Temp Monitoring", policy number 3.11, last reviewed on 1/24/14, indicated:
a. Under "Policy", it reads: "...Refrigerators/freezers shall be cleaned according to the schedule below".
b. In the grid, it indicated that "Cleaning Frequency of the "Patient nourishment" refrigerators would be "Monthly as needed" and the "Cleaning Responsibility" was that of "Housekeeping".

2. While on tour of the Geriatric Unit on 1/23/15 at 10:55 AM, in the company of staff member #44, the chief nursing officer, it was observed that the pantry refrigerator had soiled door shelves and refrigerator shelves, a large puddle of dried brown liquid under the two vegetable drawers, a dried red liquid spot (3 inches in diameter) on the freezer shelf, crumbs and debris in the door gaskets of both the freezer and the refrigerator, and dried liquids on the lower face plate of the refrigerator.

3. At 11:30 AM on 1/23/15, while on tour of the Adult Unit in the company of staff member #44, the chief nursing officer, it was observed that the pantry refrigerator and freezer had crumbs present on the shelves and under both of the vegetable drawers.

4. At 2:40 PM on 1/23/15, interview with staff member #43, the plant operations manager, indicated:
a. It is the housekeeping staff responsibility to clean pantry refrigerators.
b. There is no routine schedule for cleaning the refrigerators and there is no documentation to show the last time they were cleaned by the housekeepers.

Based on observation, record review and interview, the facility failed to ensure 1 of 1 ceiling smoke barriers on the first floor were maintained to provide the fire resistance rating of the smoke barrier, failed to ensure 2 of 7 doors serving hazardous areas such as combustible storage rooms over fifty square feet in size were provided with self closing devices, failed to include the use of kitchen K class fire extinguishers in 1 of 1 written fire safety plans for the facility, failed to install 3 of 113 smoke detectors in accordance with NFPA 72, failed to replace 2 of over 100 sprinklers in the facility which had become corroded, had paint, lint or other foreign materials on them, failed to ensure cigarette butts were deposited into a noncombustible container with a self closing lid at 1 of 2 outside areas where smoking was permitted, failed to ensure 1 of 20 fire dampers in the ductwork were provided necessary maintenance at least every 6 years in accordance with NFPA 90A, failed to provide a complete written policy containing procedures to be followed in the event the automatic sprinkler system has to be placed out of service for four hours or more in a 24 hour period in order to protect 28 of 28 residents, failed to provide a complete written policy containing procedures to be followed in the event the fire alarm system has to be placed out of service for four hours or more in a 24 hour period in accordance with LSC, Section 9.6.1.8 in order to protect 28 of 28 residents and failed to ensure the elevator equipment in 1 of 1 elevator equipment rooms which is sprinklered was provided with a shunt trip.

Findings:

1. Observation with DPO1, the Director of Plant Operations, during a tour of the facility from 1:20 p.m. to 3:20 p.m. on 02/05/15 indicated one four inch in diameter conduit and four one inch in diameter conduits which contained cables and penetrated the ceiling of the Phone Room adjacent to Unit 6 were each firestopped or sealed with expandable foam.

2. In interview at the time of observation, DPO1 acknowledged the aforementioned conduits which penetrated the ceiling of the Phone Room adjacent to Unit 6 were each firestopped or sealed with expandable foam and lacked documentation demonstrating the expandable foam was an approved material for maintaining the smoke resistance of a smoke barrier.

3. Observations with DPO1 during a tour of the facility from 1:20 p.m. to 3:20 p.m. on 02/05/15 indicated the Medical Supply Room on Unit 4 and the Nursing Storage Room each measured greater than fifty feet in size but less was one hundred feet in size and were being utilized to store combustible supplies, boxes and mattresses. The entry door to each of the aforementioned hazardous area storage rooms was not provided with a self closing device.

4. In interview at the time of the observations, DPO1 acknowledged the entry door to each of the aforementioned hazardous area storage rooms was not provided with a self closing device.

5. Review of "EOC Policy & Procedure Manual: Fire Response Plan" documentation with DPO1 during record review from 9:15 a.m. to 12:15 p.m. on 02/05/15 indicated the facility's written fire safety plan did not address the use of the K class fire extinguisher located in the kitchen in relationship with the use of the kitchen overhead extinguishing system.

6. Observation with DPO1 during a tour of the facility from 1:20 p.m. to 3:20 p.m. on 02/05/15 indicated one K class fire extinguisher was observed installed in the kitchen.

7. In interview at the time of record review, DPO1 acknowledged the written fire safety plan for the facility did not include the policy to activate the overhead hood extinguishing system to suppress a fire before using a K class fire extinguisher.

8. Observations with DPO1 during a tour of the facility from 1:20 p.m. to 3:20 p.m. on 02/05/15 indicated the following smoke detector locations on the ceiling were each installed less than three feet from air handling systems:
a. in the main lobby one foot from a supply vent.
b. in the Main Server Room six inches from a ceiling mounted forced air heating unit.
c. in the corridor outside the Medical Record Storage Room six inches from a return vent.

9. In interview at the time of the observations, DPO1 acknowledged the aforementioned smoke detectors were installed on the ceiling less than three feet from air handling systems.

10. Observation with DPO1 during a tour of the facility from 1:20 p.m. to 3:20 p.m. on 02/05/15 indicated two of four sidewall sprinklers installed at the outdoor loading dock had become green with corrosion and were in need of replacement.

11. In interview at the time of observation, DPO1 acknowledged the aforementioned automatic sprinklers had become green with corrosion.

12. Observation with DPO1 during a tour of the facility from 1:20 p.m. to 3:20 p.m. on 02/05/15 indicated the staff smoking area located outside the building at the loading dock had in excess of 50 extinguished cigarette butts deposited into each of two ashtrays mounted on top of a plastic trash can. A noncombustible container with a self closing cover device into which ashtrays can be emptied was not provided in this area where staff smoking was permitted.

13. In interview at the time of observation, DPO1 acknowledged a noncombustible ashtray and metal container with a self closing cover device into which ashtrays can be emptied was not provided at the aforementioned outside smoking area.

14. Review of "Fire/Smoke Damper Maintenance Record" documentation dated 03/24/14 with DPO1 from 9:15 a.m. to 12:15 a.m. on 02/05/15 indicated the fire damper listed as "1H" was stated as "propped open, needs bus link" as the result of the most recent documented facility fire damper inspection and maintenance.

15. In interview at the time of record review, DPO1 stated no additional fire damper inspection and maintenance documentation was available for review.

16. Observation with DPO1 during a tour of the facility from 1:20 p.m. to 3:20 p.m. on 02/05/15 indicated the shutter for the fire damper in the HVAC system above the ceiling of the Clean Utility Room by the kitchen had been released and was in the fully closed position. No fusible link was in place to ensure the fire damper was being properly maintained.

17. In interview at the time of observation, DPO1 stated the aforementioned fire damper is identified as "1H" and acknowledged no fusible link was in place to ensure it was being properly maintained.

18. Review of "EOC Policy & Procedure Manual: Fire Sprinkler System" documentation with DPO1 during record review from 9:15 a.m. to 12:15 p.m. on 02/05/15 indicated the fire watch policy did not include notification of the Indiana State Department of Health, local fire department, the insurance carrier, alarm company and the building owner in the event the automatic sprinkler system has to be placed out of service for four hours or more in a 24 hour period.

19. A review of "EOC Policy & Procedure Manual: Fire Alarm System Failure" documentation noted the automatic sprinkler system was not expressly stated as a component of the facility fire alarm system and, therefore, not part of sprinkler impairment procedures upon fire alarm system failure.

20. In interview at the time of record review, MD1, the Maintenance Director, stated no additional fire watch documentation was available for review and acknowledged the written fire watch policy did not include notification of the Indiana State Department of Health, local fire department, the insurance carrier, alarm company and the building owner in the event the automatic sprinkler system has to be placed out of service for four hours or more in a 24 hour period.

21. Review of "EOC Policy & Procedure Manual: Fire Alarm System Failure" documentation with DPO1 during record review from 9:15 a.m. to 12:15 p.m. on 02/05/15 indicated the fire watch policy did not include notification of the Indiana State Department of Health in the event the fire alarm system has to be placed out of service for four hours or more in a 24 hour period.

22. In interview at the time of record review, DPO1 stated no additional fire watch documentation was available for review and acknowledged the written fire watch policy did not include notification of the Indiana State Department of Health in the event the fire alarm system has to be placed out of service for four hours or more in a 24 hour period.

23. Observation with DPO1 during a tour of the facility from 1:20 p.m. to 3:20 p.m. on 02/05/15 indicated the elevator equipment room on the second floor was provided with a sprinkler head. No evidence of shunt trip installation, which is designed to automatically disconnect power to the affected elevator, was noted in the facility.

24. In interview at the time of observation, DPO1 stated he/she was unaware if a shunt trip had been installed in the aforementioned elevator equipment room.

Based on observation, the facility failed to ensure storage of trash in such a manner that it did not pose a health hazard in 1 instance.

Findings:

1. On 1-20-15 at 11:05 am in the presence of employee #A5, Plant Operations/Safety Director, it was observed on the ground, in the outside area where the trash compactor was stored, there was a considerable amount of trash such paper cups, bags and miscellaneous paper items, as well as plastic bags, spoons and plastic wrap. This created a condition conducive to harboring rodents and vermin.

Based on observation, the facility located one (1) alcohol-based hand sanitizer in a manner to cause a fire hazard to employees.

Findings:

1. On 1-20-15 at 11:15 am in the presence of employee #A5, Plant Operations/Safety Director, it was observed in the housekeeping storage area there was 1 alcohol-based hand sanitizer located directly above an electrical light switch. It was also observed at that date and time there were streaks down the wall which appeared to have been residue from the sanitizer material. This posed a fire hazard if the flammable alcohol was sprayed into the electrical ignition source.

Based on document review and interview, the facility failed to ensure documentation of preventive maintenance (PM) for 5 pieces of equipment.

Findings:

1. On 1-20-15 at 10:30 am, employee #A5, Plant Operations/Safety Director, was requested to provide current documentation of PM on a centrifuge, kitchen dishwasher, housekeeping floor scrubber, a washing machine used for patient laundering and 1 patient bed.

2. In interview, on 1-22-15 at 10:20 am, employee #A5 indicated there was no documentation of PM on the above pieces of equipment and no other documentation was provided prior to exit.

Based on policy and procedure review, observation, and interview, nursing staff failed to implement the policy related to refrigerator temperature checks.

Findings:
1. Review of the policy "Refrigerators-Cleaning Temp Monitoring", policy number 3.11, last reviewed on 1/24/14, indicated:
a. Under "Purpose", it reads: "1. Purpose: To ensure that refrigerator/freezers, which contain employee and patient nourishment and medications, are appropriately monitored and that the temperatures are accurately monitored and recorded...".
b. Under "Policy", it reads: "...The temperature shall be monitored and documented daily ...".
c. In the grid, it indicated "Temperature Monitoring Responsibility" by the "Nursing staff". The "Medication" refrigerator had "Temperature Monitoring Responsibility of the "Medication Nurse".

2. At 11:00 AM on 1/23/15, while on tour of the Geriatric Unit in the company of staff member #44, the chief nursing officer, it was observed that the January "Temperature Control Log" in the medication room had five days without a documented temperature check, 1/8/15, 1/9/15, 1/20/15, 1/21/15, and 1/22/15.

3. Review of other unit refrigerator logs for November and December indicated:
a. Unit 6 was lacking a 12/31/14 temperature check on the medication room log for December, lacked a temperature check on 11/27/14 on the pantry log, and lacked 12/30/14 and 12/31/14 temperature documentation on the December pantry temp log.
b. Unit 4 lacked documentation on the December 2014 log for 12/12/14.

4. At 11:15 AM on 1/23/15, interview with staff member #44, the chief nursing officer, indicated agreement that days of temperature documentation on the refrigerator logs were absent as listed above.

Based on policy and procedure review, observation, and interview, the infection control practitioner, failed to ensure that nursing staff maintained good hand hygiene; failed to ensure that glucometer cleaning occurs, per standards of practice; failed to ensure infection control committee approval of the cleaners and disinfectants used by the housekeeping staff; failed to ensure infection control committee approval of the cleaning processes and policies of the housekeeping staff; and failed to ensure the communicable disease history of 3 of 3 agency personnel (N22, N23, and N24).

Findings:
1. Review of the policy "Hand washing (sic)", policy number 3.15, with a last date reviewed of 1/24/14, indicated:
a. Under section "2.0 Policy", it reads: "It is the policy of (sic) facility that all employees and contract services are expected to wash their hands:...2.2 Before contact with each client, his environment, and anything that comes in contact with the client 2.3 After contact with each client, his environment, and any thing (sic) that comes in contact with the client...".
b. Under section "3.0 Procedure", it reads: "...3.2 Substitute Hand Wash - If warm, running water is not available, clean hands using an approved antiseptic hand cleaner...".

2. At 8:30 AM on 1/23/15, while observing on the Geriatric Unit in the company of staff member #45 a registered nurse, it was observed that staff members #46 and #47, nurse aides, were handing out breakfast to patients, and assisting patients in eating/drinking, and failed to sanitize their hands before and after patient care, (or between patients).

3. At 9:00 AM on 1/23/15, with a return visit to the Geriatric Unit, in the company of staff member #44, the chief nursing officer, it was observed that staff members #46 and #47 were again in the day room with patients and assisting them with activities and drinks and failed to sanitize their hands between patients.

4. Interview with staff member #44, the chief nursing officer, at 9:05 AM on 1/23/15, indicated:
a. All staff have hand sanitizer in their scrub suit pockets for use before and after patient care--and between patients.
b. When staff members #46 and #47 were asked to show/produce their hand sanitizers, both stated that they had none.

5. Review of the policy "Glucometer Use and Quality Controls", policy number WT15.3, with a last review date of 1/20/14, indicated:
a. Under "Procedure", it reads: "...2.3 The Nursing staff will clean the Glucometer meter nightly after performing control solutions...4.1 The Glucometer is cleaned after the control solution is completed."

6. At 8:15 AM on 1/23/15, during the observation of a patient glucometer check (on the Geriatric Unit), by RN (registered nurse) #45, it was observed that the RN placed the used/contaminated glucometer in the carry case, went to get the container of disinfectant wipes from the nurses' station, then took the used glucometer out of the carry case, wiped it down, and placed it back in the carry case without wiping out the carry case.

7. Per CDC (Centers for Disease Control and Prevention) recommendations, the current facility policy is inadequate as it fails to require cleaning and disinfecting of the glucometer after each use, rather than only when the nightly check of control solutions occurs, as stated in the facility policy.

8. While observing housekeeping staff at 10:15 AM on 1/21/15, in the company of staff member #43, the plant operations/maintenance director, it was noted that two of the products used in cleaning/sanitizing/disinfecting patient rooms, surfaces, and general facility areas included: Eco Lyzer liquid with a 2 oz/gallon mix instruction, and a foam cleaner (for use everywhere but on the floor) by HP Products--both with a 10 minute kill time.

9. Interview with staff member #43 at 10:20 AM on 1/21/15, indicated:
a. The infection control committee has not requested the list of products used by housekeeping staff for committee approval.
b. Housekeeping policies provided included: "Patient Rest Rooms" with no policy number and no effective date, no approval date, and no reviewed date; "Patient Rooms - Discharge Cleaning", also with no effective date, no approval date and no reviewed date.
c. The infection control committee has not approved of housekeeping policies (as listed in b. above) or processes.
d. There is no policy related to the daily cleaning of patient rooms, but staff are to clean the bathroom and floor of each patient room on a daily basis.
e. At the time of discharge, the bed, mattress, bedside table, and closet areas are cleaned, as well as the bathroom and floor.

10. At 1:00 PM on 1/21/15, interview with contracted staff member #48, the infection preventionist, indicated:
a. The infection control committee has not approved either of the housekeeping products used, or the housekeeping processes/policies for cleaning the facility.

11. While walking down the hall in preparation of entering the Geriatric Unit at 9:15 AM on 1/23/15, in the company of staff member #44, the chief nursing officer, it was observed that staff member #49, a housekeeper, sprayed the HP foam cleaner on the inside of the unit door and immediately began wiping it down without waiting the 10 minutes for effectiveness for disinfection.

12. Staff member #44 agreed that the housekeeper failed to wait the 10 minutes indicated on the spray can, that is needed for disinfection of the surface.

13. While on tour of the Geriatric Unit at 11:00 AM on 1/23/15, while in the company of staff member #44, the chief nursing officer, it was observed in 313, a vacant patient room, that a patient sock and linens were present in the closet.

14. Interview with staff member #44 at 11:05 AM on 1/23/15 indicated that all linens (patient and facility)are to be removed from the room and closet area at the time of terminal cleaning after a patient discharge.

15. Review of page 16 of a document provided indicated in section 2.1.10 Medical Exams, "Some positions that require physical capabilities [such as director care staff and maintenance, etc.] may be subject to medical exam evaluations. Once the offer has been extended, the successful job candidate can be required to undergo a medical exam...".

16. Review of page 34 of a document provided indicated under:
a. "Employee Health Standards" that "All new employees are required to have a physical examination indicating that they are suitable for performing the job they are being hired to perform. Employees are required to update their physicals on an annual basis. Employees are also required to have a negative TB (tuberculosis) test prior to employment and annually thereafter...".
b. "Hepatitis-B Vaccination Program...It is the policy of...to offer, free of charge, the compete hepatitis-B vaccination series to all employees in direct care, dietary and environmental services at time of hire. Employees have the right to refuse...but must sign a declination form...".

17. Review of the agency employee files indicated:
a. RN N22 first worked at the facility on 6/25/14 and lacked a physical form in the file, with communicable disease information (for Rubella, Rubeola, and Varicella) and lacked Hepatitis B documentation.
b. RN N23 first worked on 5/30/14 and lacked a physical form in the file, with communicable disease information (for Rubella, Rubeola, and Varicella) and lacked Hepatitis B documentation.
c. CNA (certified nurse aide) N24 first worked at the facility on 6/25/14 and lacked a physical form in the file, with communicable disease information (for Rubella, Rubeola, and Varicella) and lacked Hepatitis B documentation.

18. At 3:45 PM on 1/21/15, and 1:30 PM on 1/23/15, interview with staff member #51, the human resources director, indicated:
a. The physical examination form in the employee medical records has a physician signature authenticating that employees had childhood immunizations (Rubella, Rubeola, and Varicella) as a child.
b. The three agency staff are lacking the physical examination form that facility employees have.
c. Documentation was not provided for staff members N22, N23, or N24 prior to exit.

Based on document review and staff interview, it was determined that the hospital failed to have a written agreement with an Organ Procurement Organization and Tissue and Eye Bank Agreements which is effective in carrying out its responsibilities for the conduct of the hospital. The facility failed to have a written agreement with an Organ Procurement Organization (see A886); failed to have a written Tissue and Eye Bank Agreements (see A887); failed to have a designated Requestor (see A889); and failed to educate staff in Organ Procurement (see A891).

The cumulative effect of these systemic problems resulted in the facility's inability to ensure an effective organ procurement program that is legally responsible for the conduct of the hospital.

Based on staff interview, the hospital failed to have a written agreement with an Organ Procurement Organization.

Findings included

At 1:05 PM on 1/23/2015, staff member #AD3 (Chief Executive Officer) indicated the hospital does not have any written agreement with an Organ Procurement Organization.

Based on staff interview, the hospital failed to have a written agreement with with a tissue bank and eye bank to cooperate in the retrieval, processing, preservation, storage and distribution of tissues and eyes.

Findings included:

At 1:05 PM on 1/23/2015, staff member #AD3 (Chief Executive Officer) indicated the hospital does not have any written agreements with tissue and eye banks.

Based on documentation review and staff interview, the hospital failed to ensure at least one staff member was trained to address methodology for approaching potential donor families.

Findings included:

1. Staff personnel training files were reviewed and none of the staff training documentation addresses methodology for approaching potential donor families.

2. At 10:45 AM on 1/24/2015, staff member #AD15 (Human Resource Director) indicated no staff were trained in the methodology for approaching potential donor families and requesting organ or tissue donation.

Based on staff interview, the hospital failed to work cooperatively with the designated OPO, tissue bank and eye bank in educating staff on donation issues.

Findings included:

At 10:45 AM on 1/24/2015, staff member #AD15 (Human Resource Director) indicated the hospital does not have written agreement with an Organ Procurement Organization to address its organ procurement responsibilities; therefore, staff are not trained on organ procurement.

Based on observation, record review and interview the facility failed to:

I. Formulate treatment goals that are relevant to the patient's condition for seven (7) of eight (8) active sample patients (A6, A10, A15, B3, B4, B6, and C3). Many of the goals on the treatment plans were either basic functions of a psychiatric hospital ward, such as prevention of suicidal behavior, or consisted of adherence to treatment ("will take medication as prescribed") rather than outline a mental status or functional status level to be attained. Without a set of defined goals against which to measure progress it is impossible to judge effectiveness of treatment and to implement possible changes in treatment in the case of lack of progress (Refer to B121).

II. Develop Master Treatment Plans for eight (8) of eight (8) active sample patients (A6, A10, A15, B3, B4, B6, C3 and C4) that included individualized treatment interventions with a specific purpose and focus. Many of the interventions on the treatment plans were listed as generic discipline functions/tasks or there was failure to identify interventions based on the patients' needs. Failure to clearly describe specific modalities on patients' MTPs can hamper staff's ability to provide treatment based on individual patient needs (Refer to B122).

III. Ensure that active individualized psychiatric treatment was provided for four (4) of eight (8) active sample patients (A6, A10, A15, and B6). There was failure to provide structured treatment for these patients' specialized needs. In the cases of Patients A6 and A10, these patients functioned at low cognitive and social levels, yet adequate modalities to address their problems were not provided. Even though Patient A15 presented severe psychosis, he was assigned to attend the program designed for cognitive impairment. In the case of Patient B6, the treatment team failed to plan and implement a highly structure treatment to meet based on his/her presenting needs. Failure to ensure active treatment results in patients being hospitalized without all interventions for recovery being provided in a timely fashion, delaying improvement (Refer to B125, Section I).

IV. Ensure sufficient numbers of scheduled groups/activities by qualified staff on all three (3) units. There was only one (1) scheduled treatment group to be conducted by a social worker/counselor and one (1) scheduled activity to be conducted by a recreation staff member. All other groups/activities were discussion/recreational activities with leadership delegated to mental health technicians. This failure to provide active treatment resulted in patients being hospitalized without the opportunity to receive interventions to meet identified treatment needs, thereby delaying their improvement (Refer to B125, Section II).

V. Ensure that scheduled treatment modalities were provided as scheduled for all patients on one (1) of three (3) units (Adult). Groups/activities were started late or canceled. This deficient practice results in fragmented treatment for patients and potentially delays their improvement (Refer to B125, Section III).

Based on record review and interview the facility failed to formulate treatment goals that are relevant to the patient's condition for seven (7) of eight (8) active sample patients (A6, A10, A15, B3, B4, B6, and C3). Many of the goals on the treatment plans were either obvious basic functions of a psychiatric hospital ward, such as prevention of suicidal behavior, or consisted of adherence to treatment ("will take medication as prescribed") rather than outline a mental status or functional status level to be attained. Without a set of defined goals against which to measure progress it is impossible to judge effectiveness of treatment and to implement possible changes in treatment in the case of lack of progress.

Findings include:

A. Record Review:

1. In Patient A6's treatment plan, written on 1/15/15, the treatment goals for the identified problem "Aggression with dementia" include, "A6 will take medications without aggression or initial refusal for the remainder of his/her stay," "A10 will ask for items clearly when he/she needs them," "A10 will actively participate in groups."

2. In patient A10's treatment plan, written on 1/15/15, the treatment goals for the identified problem "Aggression with dementia" include, "A10 will take medications without aggression or initial refusal for the remainder of his/her stay," "A10 will comply with all blood draws," "A10 will participate with groups."

3. In patient A15's treatment plan, written on 1/13/15, the treatment goals for the identified problem "Disturbed Thought Process" include, "A15 will have zero (0) episodes of verbally agitated behavior," "A15 will have zero (0) episodes of physically aggressive behavior," "A15 will be 100% compliant with staff directions," "A15 will be 100% compliant with medication administration."

4. Patient B3's treatment plan, written on 9/30/14, reflected that goals identified for problem, "Suicidal" had been met as of 10/31/14. Even though the listed interventions continued there were no new identified goals on the plan.

5. In Patient B4's treatment plan, written on 1/10/15, for the identified problem, "Auditory and Visual Hallucination," a non-measurable goal was written as "Will function normally on the unit..."

Another goal for this problem was written as "(Patient) and his/her family will commit to consistent follow up with aftercare to manage hallucinations and medications properly," even though, according to a treatment plan review note on 1/19/15 reported that, this patient "is now a ward of the court and they have no placement for (him/her) yet."

6. In Patient B6's treatment plan, written on 11/22/14, for the identified problem, "Impaired Memory," the goals were listed as participating in treatment rather than outcome statements focused on the problem. These goals were listed as "Will participate in collaboration which facilitates optimum physical....;" "Will cooperate with medical treatment plan...;" "Will identify roles and responsibilities within the hospital;" "Will participate fully in health assessments."

7. In patient C4's treatment plan, written on 1/15/15, the treatment goals for the identified problem "Suicidal Ideation" include, "C4 will not harm self or attempt suicide while at Options," "C4 will create and implement a safety plan," "C4 will list three (3) goals for suicidal behavior, and what she wants from others/self from the actions."

B. Staff Interviews

1. In an interview with staff member AT1 on 1/21/15 at 2:15 PM, in answer to her treatment goals for patient A10, she answered, "You ask awfully specific questions. You know, I don't have an answer for that." She was not familiar with the goals listed in the treatment plan.

2. In an interview with staff member RN2 on 1/21/15 at 2:15 PM, in answer to her treatment goals for patient C4, she answered, "We are trying to get her to talk more. She is coming much more out of her shell." She was not familiar with the goals listed in the treatment plan.

Based on observation, record review and interview the facility failed to develop Master Treatment Plans for eight (8) of eight (8) active sample patients (A6, A10, A15, B3, B4, B6, C3 and C4) that included individualized treatment interventions with a specific purpose and focus. Many of the interventions on the treatment plans were listed as generic discipline functions/tasks or there was failure to identify interventions based on the patients' needs. Failure to clearly describe specific modalities on patients' MTPs can hamper staff's ability to provide treatment based on individual patient needs.

Findings include:

A. Record Review:

1. Patient A6:

For problem identified as "Aggression with Dementia" in treatment plan dated 1/15/15, the only nursing interventions were listed as expected role functions, "Administer medication as prescribed, assess for adverse side effects and compliance with taking medications." A physician intervention was identified as a nursing intervention, "Prescribe and monitor medications to address: agitation, outbursts and mood stabilization." There were no specific nursing interventions to address the patient's cognitive deficits in the care of this patient in the clinical area.

Medications were not addressed in the treatment plan by the physician.

2. Patient A10:

For problem identified as "Aggression with Dementia" in treatment plan dated 1/15/15, the only nursing interventions were listed as expected role functions, "Administer medication as prescribed, assess for adverse side effects and compliance with taking medications." A physician intervention was identified as a nursing intervention, "Prescribe and monitor medications to address: agitation, outbursts." There were no specific nursing interventions to address the patient's cognitive deficits in the care of this patient in the clinical area.

The social work intervention was not clearly stated. It was written as "Individual therapy to educate patient on perceived benefits of cutting and alternate, more appealing means to those benefits."

Medications were not addressed in the treatment plan by the physician.

3. Patient A15:

In treatment plan written on 1/13/15, for problem identified as "Disturbed Thought Process," the only nursing intervention was listed as an expected role function, "Administer medication as prescribed, assess for adverse side effects." There were no specific nursing interventions for to address this patient's behaviors in the clinical area.

4. Patient B3:

In treatment plan written on 12/11/14, for problem identified as "Suicide Risk/Self-Harm Behaviors," the only nursing intervention was listed as an expected role function, "Administer medication as prescribed, assess for adverse side effects." According to a physicians note on 12/11/14, Patient B3 was "admitted after cutting self...attempted to cut self in this facility which required suturing." There were no specific nursing interventions for patient safety, nor were preventive measures related to self-cutting and suicide risk identified in the plan.

The social work intervention was not clearly stated. It was written as "Individual therapy to educate patient on perceived benefits of cutting and alternate, more appealing means to those benefits."

During interview on 1/20/15 at 9:15 a.m., Patient B3 reported that he/she is currently taking Adderall, Prozac and Lithium. These medications were not addressed by the physician in the treatment plan.

5. Patient B4:

a. In treatment plan written on 1/10/15, for problem identified as "Suicidal Ideations with Attempt," the only nursing intervention was listed as an expected role function, "Administer medication as prescribed, assess for adverse side effects." There were no specific nursing interventions for patient safety, nor were preventive measures related to suicide risk identified in the plan.

b. In treatment plan written on 1/10/15, for problem identified as "Auditory and Visual Hallucination," the only nursing intervention was listed as an expected role function, "Administer medication as prescribed, assess for adverse side effects." There were no specific nursing interventions for to address this patient's behaviors in the clinical area.


6. Patient B6:

In treatment plan written on 11/22/14, for problem identified as "Impaired Memory," the nursing intervention was listed as an expected role function: "Administer medication as prescribed, assess for adverse side effects." Another nursing intervention was incomplete: "Assess patient for: "One listed nursing intervention was a physician role function: "Prescribe and monitor medications to address: Side effects and effectiveness."

There were no identified physician interventions in this treatment plan.

A social work intervention was listed as "Individual therapy to educate patient on: Good morals and behaviors." Meaning of this focus for treatment was not clear. Another social work intervention was incomplete: "Family therapy to educate on:"

7. Patient C3:

In treatment plan written on 12/22/14, for problem identified as "Disturbed Thought Process," the only nursing intervention was listed as an expected role function, "Administer medication as prescribed, assess for adverse side effects." There were no specific nursing interventions for to address this patient's behaviors in the clinical area.

During interview on 1/20/15 at 1:40 p.m., Patient C3 reported, "I am legally blind," This issue was not addressed in the treatment plan by nursing.

8. Patient C4:

In treatment plan written on 1/16/15, for problem identified as "Suicidal Ideation," there were no identified nursing or physician interventions.

B. Interviews:

1. During review of Patients B3 and B6's treatment plans on 1/21/15 at 11:30 AM, NP6 acknowledged that the interventions should be patient specific.

2. During interview with review of treatment plans on 1/21/15 at 1:25 PM, the DON stated related that after an patient assessment was performed by the nurse, the nursing interventions on the plan should be aimed at helping the patient to reach his/her maximum potential in the hospital.

Based on observation, interview and record review, the hospital failed to:

I. Ensure that active individualized psychiatric treatment was provided for four (4) of eight (8) active sample patients (A6, A10, A15, and B6). There was failure to provide structured treatment for these patients' specialized needs. In the cases of Patients A6 and A10, these patients functioned at low cognitive and social levels, yet adequate modalities to address their problems were not provided. Even though Patient A15 presented severe psychosis, he was assigned to attend the program designed for cognitive impairment. In the case of Patient B6, the treatment team failed to plan and implement a highly structure treatment to meet based on his/her presenting needs. Failure to ensure active treatment results in patients being hospitalized without all interventions for recovery being provided in a timely fashion, delaying improvement.

II. Ensure sufficient numbers of scheduled groups/activities by qualified staff on all three (3) units. There was only one (1) scheduled treatment group to be conducted by a social worker/counselor and one (1) scheduled activity to be conducted by a recreation staff member. All other groups/activities were discussion/recreational activities with leadership delegated to mental health technicians. This failure to provide active treatment resulted in patients being hospitalized without the opportunity to receive interventions to meet identified treatment needs, thereby delaying their improvement.

III. Ensure that scheduled treatment modalities were provided as scheduled for all patients on one (1) of three (3) units (Adult). Groups/activities were started late or canceled. This deficient practice results in fragmented treatment for patients and potentially delays their improvement.

Finding include:

I. Findings related to individual patients:

A. Patient Review:

1. Patient A6:

a. As documented in psychiatric evaluation (1/14/15), this patient was diagnosed with "dementia with behavior disturbances."

b. On 1/20/2015, at 1:00, 2:00 and 3:00 PM on the geriatric unit, patient A6 was found sleeping in a chair in his/her room. The patient was breathing, but did not respond to verbal stimuli or gentle touching of his/her arm.

c. On 1/20/2015, at 3:15, staff member RN1 explained that patient A6 is "here to get medications adjusted, but he or she refuses to take them." The staff member went on to explain that "the group therapist goes up and down the hallway, but what can he do if the patient refuses to come?" When asked whether staff engage the patient in treatment in the room, she said, "No, we don't have enough staff."

2. Patient A10:

a. As documented in psychiatric evaluation (1/14/15), this patient was diagnosed with "dementia with behavior disturbances."

b. On 1/20/2015, from 2:15 to 2:45 PM on the geriatric unit, patient A10 was observed in the group room during reminiscence group. The patient had the back turned to the group and was watching TV while the group proceeded. The patient did not make any verbal contributions to the group.

c. On 1/20/2015, at 3:05, staff member T1 who led the group explained that patient A10 is difficult to engage. When asked if he had noticed that the patient had been watching TV, T1 acknowledged that he "forgot to turn off the TV."

3. Patient A15:

a. Patient A15 presented severe psychosis (sic) as identified as the principal problem in the treatment plan (1/11/15), and through direct observation in a group therapy session on 1/20/15 from 2:30 to 3:00 p.m., when during the entire period of observation the patient was engaged in a conversation (judged by verbalization and gesturing) with an invisible partner."

b. On 1/20/15, from 2:15 to 2:45 PM on the geriatric unit, patient A15 was observed in the group room during reminiscence group. The patient was not participating in the group. Instead the patient was gesticulating wildly with both hands and repeatedly turned the head as if in response to internal stimuli.

c. On 1/20/15, at 2:50, AT1 explained that patient A15 "likes listening to music." She agreed that reminiscence group had no therapeutic value for this non-demented, floridly psychotic patient. RN1 at 3:20 PM explained that A15 was seriously visually impaired. She went on, "Medications is all we can do for him/her. He/she is so psychotic; you can't get through to him/her. Sometimes I take him/her outside for a smoke, then he/she starts talking with you. We don't have enough staff to do 1:1 with A15."

d. On 1/20/15 at 2:45 PM, as reminiscence group ended, patient A15 was asked if he/she had benefited from attending the group. A15 responded by denying that he/she had attended, adding, "I don't go to any groups here."

4. Patient B6:

a. Patient B6 was 17 year old male admitted on 9/20/14. According to psychiatric evaluation (9/20/15), Patient B6 was admitted for "depression" and "tied sheet around neck + (and) doorknob."

b. Observations of this patient on 1/20/15 from 2:30-2:50 PM revealed Patient B6 to be disruptive during a group session conducted for the adolescent patients by a mental health technician. S/he constantly moved about on the sofa and in and out of the session. At times, s/he walked about the hall talking to other patients and staff members.

c. During interview on 1/20/15 at 2:50 PM, she RN2 reported that Patient B6 has been in the hospital since September and since s/he has been through the program, s/he has a doctor's order requiring attendance at only one group in the morning and one in the evening. She related that Patient B6 is given packets instead, but has completed most of these. She stated that this patient is allowed to get up and pace in the hallway.

d. During interview on 1/21/15 at 10:45 AM, Patient B6 stated, "I am just waiting for placement. I am done with my treatment plan. I have to do one (1) group a day-any one (1) I choose since I've done them all. I usually do most."

e. During interview on 1/21/15 at 11:30 AM, NP6 stated that Patient B6 "does not require acute active treatment at this time but is here waiting for placement." She reported that she had written an order for Patient B6 to attend only two (2) groups daily, adding that this order was "probably a mistake."

B. Staff Interviews:

1. An interview was performed on 1/21/2015 at 9:20 to 9:40 AM, with the Medical Director. The Director agreed that the observations made about the lack of active treatment in the psychogeriatric program were accurate, and that, specifically, the enrollment of a psychotic patient in a reminiscence group or the active operation of a distracting TV set during group therapy are not consistent with active therapy.

2. On 1/21/2015 at 1:15, the Director of Social Work was interviewed and confirmed that there are weaknesses with the group therapy program. She explained that disciplinary actions have been initiated against a contractual part-time licensed mental health counselor for failing to fully deliver the contractually required group therapy sessions on weekends.

II. Failure to ensure sufficient numbers of scheduled groups/activities by qualified staff:

A. The program schedules for all three (3) Units (Adolescent, Adult and Geropsychiatry) were provided for review by administration. Review revealed only one (1) scheduled treatment group to be conducted by a social worker/counselor and one (1) scheduled activity to be conducted by a recreation staff member each day of the week. All other groups/activities were discussion/recreational activities with leadership delegated to mental health technicians.

B. The above schedules were verified by the Director of Social Work on 1/22/15. During interview on 1/22/15 at 9:40 AM he related that the treatment "could be beefed up." When asked if a recreational therapist works every week-end, he responded "They try to rotate weekends." He acknowledged the need for more scheduled treatment stating, "We have been talking about this."

C. During interview on 1/21/15 at 11:20 AM non-sample Patient C5 reported that on the Adult Unit each day at 9:00 AM there is an activity such as arts and crafts or passing a ball. This activity is usually followed by a group that is more structured and "we talk about things such as "a drinking problem." S/he stated then we have "a break at 10:00, then we go to lunch, then we watch TV in the afternoon, then we have supper, and then we watch TV. This has been two (2) weeks wasted."

III. Failure to ensure that groups/activities were conducted as scheduled:

A. Observations on the Adult Unit on 1/20/15 from 1:15-2:00 PM revealed that a group titled "Psych Ed (Psychiatric Education) Group" scheduled from 1:00-2:00 PM led by a Mental Health Technician (MHT) for nine (9) patients was ended at 1:30 PM At this time the patients were allowed to go outside even though the break was not scheduled until 2:45 PM; some patients were given the opportunity to smoke. The remainder of the patients sat in the dayroom watching television, went to bed or roamed the hallway.

This group was interrupted two (2) times for a staff member to give medications to a patient and teach him/her how to use an inhaler.

B. Observations on the Adult Unit on 1/20/15 from 2:00-2:15 PM revealed that a group titled "Discharge Planning-MHT (Mental Health Technician) and Patient led" scheduled from 2:00-2:45 PM was not conducted. From 2:00-2:15 PM several patients were sitting in the dayroom where the group was to be held. At 2:15 PM MHT handed out a form regarding discharge. Two (2) patients ask if they were going to be told what to do with the form. One (1) MHT told the patients that she thought "someone would help them with the form later." The other MHT (MHT2) stated that she had not seen the form before this time.

During observations on the Adult Unit on 1/20/15 at 2:15 PM, sample Patient C3 and non-sample Patient C8 were in their beds. Sample Patient C4 and non-sample patients C2 and C9 were roaming about the ward.

During interview at 2:20 PM, MHT2 was asked about the cancellation of the group about "discharge" scheduled on the program schedule, she reported "Usually there is no group at this time."

C. Non-sample Patient C5 was admitted on 1/11/15 with the diagnosis of Psychosis NOS. During observations on the Adult Unit, this patient requested interview by the surveyors. During interview on 1/21/15 at 11:20 AM Patient C5 reported that on the Adult Unit at 9:00 a.m. there is an activity such as arts and crafts or passing a ball. This activity is usually followed by a group that is more structured and "we talk about things such as a drinking problem." S/he stated then we have "a break at 10:00, then we go to lunch, then we watch TV in the afternoon, then we have supper, and then we watch TV. This has been two (2) weeks wasted."

2. On 1/21/2015 at 1:15, the Director of Social Work was interviewed and confirmed that there are weaknesses with the group therapy program. She explained that disciplinary actions have been initiated against a contractual part-time licensed mental health counselor for failing to fully deliver the contractually required group therapy sessions on weekends.

Based on the review of the records of patients A6, A10 and C4, and on an interview with the Medical Director, the hospital fails to ensure that the physicians' progress notes convey a clear picture of the patient's progress (or lack thereof) or are related to the goals specified in the treatment plan.

Findings

A. Record Review:

1. In patient A6's chart, the daily progress notes by physician MD1 read as follows:

1/16/15. Chief Complaint: I feel bad. Pt was confused. Delusional. Agitated. Accusing people of stealing. Plan: Seroquel 25 mg BID. Redirect. Reality orientation. [illegible]

1/17/15. Chief Complaint: I feel bad. Pt appears confused. Recurrent paranoid delusions. Plan: Seroquel was increased. Redirect. Call on [internist] about glucose.

1/18/15. Chief Complaint: I feel bad. Pt was agitated. Verbally abusive. Paranoid [illegible]. Refuses meds. Plan: [Increase] Seroquel to 25 mg TID. Redirect. Limit set [sic].

1/19/15. Chief Complaint: Pt is agitated at times. Confused. Delusional. [illegible] ADL. Plan: Seroquel was increased to 25 mg TID. Continue meds. Redirect. Encourage ADL.

1/20/15. Chief Complaint: Pt was [illegible] combative, agitated. Combative in the morning. Taken straight to her room at 10 hr. Then went to sleep. Was found lethargic. Ambulance was called. Plan: Transfer to Askenazi Hospital for further evaluation and treatment.

2. In patient A10's chart, the daily progress notes by physician (Lev) read as follows:

1/17/15. Chief Complaint: I feel OK. Pt appears in better mood. No delusions or hallucinations. Under "Objective," mental status checkmarks suggest everything "WNL" (within normal limits) except slow speech, poverty of ideas, blunted affect and insight and judgment rated as poor. Under "Plan," the doctor lists: Continue meds, support, encourage ADL.

1/18/15. Chief Complaint: I feel OK today. Pt appears in better mood. Quiet. Keeps to him-/herself. Under "Objective," mental status checkmarks suggest everything "WNL" except insight and judgment rated as poor. Under "Plan," the doctor lists: Continue meds, support, encourage ADL.

3. In patient C4's chart, the daily progress notes by physician (Lev) read as follows:

1/17/15. Chief Complaint: I feel better today. Pt appears in better mood today. Pleasant. Under "Objective," mental status checkmarks suggest everything "WNL" except insight and judgment rated as poor. Plan: Continue meds. Support. Encourage ADLs.

1/18/15. Chief Complaint: I feel better. Pt appears in fair mood. Pleasant. Cooperative Under "Objective," mental status checkmarks suggest everything "WNL" except insight and judgment rated as fair. Plan: Continue meds. Support. Encourage ADLs.

B. Staff Interview:

An interview was performed on 1/21/15 at 9:20 to 9:40 AM, with the Medical Director. The Director agreed with the observation that the physicians' progress notes are "skimpy." He explained that "we rely too much on checklists," and concurred that the hand-written remarks are not reflecting progress (or lack thereof) in reference to the treatment plan.

Based on observation, interview and document review, the facility failed to:

I. Staff adequate numbers of Registered Nurses for all three units (Adolescent, Adult and Geropsychiatry). Staffing review revealed that one RN covered 2-3 acute patient units on the 7:00 a.m. to 7:00 p.m. shift of duty. This staffing pattern resulted in lack of a) ongoing professional patient assessments and preventive interventions and b) lack of direction and supervision of non-professional nursing personnel in the provision of care to acutely ill patients. (Refer to B150)


In addition,

A. The Medical Director failed to:

1. Ensure that treatment plan goals are relevant to the patient ' s condition for 7 of 8 active sample patients (A6, A10, A15, B3, B4, B6, and C3). Without a set of defined goals against which to measure progress it is impossible to judge effectiveness of treatment and to implement possible changes in treatment in the case of lack of progress (Refer to B44, Section I).

2. Ensure that treatment plans for 8 of 8 active sample patients (A6, A10, A15, B3, B4, B6, C3 and C4) included individualized treatment interventions with a specific purpose and focus. Failure to clearly describe specific modalities on patients ' MTPs can hamper staff ' s ability to provide treatment based on individual patient needs. (Refer to B144, Section II)

3. Ensure that active individualized psychiatric treatment was provided for 4 of 8 active sample patients (A6, A10, A15, and B6). There was failure to provide structured treatment for these patients ' specialized needs. Failure to ensure active treatment results in patients being hospitalized without all interventions for recovery being provided in a timely fashion, delaying improvement. (Refer to B144, Section III)

4. Ensure sufficient numbers of scheduled groups/activities by qualified staff on all three units. There was only one scheduled treatment group to be conducted by a social worker/counselor and one scheduled activity to be conducted by a recreation staff member. This failure to provide active treatment resulted in patients being hospitalized without the opportunity to receive interventions to meet identified treatment needs, thereby delaying their improvement. (Refer to B144, Section IV)

5. Ensure that scheduled treatment modalities were provided as scheduled for all patients on 1 of 3 units (Adult). Groups/activities were started late or canceled. This deficient practice results in fragmented treatment for patients and potentially delays their improvement. (Refer to B144, Section V)


II. Provide or have available psychological services to meet the needs of the patients. Without access to such services the differential diagnosis of certain psychiatric conditions, especially major Neurocognitive disorders as defined in DSM-5 is less accurate than it needs to be in order to permit specific interventions including neuroimaging and specific pharmacotherapy. (Refer to B144 Section VI)


B. The Director of Nursing failed to:

1. Ensure that Master Treatment Plans for 8 of 8 active sample patients (A6, A10, A15, B3, B4, B6, C3 and C4) included individualized nursing interventions based on the patients ' needs. The absence of individualized nursing interventions on patients ' treatment plans hampers staff ' s ability to provide individualized nursing care to patients.
(Refer to B148, Section II)


2. Ensure that scheduled treatment modalities were provided as scheduled for all patients on 1 of 3 units (Adult). Groups/activities were started late or canceled. This deficient practice results in fragmented treatment for patients and potentially delays their improvement. (Refer to B148, Section III)

Based on observation, interview and document review, the Medical Director failed to:

I. Ensure that in the treatment plans, treatment goals are relevant to the patient ' s condition for 7 of 8 active sample patients (A6, A10, A15, B3, B4, B6, and C3). Many of the goals on the treatment plans were either obvious basic functions of a psychiatric hospital ward, such as prevention of suicidal behavior, or consisted of adherence to treatment ( " will take medication as prescribed " ) rather than outline a mental status or functional status level to be attained. Without a set of defined goals against which to measure progress it is impossible to judge effectiveness of treatment and to implement possible changes in treatment in the case of lack of progress (refer to B121).

II. Ensure that treatment plans for 8 of 8 active sample patients (A6, A10, A15, B3, B4, B6, C3 and C4) included individualized treatment interventions with a specific purpose and focus. Many of the interventions on the treatment plans were listed as generic discipline functions/tasks or there was failure to identify interventions based on the patients ' needs. Failure to clearly describe specific modalities on patients ' MTPs can hamper staff ' s ability to provide treatment based on individual patient needs. (Refer to B122)

III. Ensure that active individualized psychiatric treatment was provided for 4 of 8 active sample patients (A6, A10, A15, and B6). There was failure to provide structured treatment for these patients ' specialized needs. In the cases of Patients A6 and A10, these patients functioned at low cognitive and social levels, yet adequate modalities to address their problems were not provided. Even though Patient A15 presented severe psychosis, he was assigned to attend the program designed for cognitive impairment. In the case of Patient B6, the treatment team failed to plan and implement a highly structure treatment to meet based on his/her presenting needs. Failure to ensure active treatment results in patients being hospitalized without all interventions for recovery being provided in a timely fashion, delaying improvement. (Refer to B125, Section I)

IV. Ensure sufficient numbers of scheduled groups/activities by qualified staff on all three units. There was only one scheduled treatment group to be conducted by a social worker/counselor and one scheduled activity to be conducted by a recreation staff member. All other groups/activities were discussion/recreational activities with leadership delegated to mental health technicians. This failure to provide active treatment resulted in patients being hospitalized without the opportunity to receive interventions to meet identified treatment needs, thereby delaying their improvement. (Refer to B125, Section II)

V. Ensure that scheduled treatment modalities were provided as scheduled for all patients on 1 of 3 units (Adult). Groups/activities were started late or canceled. This deficient practice results in fragmented treatment for patients and potentially delays their improvement. (Refer to B125, Section III)

VI. Provide or have available psychological services to meet the needs of the patients. Without access to such services the differential diagnosis of certain psychiatric conditions, especially major Neurocognitive disorders as defined in DSM-5 is less accurate than it needs to be in order to permit specific interventions including neuroimaging and specific pharmacotherapy (Refer to B151).

Interview with the Medical Director

An interview was performed on 1/21/15 at 9:20 to 9:40 AM, with the Medical Director. The Director agreed with the observation that the physicians' progress notes are "skimpy." He explained that "we rely too much on checklists," and concurred that the hand-written remarks are not reflecting progress (or lack thereof) in reference to the treatment plan. He further agreed that the observations made about the lack of active treatment in the psychogeriatric program were accurate, and that, specifically, the enrollment of a psychotic patient in a reminiscence group or the active operation of a distracting TV set during group therapy are not consistent with active therapy. The Medical Director confirmed that there is no psychologist or neuropsychologist credentialed at the hospital as either regular or consulting professional staff. "I have made this case many times to leadership here," but, he said he had never "made any headway."

Based on observation, interview and document review, the Director of Nursing failed to:

I. Staff adequate numbers of Registered Nurses for all three (3) units (Adolescent, Adult and Geropsychiatry). Staffing review revealed that one RN covered two (2) to three (3) acute patient units on the 7:00 AM to 7:00 PM shift of duty. This staffing pattern resulted in lack of a) ongoing professional patient assessments and preventive interventions and b) lack of direction and supervision of non-professional nursing personnel in the provision of care to acutely ill patients (Refer to B150).

II. Ensure that Master Treatment Plans for eight (8) of eight (8) active sample patients (A6, A10, A15, B3, B4, B6, C3 and C4) included individualized nursing interventions based on the patients' needs. Nursing interventions were listed as generic discipline functions/tasks, were physician interventions or there was failure to identify safety and preventive interventions to care for patients presenting problems as suicide, self-mutilation and psychotic symptoms. The absence of individualized nursing interventions on patients' treatment plans hampers staff's ability to provide individualized nursing care to patients.

Findings Include:

A. Record Review:

1. Patient A6:

For problem identified as "Aggression with Dementia" in treatment plan dated 1/15/15, the only nursing interventions were listed as expected role functions, "Administer medication as prescribed, assess for adverse side effects and compliance with taking medications." A physician intervention was identified as a nursing intervention, "Prescribe and monitor medications to address: agitation, outbursts and mood stabilization." There were no specific nursing interventions to address the patient's cognitive deficits in the care of this patient in the clinical area.

2. Patient A10:

For problem identified as "Aggression with Dementia" in treatment plan dated 1/15/15, the only nursing interventions were listed as expected role functions, "Administer medication as prescribed, assess for adverse side effects and compliance with taking medications." A physician intervention was identified as a nursing intervention, "Prescribe and monitor medications to address: agitation, outbursts." There were no specific nursing interventions to address the patient's cognitive deficits in the care of this patient in the clinical area.

3. Patient A15:

In treatment plan written on 1/13/15, for problem identified as "Disturbed Thought Process," the only nursing intervention was listed as an expected role function, "Administer medication as prescribed, assess for adverse side effects." There were no specific nursing interventions for to address this patient's behaviors in the clinical area.

4. Patient B3:

In treatment plan written on 12/11/14, for problem identified as "Suicide Risk/Self-Harm Behaviors," the only nursing intervention was listed as an expected role function, "Administer medication as prescribed, assess for adverse side effects." There were no specific nursing interventions for patient safety, nor were preventive measures related to self-cutting and suicide risk identified in the plan.

5. Patient B4:

a. In treatment plan written on 1/10/15, for problem identified as "Suicidal Ideations with Attempt," the only nursing intervention was listed as an expected role function, "Administer medication as prescribed, assess for adverse side effects." There were no specific nursing interventions for patient safety, nor were preventive measures related to suicide risk identified in the plan.

b. In treatment plan written on 1/10/15, for problem identified as "Auditory and Visual Hallucination," the only nursing intervention was listed as an expected role function, "Administer medication as prescribed, assess for adverse side effects." There were no specific nursing interventions for to address this patient's behaviors in the clinical area.

6. Patient B6:

In treatment plan written on 11/22/14, for problem identified as "Impaired Memory," the nursing intervention was listed as an expected role function: "Administer medication as prescribed, assess for adverse side effects." Another nursing intervention was incomplete: "Assess patient for: "One listed nursing intervention was a physician role function: "Prescribe and monitor medications to address: Side effects and effectiveness."

7. Patient C3:

In treatment plan written on 12/22/14, for problem identified as "Disturbed Thought Process," the only nursing intervention was listed as an expected role function, "Administer medication as prescribed, assess for adverse side effects." There were no specific nursing interventions for to address this patient's behaviors in the clinical area.

During interview on 1/20/15 at 1:40 p.m., Patient C3 reported, " I am legally blind. " This issue was not addressed in the treatment plan by nursing.

8. Patient C4:

In treatment plan written on 1/16/15, for problem identified as "Suicidal Ideation," there were no identified nursing interventions.

B. Interview:

During interview with review of treatment plans on 1/21/15 at 1:25 PM, the DON stated related that after an patient assessment was performed by the nurse, the nursing interventions on the plan should be aimed at helping the patient to reach his/her maximum potential in the hospital.

III. Ensure that scheduled treatment modalities were provided as scheduled for all patients on one (1) of three (3) units (Adult). Groups/activities were started late or canceled. This deficient practice results in fragmented treatment for patients and potentially delays their improvement (Refer to B125, Section III).

Based on observation, interview and document review, the Director of Nursing failed to staff adequate numbers of Registered Nurses for all three (3) units (Adolescent, Adult and Geropsychiatry). Staffing review revealed that one (1) RN covered two (2) to three (3) acute patient units on the 7:00 AM to 7:00 PM shift of duty. This staffing pattern resulted in lack of a) ongoing professional patient assessments and preventive interventions and b) lack of direction and supervision of non-professional nursing personnel in the provision of care to acutely ill patients.

Findings include:

A. Options Behavioral Health System is a 40 bed facility providing acute psychiatric services.

B. Review of Nursing Needs Assessments completed on each unit by a registered nurse on the first day of the survey (1/20/15):

1. The Adolescent Unit, with a capacity of 12 beds, had a census of 10 patients on the first day of the survey. The Nursing Needs Assessment form noted that four (4) patients were potentially assaultive and were on assault precautions, five (5) patients were a low risk for suicide, two (2) patients had been admitted within 48 hours, one (1) patient was on elopement precautions and two (2) patients were on constant/line-of-sight supervision.

2. The Adult Unit, with a capacity of 12 beds, had a census of nine (9) patients on the first day of the survey. The Nursing Needs Assessment form noted that one (1) patient was on detoxification protocol, one (1) patient was potentially assaultive, one (1) patient was actively assaultive, nine (9) patients were a low risk for suicide and two (2) patients constantly demanded staff time.

3. The Geropsychiatric Unit, with a capacity of 16 beds, had a census of 15 patients on the first day of the survey. The Nursing Needs Assessment form noted that one (1) patient required partial assistance with aspects of self-care, 10 patients required total assistance in three or more self-help skills, 11 patients required partial assistance from staff with mobility, two (2) patient needed decubitus care five (5) patients were potentially assaultive, three (3) patients were actively assaultive, one (1) patient was a low risk for suicide, one (1) patient was presenting hallucinations and delusions, three (3) patients were admitted within the last 48 hours, 13 patients were on assault precautions, one (1) patient was on elopement precautions and 14 patients were on fall precautions.

C. Review of staffing data from 1/13-20/15 revealed two (2) shifts of duty with only one (1) registered nurse to cover two (2) or three (3) of these acute units. With this staffing pattern, when the RN is on one (1) of the units, s/he would not be able to respond to needs on the other acute unit(s). Time for on-going professional assessments and preventive interventions required for these acute patients by a professional nurse would be negligible.

1. On 1/13/15 on the 7:00 AM to 7:00 PM shift of duty there was only one (1) registered nurse on duty for all three (3) wards. On this date there were 10 patients on the Adolescent Unit, four (4) patients on the Adult Unit and 10 patients on the Geropsychiatric Unit. This was a total of 24 patients on three (3) separate units.

2. On 1/19/15 on the 7:00 AM to 7:00 PM shift of duty there was only one (1) RN on duty for the Adolescent Unit with 11 patients and the Adult Unit with eight (8) patients. This was a total of 19 patients on two (2) separate units.

3. Observations of the units on 1/22/15 at 9:25 AM revealed only one (1) RN on duty for the Adolescent and the Adult Units. At this time, RN2 verified that she had been the only RN on duty since 7:00 a.m. She stated, "One (1) of the nurses called out." She related that another nurse should be in by noon. During follow-up observations of the units at 10:15 revealed that the only RN assigned to the Adolescent and Adult Units was attending a treatment team meeting in a conference room on the Adult Unit, leaving the Adolescent Unit without an RN being immediately available. At 10:25 the DON reported that an RN had reported on duty to cover the Adolescent Unit.


C. Policy Review:

1. Review of policy, "Staffing Policy," with revision date of 11/14/13, revealed the following procedural statements: # (2) "The facility will provide continuous (24) care, and shall maintain staffing levels accordingly;" # (4) "In addition to staff assigned specifically to patient/resident needs and supervision, there shall also be additional professional staff available to provide assistance and direction during periods of emergencies."

The last section of this policy: "Staffing Levels" referred to a Staff Grid. This grid stated the following minimum staffing for registered nurses for first and second shifts of duty:

a. For each of the Adolescent and Adult Units the following numbers were listed as staffing minimums for RNs:

For 1-5 patients, 1 RN.

For 6-12 patients, 1 RN with a note stating that this requirement "will be adjusted based on patient acuity and prior approval of the CNO (Central Nursing Office).

b. For the Geropsychiatric Unit the following numbers were listed as staffing minimums for RNs:

For 1-6 patients, 1 RN.

For 7-9 patients, 1 RN with a note stating that this requirement "will be adjusted based on patient acuity and prior approval of the CNO (Central Nursing Office).

2. As presented in the staffing data in section B above, the staffing for RNs on the first and second shifts of duty failed to meet policy requirements.

D. Interviews:

1. On 1/21/15 at 9:45 AM the DON verified that there was only one (1) RN on duty to cover the three (3) units on the 7:00 AM to 7:00 PM shift. She reported, "Two (2) RNs called out and we were unable to get another nurse to come in."

2. During interview on 1/21/15 at 10:20 AM, RN2 stated, "I occasionally cover both the Adolescent and Adults Units." She acknowledged that more nurses were needed. At times I have 21 patients. She added, "I must set priorities. Charting may not get done or I stay over to finish. Patients lack my attention."

3. During interview on 1/21/15 at 2:15 PM verified that only one (1) RN was on duty to cover all three (3) wards on the 7:00 AM to 7:00 PM shift of duty on January 13, 2015. The CEO stated awareness of this staffing and the possible effects on patient care. He stated, "We tried every way to get someone else that day."

4. An interview was conducted on 1/22/15 at 9:25 AM with RN7 and LPN8. LPN8 stated, "Usually two (2) to three (3) days out of seven (7), there is only one (1) RN for the Geropsychiatry and Adolescent Units." She added, "(DON) is usually available." When asked if the DON stays on one (1) of the Units the whole shift, LPN8 replied, "If she has to go to a meeting, she goes and then returns." LPN8 verified that the treatment team meetings are usually held on the Adult Unit and that the RN covering the Adolescent Unit would leave that ward to attend the team meeting in the Adult Unit conference room.

Based on interviews with the medical director and the clinical director, the hospital failed to provide or have available psychological services to meet the needs of the patients. Without access to such services the differential diagnosis of certain psychiatric conditions, especially major Neurocognitive disorders as defined in DSM-5 is less accurate than it needs to be in order to permit specific interventions including neuroimaging and specific pharmacotherapy.

Findings

A. Interview with the Medical Director

An interview was performed on 1/21/15 at 9:20 to 9:40 AM, with the Medical Director. The Medical Director confirmed that there is no psychologist or neuropsychologist credentialed at the hospital as either regular or consulting professional staff. "I have made this case many times to leadership here," but, he said he had never "made any headway." He agreed that in a hospital with a psychogeriatric unit and a substantial number of patients with Neurocognitive disorders, a mechanism to assess cognitive impairment in a systematic manner should be available.

B. Interview with the Clinical Director

On 1/21/15, in an interview at 1:30 PM, the Clinical Director confirmed that "to my best knowledge" there is no policy for access to psychological services. However, after some research, he identified a "Policy: Psychological Consultation" (Policy No. CTS-119). The policy provides that an "[a]ttending physician orders a psychological consultation," and then nursing staff "contacts Credentialing Coordinator for privilege status of psychologist, [and] notifies psychologist that a testing consultation has been ordered by attending physician." However, there are no clinical psychologists credentialed at the hospital. When asked what happens if an attending physician actually wanted to have objective or projective testing or a neuropsychological assessment done, the Clinical Director shrugged his shoulders and said, "Can't be done."