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Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.13, PATIENT RIGHTS, was out of compliance.

A-0130 The patient has the right to participate in the development and implementation of his or her plan of care. The facility failed to ensure physicians conducted comprehensive psychiatric evaluations (CPEs) in a timely manner in order to determine patients' psychiatric needs in 2 of 18 records reviewed (Patients #1 and #7) .This failure created a delay in patients' involvement in their plans of care and in the development of their treatment plans.

A-0144 The patient has the right to receive care in a safe setting. The facility failed to ensure the physical safety of 3 of 16 patients admitted for suicidal ideation (Patients #12, #13 and #17). Specifically, 2 of 16 patients on suicide precautions were in possession of items which could be used in a suicide attempt (Patients #12 and #17), and 2 patients (Patients #12 and #13) on suicide precautions shared rooms with patients wearing shoestrings. The failure allowed Patient #13 to attempt suicide while in the care of the facility.

Based on interviews and record review, the facility failed to ensure physicians conducted comprehensive psychiatric evaluations (CPEs) in a timely manner in order to determine patients' psychiatric needs in 2 of 18 records reviewed (Patients #1 and #7).

This failure created a delay in patients' involvement in their plans of care and in the development of their treatment plans.

Findings include:

Policy:

The Admission Process Inpatient policy read, the Comprehensive Psychiatric Evaluation (CPE) must have been completed and dictated within 24 hours of admission.

1. The facility failed to ensure 2 of 18 patients had comprehensive psychiatric evaluations (CPEs) performed within 24 hours of admission.

a. According to Physician Orders - Final, Patient #1 was admitted to the facility on 2/9/18 at 5:10 p.m. The Admission Form specified Patient #1 was admitted for depression, suicidal ideation and paranoia. The Complete Psychiatric Evaluation (CPE) was completed by Physician #34 on 2/10/18 at 10:00 p.m. (more than 24 hours after admission). Physician #34 documented Patient #1 was sleeping at this time; therefore, the CPE was completed based on staff report and chart review and without any direct input from Patient #1. There was no documentation why the CPE was delayed and not completed within 24 hours, which resulted in the patient not being able to participate in his care plan in a timely manner.

b. According to Physician Orders - Final, Patient #7 was admitted to the facility on 2/7/18 at 12:58 p.m. The Admission Form specified Patient #7 was admitted for heroin detoxification. The CPE was completed by Physician #4 on 2/8/18 at 2:31 p.m. (more than 24 hours after admission). There was no documentation why the CPE was delayed and not completed within 24 hours, which resulted in the patient not being able to participate in his care plan in a timely manner.

c. An interview was conducted with the Director of Clinical Services (Director) #23 on 3/7/18 at 1:41 p.m. Director #23 reviewed the admission process at the facility, and stated the expectation was that all patients received a Comprehensive Psychiatric Evaluation (CPE) within 24 hours of admission to the facility.

d. On 3/7/18 at 9:54 a.m., an interview was conducted with Physician #3 who stated the expectation was the Comprehensive Psychiatric Evaluation (CPE) was to be completed within 24 hours of a patient's admission. Physician #3 stated there was a delay in beginning the medication management services for Patient #1 by one day due to the delayed completion of the CPE.

Based on observations, interviews and record review the facility failed to ensure the physical safety of 3 of 16 patients admitted for suicidal ideation (Patient #12, #13 and #17). Specifically, 2 of 16 patients on suicide precautions were in possession of items which could be used in a suicide attempt (Patient #12 and #17) and 2 patients (Patients #12 and #13) on suicide precautions shared rooms with patients wearing shoestrings. The failure allowed Patient #13 to attempt suicide while in the care of the facility.

Findings include:

Policy:

According to the Levels of Observation and Precautions policy, when on suicide precautions "personal items that pose a threat to patients will be removed and locked, such as belts, strings, jewelry (except wedding rings), makeup compacts, etc." A physician's order is required to discontinue a special level of precaution.

1. The facility failed to prevent access to items which posed a ligature risk to patients on suicide precautions.

a. Patient #13 was admitted for suicidal ideation on 11/28/17 following two weeks of increasing depression. An order was written by Physician #3 on 11/28/17 at 4:00 p.m. to place Patient #13 on suicide precautions. Review of an incident report, submitted by Patient Care Associate (PCA) #19 and Registered Nurse (RN) #11 on 11/29/17 at 5:06 p.m., revealed Patient #13 had attempted suicide at 4:49 p.m. on 11/29/17, by tying a shoestring around his neck. There was no documentation on the incident report to show an investigation was completed to determine where Patient #13 had obtained the shoestring.

Patient #12 was admitted on 2/18/18 for self-injurious behavior with a longstanding history of suicide attempts and was determined to be a danger to himself. Physician #3 wrote an order for suicide precautions on 2/18/18 at 5:00 p.m. which was not discontinued until 3/7/18. Patient #12 was observed to have shoestrings in his shoes on 3/6/18.

According to the medical record Patient #14 was admitted on 2/11/18 at 11:09 p.m. for suicidal ideation with a plan but would not share the plan with staff at the time of admission. An order for suicide precautions was written by Physician #3 on 2/12/18 at 3:00 a.m. Patient #14 was observed to have shoes with shoestrings on 3/6/18. The order for suicide precautions was not discontinued until 3/7/18.

The access to shoestrings by the above three patients was in conflict with the facility policy for patients on suicide precautions.

b. On 3/6/18 at 4:51 p.m. an interview was conducted with Director of Nursing (Director) #1. Director #1 stated, suicide precautions included placement of the patient close to the nursing station and a search of personal belongings to remove items such as weapons, belts and strings. Additionally, the roommates of patients on suicide precautions should have the same items removed. The reason for removal of the items was for the safety of patients in the facility.

Director #1 stated he did not recall performing a "deep dive" investigation to identify how Patient #13 obtained a shoestring to use in a suicide attempt. He confirmed there was no tracking system to identify which patients on the adult units were in possession of shoestrings or if any were missing.

Director #1 stated he was not sure how many patients on suicide precautions were in possession of shoestrings or had roommates with shoestrings in their shoes. According to Director #1, adolescents were never allowed to keep any type of string, belt or weapon when admitted. He confirmed the philosophy of the corporation was to minimize the removal of restricted items from patients in order to maintain their dignity while in the facility.

c. Observations of the two inpatient adult units were conducted on 3/6/18 between 1:30 p.m. and 2:00 p.m. According to the census, 16 patients were on suicide precautions and two of those (Patient #12 and #17) were wearing shoestrings in their shoes. A total of five patients on the units were wearing shoes with shoestrings in them and two of those patients ( Patient #12 and #13) shared rooms with patients on suicide precautions.

d. During an interview conducted with the Director of Quality, Risk and Compliance (Director #2) on 3/6/18 at 3:48 p.m. she stated the corporation which owned the facility would not allow shoestrings to be taken away from every patient for the protection of one patient. All patients were routinely monitored every 15 minutes by PCAs to ensure their safety while in the facility. Because Patient #13 did not require emergency care at an outside facility (after the suicide attempt) and there was no change in his vital signs, the investigation did not go beyond the nursing department. In the case of Patient #13, the facility was not able to determine where the shoestring came from. According to Director #2, "in this setting it is common for patients to put things around their neck."

e. An interview was conducted with Patient Care Assistant (PCA) #5 on 3/6/18 at 11:27 a.m. in which he stated, his duty was to perform observations of patients throughout his assigned unit every 15 minutes. During the observations PCA #5 stated he ensured there was no access to items which could be used by patients to cause harm to themselves or others and included anything used to cut or strangle. When asked about patients with shoestrings in their shoes, PCA #5 stated it was not the facility practice to remove items like shoestrings from every patient on the unit but only those who were actively suicidal. Patients who were on suicide precautions were placed in rooms close to the nurses station to decrease their chances of entering other patients rooms to gain access to the restricted item.

PCA #5 confirmed he was present on 11/29/17 when Patient #13 attempted suicide with a shoestring. He stated no change was made in the facility practice which allowed adult patients to keep their shoestrings.

f. PCA #12 was interviewed on 3/7/18 at 11:31 a.m. According to PCA #12, when an adult patient was admitted to the facility it was the PCAs responsibility to search the patients belongings and remove restricted items but patients were allowed to keep their shoestrings even if they were on suicide precautions. He was not aware of the reason for the exception other than a potential for falling in elderly patients.

g. On 3/7/18 between 9:30 a.m. and 10:00 a.m. additional observations were made of the two inpatient adult units. Patients who wore shoes which had openings for shoestrings did not have the shoestring.

h. The Nurse Manager (Manager #18) of the inpatient adult units was interviewed on 3/7/18 at 9:45 a.m. According to Manager #18, based on the observations made by surveyors, patients on suicide precautions had been re-evaluated and the precautions discontinued by physician order. She stated all shoestrings were collected from every patient overnight. She added, collecting the shoestrings was a "knee jerk reaction" and they would be redistributed.

Redistribution of the shoestrings was in direct conflict of facility policy.

i. On 3/7/18 at 2:28 p.m. an interview was conducted with RN #11. RN #11 was assigned to work on the unit with Patient #13 on 11/29/17. According to RN #11 she recalled the incident after review of the incident report and confirmed the patient was on suicide precautions but did not know how he had gained access to the shoestring. RN #11 stated Patient #13 should not have had access to a shoestring because he was intent on committing suicide and the policy stated a patient on suicide precautions was not allowed to have strings.

j. An interview was conducted with Physician #4 on 3/6/18 at 12:30 p.m. Physician #4 stated the corporate owner of the facility wanted to meet patients with a level of respect and dignity by allowing them more access to their personal belongings to provide a more positive consumer experience. According to Physician #14, suicide precautions involved placing the patient in a room closer to the nurses station, no access to cords or strings and safety checks performed every 15 minutes. He stated the process should apply to all patients on suicide precautions. Typically patients with similar diagnoses were roomed together, however, Physician #4 stated he was unsure if there was a process in place which prevented a suicidal patient from entering another patients room. Physician #4 stated the suicide attempt made by Patient #13 had not been brought up at the medical staff meeting but he assumed the incident would have raised awareness by management and questioned who should or should not have shoestrings.

Physician #4 added, strangulation is the greatest suicide risk for patients in this type of facility. "Seems like we should tighten the policy" on who is allowed to have items that pose a hanging risk to patients.

Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.42, INFECTION CONTROL, was out of compliance.

A-0749 The infection control officer or officers must develop a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel. The facility failed to maintain infection control processes in the areas of isolation precautions, hand hygiene and glove changing practices. Additionally, the facility failed to ensure laboratory test results were determined to ensure infection control measures were implemented.

Based on observations, interviews, and record review, the facility failed to maintain infection control processes in the areas of isolation precautions, hand hygiene and glove changing practices. Additionally, the facility failed to ensure laboratory test results were determined to ensure infection control measures were implemented.

Findings include:

Policy:

The Care of a Patient with MRSA policy read, physician ordered a wound or sputum culture for MRSA screen if the patient had a history of MRSA and was experiencing respiratory symptoms (i.e., purulent sputum, productive cough, fever, elevated WBCs, etc.) or had a draining wound.

Nursing staff isolated the patient in a private room when respiratory MRSA was active or suspected.

The Hand Hygiene policy read, all employees apply an alcohol based sanitizer before and after touching patients or items in the patient care environment and removed gloves after caring for a patient or after touching potentially infectious material and decontaminated hands with alcohol based sanitizer or washed hands with soap and water if visibly soiled.

1. The facility failed to initiate isolation precautions for a patient (Patient #14) with a known history of methicillin-resistant staphylococcus aureus (MRSA) while the patient's laboratory results were pending. Also, the facility failed to track the laboratory test results and was unaware the patient's infection status was not determined prior to the patient's discharge.

a. Review of Patient #14's medical record showed he was admitted on 2/12/18 at 6:30 a.m. for suicidal ideation and alcohol withdrawal. An Infection Screening was conducted at 07:10 a.m. by Intake Screener (Screener) #33. Patient #14 checked "yes" in the boxes which indicated he currently had a cough with phlegm, a sore throat, chills, fatigue, diarrhea, and shortness of breath. Patient #14 checked the box "no" for MRSA symptoms within the last 3 months, but marked "yes" as susceptible to infections that are difficult to treat. The Infection Screening was signed by Screener #33 at 7:10 a.m. and the Director of Nursing (DON) #1 reviewed Patient #14's infection risk and signed as the Consulting RN at 9:30 a.m.

An Inpatient/PHP Nursing Part II Admission Assessment (Admission Assessment) was completed on 2/12/18 at 10:55 a.m. which revealed Patient #14 reported 40 to 50 previous surgeries due to MRSA infections. In addition, the nutrition screening in the Admission Assessment showed Patient #14 had open healing areas on his right thumb and index finger, and ten cuts were documented on Patient #14's body, which were described as weather-related from being outside.

A History and Physical was documented by Nurse Practitioner (NP) #20 the following day on 2/13/18 at 07:45 a.m. NP #20 recorded an abnormal skin assessment for Patient #14 with scabs noted on his right arm. NP #20 also documented Patient #14 had a history of a communicable disease and specified MRSA. NP #20 did not note MRSA as an active problem but listed MRSA as a problem deferred until after discharge.

A review of the Physician Orders in Patient #14's medical record revealed a MRSA screen (a laboratory test) was ordered by NP #20 on 2/14/18 at 10:33 a.m.

b. A review of the facility's laboratory log revealed a nasal swab for MRSA was ordered by NP #20 on 2/14/18 and collected on 2/15/18. No result of the MRSA screen was found in the review of the Patient's medical record.

c. On 3/6/18 at 12:09 p.m., Nurse Manager and Infection Prevention Control Registered Nurse (IPRN) #18 provided a laboratory patient report for Patient #14 which showed the specimen was collected on 2/15/18 and received by the laboratory on 2/16/18. The report documented the specimen submitted by the facility was incorrect, and therefore, no result of the MRSA swab was provided. This report was printed on 3/5/18, more than a week after Patient #14 was discharged.

Patient #14's medical record did not contain any documentation that the patient was placed on any type of infection precaution during his stay in the facility. There were no physician orders, progress notes, or nursing notes which revealed any type of isolation of Patient #14.

d. An interview was conducted on 3/7/18 at 8:55 a.m. with Registered Nurse (RN) #10. She stated if a patient was tested for a MRSA infection, a patient was kept in a room by himself while the test was being processed. She stated an order was put in the computer system for the patient to have no roommate. She stated this was because the facility did not want to spread "stuff" around.

RN #10 reviewed the medical record for Patient #14 and stated she was unable to locate the result of Patient #14's MRSA screening. RN #10 stated it was important to monitor laboratory results to ensure the patient was being taken care of properly and did not infect others.

e. On 3/7/18 at 7:50 a.m., an interview was conducted with Nurse Practitioner (NP) #20 who stated the MRSA test he had ordered for Patient #14 was returned with an invalid result; however, he stated he was unaware the test result was invalid until 3/6/18, more than a week after the patient was discharged. NP #20 stated Patient #14 should have been placed in a room alone. NP #20 stated, in this situation, he typically placed an order for no roommate, but his review of Patient #14's medical record did not reveal this order. NP #20 stated isolating the patient was important so the facility did not have to worry about the patient infecting his roommate. NP #20 stated it was important to ensure laboratory results were obtained so patients were treated appropriately, and that he relies on the laboratory and the nursing staff to ensure test results were available.

f. An interview was conducted on 3/7/18 at 10:45 a.m. with the Nurse Manager and Infection Prevention Control Registered Nurse (IPRN) #18 who stated when a patient was admitted who had a history of MRSA, the Nurse Practitioner ordered a nasal swab to determine whether the patient had active MRSA. IPRN #18 stated the facility was confident Patient #14 did not have active MRSA, and therefore, the patient was out on the unit participating with the other patients during his stay in the facility. However, IPRN #18 stated the purpose of sending the nasal swab was to ensure the patient did not have active MRSA, and in retrospect, she probably would have placed a patient with a history of MRSA on precautions without a roommate until she verified the patient did not have an actively transmittable infection.

IPRN #18 stated it is the Nurse Practitioner's and night shift nurses' responsibility to ensure the facility received laboratory results, and the facility relied on the laboratory to notify them of any critical laboratory values for patients. IPRN #18 stated she was unaware until after Patient #14's discharge that his MRSA screening results were not valid and, therefore, undetermined.

2. The facility failed to ensure staff removed used gloves and performed hand hygiene before providing care to the next patient.

a. On 3/6/18 at 7:47 a.m., a tour was conducted of the Sunrise unit. At 7:54 a.m., Patient Care Advocate (PCA) #21 was observed taking vital signs of patients. PCA #21 was observed with gloves on taking the blood pressure and oral temperature of Patient #A. Once finished, PCA #21 disposed of the oral thermometer cover and returned the thermometer to the basket on the vitals machine and then removed the pulse oximetry probe. PCA #21 then wrote on her clipboard, still wearing the same gloves. PCA #21 then removed the blood pressure cuff from Patient #A's arm and placed it on Patient #B's arm. PCA #21 then placed a new cover onto the thermometer probe and placed it into Patient #B's mouth. The pulse oximetry probe was then placed on Patient #B's finger. The thermometer probe was then removed from Patient #B's mouth, and the cover was disposed. The thermometer was placed in the basket, and PCA #21 then wrote on her clipboard. She then removed the pulse oximetry probe and blood pressure cuff from Patient #B. PCA #21 then wrapped up the blood pressure cuff and pulse oximetry cord and, still wearing the same gloves, opened the door leading into the "girls" side of the Sunrise unit.

Once through the door, PCA #21 approached a table where patients were sitting. PCA #21 was still wearing the same gloves. PCA #21 was observed taking vitals signs for Patients C, D, and E in the same manner. PCA #21 did not remove her gloves or perform hand hygiene at any point during this process. PCA #21 was still taking vital signs when the observation ended at 08:13 a.m.

b. An interview was conducted on 3/6/18 at 3:27 p.m. with Patient Care Advocate (PCA) #21 who stated she took a table full of kids' vitals signs wearing the same pair of gloves. She stated she removed her gloves and used hand sanitizer when she "touched stuff." PCA #21 stated she did not use hand sanitizer in between patients.

PCA #21 stated the purpose of hand sanitizer was to kill germs, and the purpose of gloves was to protect her hands from anything soiled and to protect her from passing germs onto other patients. PCA #21 stated it was possible her gloves could have passed germs from one patient to another when she did not change them or perform hand hygiene between taking vitals signs for different patients.

c. An interview was conducted on 3/7/18 at 8:55 a.m. with Registered Nurse (RN) #10 who stated she was both a staff nurse and a House Supervisor at the facility. RN #10 stated she did not oversee the PCAs who took patients' vitals signs, and she tried not to micromanage them. RN #10 stated it was not okay to wear the same pair of gloves from patient to patient. This was to maintain infection control. RN #10 stated she expected the PCAs to wash their hands in between patients.

d. An interview was conducted on 3/7/18 at 10:45 a.m. with the Nurse Manager and Infection Prevention Control Registered Nurse (IPRN) #18 who stated she expected staff performed hand hygiene between patients to prevent cross contamination. She stated every time staff had contact with patients they were to wash or gel their hands. IPRN #18 stated hand hygiene was the first line of defense against the spread of infection. IPRN #18 stated she was not typically present when vitals signs were taken so she was not aware hand hygiene and glove changes were not being done between patients.