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The Condition of Participation for Governing Body has not been met. The Governing Body failed to ensure that safe medication administration practices were followed and failed to ensure timely corrective measures were taken to ensure that medications were safely administered to patients throughout the hospital campus resulting in a finding of Immediate Jeopardy.

Please refer to A115, A144, A263, A286, A385 and A405



a. Review of Governing Body meeting minutes and/or documentation review between 11/1/16 and 2/6/17 failed to identify that the Governing Body reviewed the circumstances of a significant medication error that occurred on 11/1/16 to include the hospital's practice of pre-preparing patient medications. Surveyor observations made between 1/30/17 and 2/2/17 identified that medications continued to be pre-prepared in advance of medication administration on multiple patient care units. The hospital policy for medication management continued to identify the practice of pre-preparing patient medications.



b. Based on clinical record review, observations, interviews with staff, and review of hospital documentation for 1 of 3 patients reviewed for safe medication administration (Patient #13), the hospital failed to ensure that the right patient received the correct medications. The findings include:


Patient #57 was admitted with diagnoses of schizophrenia, hypertension, and Type II diabetes. Patient #57's 8:00 PM scheduled oral medications were identified as Clozaril 525 mg, Depakote 1,500 mg, Valium 10 mg, Metformin 850 mg, Vasotec 20 mg, Haldol 7.5 mg, Inderal 40 mg, Cogentin 1 mg, Lipitor 40 mg, Colace 200 mg, Senna 2 tabs, and Miralax 17 gm's.

RN #10 was on duty on 11/1/16 on the evening shift, had floated from another unit to DS2, and was responsible for administering evening medications to all patients on DS2 (21 patients). In accordance with nursing practice at this hospital, RN #10 had pre-prepared (pre-poured) all evening medications for every patient prior to the 8:00 PM medication pass. Each patient's prepackaged labeled unit dose medications were retrieved from an electronic medication dispensing system, placed in a medication cup, and placed on a tray in alphabetical order with a corresponding label with the patient's name and date of birth.

On 11/1/16 at approximately 8:00 PM, Patient #57 presented to the medication administration room requesting his/her evening medications. At that time, RN #10 identified that Patient #57's medication card was there but the medications were not. RN #10 identified that 2 patients (Patients #13 and #60) had already received medications and it was presumed that one of those patients received Patient #57's medications in error. Interview with RN #10 on 2/1/17 at 3:02 PM identified that RN #10 was unable to determine with certainty who received Patient #57's medications. In addition, RN #10 could not recall when in the medication administration process he/she signed the medication kardex for Patient's #13, #57 and #60.

Patient #13 was admitted with diagnoses of impulse control disorder and mild intellectual disabilities. Standing evening medications included Metformin 1,000 mg, Vasotec 5 mg, Zetia 10 mg, Clonazepam 1.0 mg, and Trazadone 100 mg.

Patient #60 was admitted with diagnoses of paranoid schizophrenia and left cerebral vascular accident (CVA) with aphasia. Standing evening medications included Ezetemibe 10 mg, Atrovastatin 40 mg and Coreg 3.125 mg.

Once RN #10 realized that either Patient #13 or Patient #60 received Patient #57's medications, he/she notified the Head Nurse (RN #12). Staff obtained the vital signs of Patients #13 and #60, which included blood pressure, pulse, respirations and oxygen saturation (O2 sat) levels and RN #12 notified MD #6 of this medication error. During this phone call, MD #6 identified that Patients #13 and #60 would need to be evaluated at an acute care hospital for any potential adverse drug reaction.

MD #6 arrived on the unit at approximately 8:45 PM. According to clinical record review and interview with MD #6 on 2/6/17 at 1:00 PM, MD #6 discussed the medication error with nursing staff in an attempt to identify who received the medications. Patient #13 who was in his/her bedroom when MD #6 assessed the patient as being more sedated than baseline. Patient #60 was in the unit hallway and assessed by MD #6 as alert. Staff requested 2 ambulances for transport and MD #6 assisted in completing discharge paperwork. During this time, the nursing supervisor (RN #3) was on the unit and requested that staff obtain vital signs. Vital signs for Patient #13 were obtained at 8:15 PM (Blood pressure 104/70, pulse 75, respirations 18, O2 sat 94%); 8:30 PM (blood pressure 94/60, pulse 68), 9:00 PM (blood pressure 124/84, pulse 70, respirations 16, O2 sat 88%); and again prior to 9:46 PM (blood pressure 60/40, 47, pulse 16, O2 sat 82%, blood glucose 136, mental status more sleepy). At 9:46 PM, Patient #13 was identified as obtunded and a medical emergency was called. Oxygen was administered at 15 liters with an O2 sat increase to 98%. Review of the clinical record failed to identify that mental status changes and/or other physical assessments were performed or documented.

Emergency Medical Responders arrived at 9:50 PM and Patient #13 was transported to an acute care hospital. On arrival at the acute care hospital, Patient #13 was diagnosed with medication toxicity and was placed on a ventilator for breathing assistance. Following treatment in the ICU Patient #13 recovered and returned to the facility.

Interview with RN #3 on 2/6/17 at 11:45 AM identified that prior to 9:30 PM he/she observed Patient #13 in bed, dentures had fallen out of the patient's mouth, and the patient was difficult to arouse. Vital signs were obtained and MD #6 was called to the room to re-assess the patient. Oxygen was administered and when Patient #13 was moved to a sitting position in the bed, Patient #13 vomited. RN #3 identified that he/she was not aware of the type or strength of medications that Patient #13 or Patient #60 may have been administered. RN #3 identified that had he/she known, Patients #13 and #60 would have been sent out (to the hospital) sooner.

Review of Patient #60's clinical record identified that on 11/1/16 between 8:00 PM and 10:00 PM, the patient was monitored and vital signs were stable. Patient #60 was evaluated at an acute care hospital, showed no signs of receiving the wrong medications, and returned to the facility without incident.

Following the 8:00 PM medication error, RN #10 proceeded to administer the remaining pre-prepared medications to the remaining 18 patients on the unit without evidence that the remaining 18 pre-prepared medications were checked for accuracy.

Surveyor observations made between 1/30/17 and 2/2/17 identified that medications were pre-prepared in advance of medication administration on multiple patient care units. The hospital policy for medication management identified that medication packets were to be placed in a medication cup and the cup placed in a labeled medication tray. The policy also identified that at the time of medication administration, staff would identify the correct patient by using 2 forms of identification (name and photograph) and check the medication and kardex for the correct medication, correct dosage, correct time, correct route, and discontinuance of an order.

The Condition of Participation for Patient Rights has not been met. Based on clinical record review, observations, interviews with staff, and review of hospital documentation for 1 of 3 patients reviewed for safe medication administration (Patient #13), the hospital failed to ensure that the patient received care in a safe setting when nursing staff failed to ensure that the right patient received the correct medications, resulting in a finding of Immediate Jeopardy.


Please refer to A144

1. Based on clinical record review, observations, interviews with staff, and review of hospital documentation for 1 of 3 patients reviewed for safe medication administration (Patient #13), the hospital failed to ensure that the patient received care in a safe setting when nursing staff failed to ensure that the right patient received the correct medications, resulting in a finding of Immediate Jeopardy. The findings include:


Patient #57 was admitted with diagnoses of schizophrenia, hypertension, and Type II diabetes. Patient #57's 8:00 PM scheduled oral medications were identified as Clozaril 525 mg, Depakote 1,500 mg, Valium 10 mg, Metformin 850 mg, Vasotec 20 mg, Haldol 7.5 mg, Inderal 40 mg, Cogentin 1 mg, Lipitor 40 mg, Colace 200 mg, Senna 2 tabs, and Miralax 17 gm's.

RN #10 was on duty on 11/1/16 on the evening shift, had floated from another unit to DS2, and was responsible for administering evening medications to all patients on DS2 (21 patients). In accordance with nursing practice at this hospital, RN #10 had pre-prepared (pre-poured) all evening medications for every patient prior to the 8:00 PM medication pass. Each patient's prepackaged labeled unit dose medications were retrieved from an electronic medication dispensing system, placed in a medication cup, and placed on a tray in alphabetical order with a corresponding label with the patient's name and date of birth.

On 11/1/16 at approximately 8:00 PM, Patient #57 presented to the medication administration room requesting his/her evening medications. At that time, RN #10 identified that Patient #57's medication card was there but the medications were not. RN #10 identified that 2 patients (Patients #13 and #60) had already received medications and it was presumed that one of those patients received Patient #57's medications in error. Interview with RN #10 on 2/1/17 at 3:02 PM identified that RN #10 was unable to determine with certainty who received Patient #57's medications. In addition, RN #10 could not recall when in the medication administration process he/she signed the medication kardex for Patient's #13, #57 and #60.

Patient #13 was admitted with diagnoses of impulse control disorder and mild intellectual disabilities. Standing evening medications included Metformin 1,000 mg, Vasotec 5 mg, Zetia 10 mg, Clonazepam 1.0 mg, and Trazadone 100 mg.

Patient #60 was admitted with diagnoses of paranoid schizophrenia and left cerebral vascular accident (CVA) with aphasia. Standing evening medications included Ezetemibe 10 mg, Atrovastatin 40 mg and Coreg 3.125 mg.

Once RN #10 realized that either Patient #13 or Patient #60 received Patient #57's medications, he/she notified the Head Nurse (RN #12). Staff obtained the vital signs of Patients #13 and #60, which included blood pressure, pulse, respirations and oxygen saturation (O2 sat) levels and RN #12 notified MD #6 of this medication error. During this phone call, MD #6 identified that Patients #13 and #60 would need to be evaluated at an acute care hospital for any potential adverse drug reaction.

MD #6 arrived on the unit at approximately 8:45 PM. According to clinical record review and interview with MD #6 on 2/6/17 at 1:00 PM, MD #6 discussed the medication error with nursing staff in an attempt to identify who received the medications. Patient #13 who was in his/her bedroom when MD #6 assessed the patient as being more sedated than baseline. Patient #60 was in the unit hallway and assessed by MD #6 as alert. Staff requested 2 ambulances for transport and MD #6 assisted in completing discharge paperwork. During this time, the nursing supervisor (RN #3) was on the unit and requested that staff obtain vital signs. Vital signs for Patient #13 were obtained at 8:15 PM (Blood pressure 104/70, pulse 75, respirations 18, O2 sat 94%); 8:30 PM (blood pressure 94/60, pulse 68), 9:00 PM (blood pressure 124/84, pulse 70, respirations 16, O2 sat 88%); and again prior to 9:46 PM (blood pressure 60/40, 47, pulse 16, O2 sat 82%, blood glucose 136, mental status more sleepy). At 9:46 PM, Patient #13 was identified as obtunded and a medical emergency was called. Oxygen was administered at 15 liters with an O2 sat increase to 98%. Review of the clinical record failed to identify that mental status changes and/or other physical assessments were performed or documented.

Emergency Medical Responders arrived at 9:50 PM and Patient #13 was transported to an acute care hospital. On arrival at the acute care hospital, Patient #13 was diagnosed with medication toxicity and was placed on a ventilator for breathing assistance. Following treatment in the ICU Patient #13 recovered and returned to the facility.

Interview with RN #3 on 2/6/17 at 11:45 AM identified that prior to 9:30 PM he/she observed Patient #13 in bed, dentures had fallen out of the patient's mouth, and the patient was difficult to arouse. Vital signs were obtained and MD #6 was called to the room to re-assess the patient. Oxygen was administered and when Patient #13 was moved to a sitting position in the bed, Patient #13 vomited. RN #3 identified that he/she was not aware of the type or strength of medications that Patient #13 or Patient #60 may have been administered. RN #3 identified that had he/she known, Patients #13 and #60 would have been sent out (to the hospital) sooner.

Review of Patient #60's clinical record identified that on 11/1/16 between 8:00 PM and 10:00 PM, the patient was monitored and vital signs were stable. Patient #60 was evaluated at an acute care hospital, showed no signs of receiving the wrong medications, and returned to the facility without incident.

Following the 8:00 PM medication error, RN #10 proceeded to administer the remaining pre-prepared medications to the remaining 18 patients on the unit without evidence that the remaining 18 pre-prepared medications were checked for accuracy.

Surveyor observations made between 1/30/17 and 2/2/17 identified that medications were pre-prepared in advance of medication administration on multiple patient care units. The hospital policy for medication management identified that medication packets were to be placed in a medication cup and the cup placed in a labeled medication tray. The policy also identified that at the time of medication administration, staff would identify the correct patient by using 2 forms of identification (name and photograph) and check the medication and kardex for the correct medication, correct dosage, correct time, correct route, and discontinuance of an order.



29049

2. Based on an observation of dining and staff interviews, the facility failed to ascertain utensils were accounted for to ensure patients were cared for in a safe setting. The finding included:


Observation of dining on 2/2/17 at 11:30 AM in a common area where patients were being served lunch cafeteria style it was noted that three individual plastic canisters contained utensils, one with forks, one with knives and one with spoons. Each patient had access to the individual canisters when going through the line and removed the utensils they preferred. It was noted that eight patients were being observed by MHA #4. Multiple patients had a different number and type of utensils. Interview with MHA #4 indicated although she did not write it down or conduct the count formerly she memorized every utensil each patient had in her area and ensured that each utensil was disposed of prior to re-entering the patient care unit in a psychiatric setting. Further interview with MHA #4 indicated the hospital did not have a policy for this procedure it was just a practice that was followed when observing dining.

Based on observations, interview with facility staff and review of policy and procedures, the facility failed to ensure that patients were free from verbal abuse. The findings include:



Observations on 1/31/17 with DNS #3 at 11:30 A.M. identified a group of patients standing in the doorway of the lounge. Included in the group was Registered Nurse (RN) #9. Further observation identified and heard RN #9 speaking to a patient and was heard to state to the patient "you have a big mouth". During an interview with DNS #3, she stated that RN #9 was kidding with the patient, however at the same time, RN # 9 approached DNS #3 and stated in part that he was "sick of all of this after thirty one years" and spoke further of his frustration. DNS # 3 stated that a fitness for duty assessment and investigation would be conducted immediately to ascertain RN #9's ability to work.


Review of the Assessment and Reporting of Victims of Abuse, Neglect or Exploitation policy and procedure identified that every patient has a right to be free from verbal, physical, sexual, and emotional abuse, neglect and exploitation.

The Condition of Participation for QAPI has not been met. The hospital QAPI program failed to ensure that safe medication practices were followed and failed to ensure timely corrective measures were taken to ensure that medications were safely administered to patients throughout the hospital campus. Based on clinical record review, observations, interviews with staff, and review of hospital documentation for 1 of 3 patients reviewed for safe medication administration (Patient #13), the hospital failed to ensure that right patient received the correct medications resulting in a finding of Immediate Jeopardy.

Please refer to A286

Based on clinical record review, interviews with staff, and review of hospital documentation, the hospital QAPI program failed to ensure that safe medication practices were included in the hospital wide QAPI efforts to ensure timely corrective measures were taken when it was identified that for 1 of 3 patients reviewed for safe medication administration (Patient #13), the hospital failed to ensure that right patient received the correct medications, resulting in a finding of Immediate Jeopardy. The findings include:


Review of QAPI meeting minutes and/or documentation review between 11/1/16 and 2/6/17 failed to identify that the circumstances of a significant medication error that occurred on 11/1/16 was included in the hospital's QAPI program to measure, analyze and track adverse patient events to affect timely measurable improvements to reduce errors to include the hospital's practice of pre-preparing patient medications. Surveyor observations made between 1/30/17 and 2/2/17 identified that medications continued to be pre-prepared in advance of medication administration on multiple patient care units. The hospital policy for medication management continued to identify the practice of pre-preparing patient medications.

Patient #57 was admitted with diagnoses of schizophrenia, hypertension, and Type II diabetes. Patient #57's 8:00 PM scheduled oral medications were identified as Clozaril 525 mg, Depakote 1,500 mg, Valium 10 mg, Metformin 850 mg, Vasotec 20 mg, Haldol 7.5 mg, Inderal 40 mg, Cogentin 1 mg, Lipitor 40 mg, Colace 200 mg, Senna 2 tabs, and Miralax 17 gm's.

RN #10 was on duty on 11/1/16 on the evening shift, had floated from another unit to DS2, and was responsible for administering evening medications to all patients on DS2 (21 patients). In accordance with nursing practice at this hospital, RN #10 had pre-prepared (pre-poured) all evening medications for every patient prior to the 8:00 PM medication pass. Each patient's prepackaged labeled unit dose medications were retrieved from an electronic medication dispensing system, placed in a medication cup, and placed on a tray in alphabetical order with a corresponding label with the patient's name and date of birth.

On 11/1/16 at approximately 8:00 PM, Patient #57 presented to the medication administration room requesting his/her evening medications. At that time, RN #10 identified that Patient #57's medication card was there but the medications were not. RN #10 identified that 2 patients (Patients #13 and #60) had already received medications and it was presumed that one of those patients received Patient #57's medications in error. Interview with RN #10 on 2/1/17 at 3:02 PM identified that RN #10 was unable to determine with certainty who received Patient #57's medications. In addition, RN #10 could not recall when in the medication administration process he/she signed the medication kardex for Patient's #13, #57 and #60.

Patient #13 was admitted with diagnoses of impulse control disorder and mild intellectual disabilities. Standing evening medications included Metformin 1,000 mg, Vasotec 5 mg, Zetia 10 mg, Clonazepam 1.0 mg, and Trazadone 100 mg.

Patient #60 was admitted with diagnoses of paranoid schizophrenia and left cerebral vascular accident (CVA) with aphasia. Standing evening medications included Ezetemibe 10 mg, Atrovastatin 40 mg and Coreg 3.125 mg.

Once RN #10 realized that either Patient #13 or Patient #60 received Patient #57's medications, he/she notified the Head Nurse (RN #12). Staff obtained the vital signs of Patients #13 and #60, which included blood pressure, pulse, respirations and oxygen saturation (O2 sat) levels and RN #12 notified MD #6 of this medication error. During this phone call, MD #6 identified that Patients #13 and #60 would need to be evaluated at an acute care hospital for any potential adverse drug reaction.

MD #6 arrived on the unit at approximately 8:45 PM. According to clinical record review and interview with MD #6 on 2/6/17 at 1:00 PM, MD #6 discussed the medication error with nursing staff in an attempt to identify who received the medications. Patient #13 who was in his/her bedroom when MD #6 assessed the patient as being more sedated than baseline. Patient #60 was in the unit hallway and assessed by MD #6 as alert. Staff requested 2 ambulances for transport and MD #6 assisted in completing discharge paperwork. During this time, the nursing supervisor (RN #3) was on the unit and requested that staff obtain vital signs. Vital signs for Patient #13 were obtained at 8:15 PM (Blood pressure 104/70, pulse 75, respirations 18, O2 sat 94%); 8:30 PM (blood pressure 94/60, pulse 68), 9:00 PM (blood pressure 124/84, pulse 70, respirations 16, O2 sat 88%); and again prior to 9:46 PM (blood pressure 60/40, 47, pulse 16, O2 sat 82%, blood glucose 136, mental status more sleepy). At 9:46 PM, Patient #13 was identified as obtunded and a medical emergency was called. Oxygen was administered at 15 liters with an O2 sat increase to 98%. Review of the clinical record failed to identify that mental status changes and/or other physical assessments were performed or documented.

Emergency Medical Responders arrived at 9:50 PM and Patient #13 was transported to an acute care hospital. On arrival at the acute care hospital, Patient #13 was diagnosed with medication toxicity and was placed on a ventilator for breathing assistance. Following treatment in the ICU Patient #13 recovered and returned to the facility.

Interview with RN #3 on 2/6/17 at 11:45 AM identified that prior to 9:30 PM he/she observed Patient #13 in bed, dentures had fallen out of the patient's mouth, and the patient was difficult to arouse. Vital signs were obtained and MD #6 was called to the room to re-assess the patient. Oxygen was administered and when Patient #13 was moved to a sitting position in the bed, Patient #13 vomited. RN #3 identified that he/she was not aware of the type or strength of medications that Patient #13 or Patient #60 may have been administered. RN #3 identified that had he/she known, Patients #13 and #60 would have been sent out (to the hospital) sooner.

Review of Patient #60's clinical record identified that on 11/1/16 between 8:00 PM and 10:00 PM, the patient was monitored and vital signs were stable. Patient #60 was evaluated at an acute care hospital, showed no signs of receiving the wrong medications, and returned to the facility without incident.

Following the 8:00 PM medication error, RN #10 proceeded to administer the remaining pre-prepared medications to the remaining 18 patients on the unit without evidence that the remaining 18 pre-prepared medications were checked for accuracy.

Surveyor observations made between 1/30/17 and 2/2/17 identified that medications were pre-prepared in advance of medication administration on multiple patient care units. The hospital policy for medication management identified that medication packets were to be placed in a medication cup and the cup placed in a labeled medication tray. The policy also identified that at the time of medication administration, staff would identify the correct patient by using 2 forms of identification (name and photograph) and check the medication and kardex for the correct medication, correct dosage, correct time, correct route, and discontinuance of an order.

Based on a review of clinical records, staff interviews, and policy review for one of three patients reviewed for oxygen (O2) orders, (Patient #B2N10), the hospital failed to ensure that physician orders for oxygen therapy included titration parameters. The findings include:

a. Patient #B2N10's diagnoses included COPD. The monthly integrated treatment plan dated 1/26/17 identified that the Patient will utilize O2 therapy as prescribed to maintain O2 level above 90% and documentation will be found in the nursing notes. Physician orders initiated on and dated 12/22/16 directed O2 at 1-4 liters/minute titrate as needed to keep O2 saturations > 90%. The order failed to reflect parameters for the titration of the Oxygen. An additional physician's order initiated on and dated 12/22/16 directed O2 saturation levels every shift. Observation on 1/31/17 at 10:15 AM noted Patient #B2N10 with O2 via nasal cannula at 2 liters/minute. Interview with the B2N Unit Director on 1/31/17 at 10:15 AM identified that he/she believed the Patient was getting O2 at 3 liters/minute.
The hospital O2 policy did not direct O2 titration and/or parameters for titration. The Medical staff rules and regulations identified that all treatment orders will be recorded on the physician's order sheet and the required components.

The Condition of Participation for Nursing Services has not been met. Based on clinical record review, observations, interviews with staff, and review of hospital documentation for 1 of 3 patients reviewed for safe medication administration (Patient #13), nursing staff failed to ensure that the right patient received the correct medications, resulting in a finding of Immediate Jeopardy.

Please refer to A405

1. Based on a review of clinical records and staff interviews for two of two sampled patients reviewed for nursing assessment (Patient #16 and #23), the hospital failed to assess withdrawal symptoms every four hours in accordance with the physician's orders. The findings included:


a. Review of the clinical record identified Patient #16 was admitted to the hospital on 1/24/17 with diagnoses that included alcohol, cannabis and cocaine dependence. Physician orders dated 1/24/17 directed Lorazepam 1 milligram (mg) orally every four hours as needed for signs and symptoms of alcohol withdrawal for the first twenty-four hours. Physician's orders dated 1/25/17 directed Lorazepam 1 mg orally at 12:00 PM, 4:00 PM and 10:00 PM and on 1/26/17 Lorazepam 1 mg orally at 9:00 AM, 12:00 PM and 10:00 PM. Review of the nurses notes dated 1/24/17 through 1/26/17 failed to identify a comprehensive alcohol withdrawal assessment was conducted on eight (8) out of ten (10) occasions.


b. Review of the clinical record identified Patient #23 was admitted to the hospital on 1/23/17 with diagnoses that included alcohol dependence. Physician's orders dated 1/23/17 directed Lorazepam 1 milligram (mg) orally every four hours as needed for signs and symptoms of alcohol withdrawal for the first twenty four hours. Physician's orders dated 1/24/17 directed Lorazepam 1 milligram (mg) orally at 12:00 PM, 4:00 PM and 10:00 PM and on 1/25/17 at 9:00 AM 12:00 PM and 10:00 PM. Review of the nurses notes dated 1/23/17 through 1/25/17 failed to identify a comprehensive alcohol withdrawal assessment was conducted on seven (7) of nine (9) occasions.

Interview with Head Nurse #3 on 1/30/17 at 11:00 AM indicated a comprehensive alcohol withdrawal assessment includes vital signs, nausea, vomiting, tremor, sweating, anxiety, restlessness, hallucinations, headache and change in mentation. Further interview with Head Nurse #3 identified withdrawal symptoms should have been conducted for Patient #16 and #23 and documented prior to each administration of Lorazepam in accordance with the physician's orders and were not.

1. Based on medical record reviews, review of hospital policies and interviews for 1 of 3 patients who utilized oxygen (O2) (Patient #B2N10), the hospital failed to ensure that the treatment plan interventions for the use and monitoring of O2 levels were followed. The finding includes:


a. Patient #B2N10's diagnoses included COPD. The monthly integrated treatment plan dated 1/26/17 identified that the Patient will utilize O2 therapy as prescribed to maintain O2 level above 90% and documentation will be found in the nursing notes. Physician orders initiated on and dated 12/22/16 directed O2 at 1-4 liters/minute titrate as needed to keep O2 saturations > 90%. An additional physician's order initiated on and dated 12/22/16 directed O2 saturation levels every shift (3 times a day). Observation on 1/31/17 at 10:15 AM noted Patient #B2N10 with O2 via nasal cannula at 2 liters/minute. A review of the Patient's record was conducted on 1/31/17 with the B2N Unit Director. The vital sign sheet dated 1/14/17 through 1/30/17 noted that O2 saturation level monitoring was not performed in accordance with the written treatment plan. O2 saturation monitoring was only obtained/documented once on 1/14, 1/15, 1/16, 1/18, 1/19, 1/23 and 1/26/17 and twice on all other days, not every shift as stated in the treatment plan. Interview with the Director of Regulatory Compliance on 2/3/17 at 12:45 PM indicated that the facility had three 8 hour nursing shifts.



2. Based on medical record reviews, review of hospital policies and interviews for 1 of 3 patients who exhibited threatening behaviors and/or behavioral dyscontrol (Patient #39), the hospital failed to ensure that treatment plan interventions related to behaviors were individualized to reflect the patient's specific behavioral needs. The finding includes:


a. Patient #39 was admitted on 9/26/16 and diagnoses included Schizoaffective Disorder, Bipolar Type. The quarterly integrated treatment plan (ITP) dated 1/24/17 identified that the patient had aggressive behaviors, discharge criteria included that the patient will create effective coping skills, and interventions included, in part, music therapy. The monitoring sheets dated 1/31/17 from 3:30 PM to 4:45 PM indicated that Patient #39 was yelling and screaming and the intervention was engagement. The monitoring sheets dated 1/31/17 at 5:00 PM noted that Patient #39 was threatening and throwing a blanket and the intervention was engagement. Observation on 2/1/17 at 10:38 AM identified that there was a "Blue Room" on Patient #39's unit (B4N) with a mattress on the floor and crumpled blanket, washcloth and tissues. Interview with the Unit Director on 2/1/17 at 10:55 AM noted that Patient #39 exhibited threatening behavior on 1/31/17 between 4:00 PM and 4:30 PM, went into the "Blue Room" voluntarily, with the door left opened, and eventually calmed down. He/she further indicated that in the past, the "Blue Room" was utilized successfully by Patient #39 to calm down. Review of Patient #39's record with the Unit Director on 2/1/17 at 10:55 AM identified that the ITP lacked documentation for the use of the "Blue Room" as an effective coping skill and/or intervention for Patient #39.



3. Based on review of clinical records, review of hospital policy, review of hospital documentation and interviews with hospital personnel for 1 (Patient #20) of 3 patients identified at risk for aspiration and/or choking, documentation and interviews failed to reflect that the patient was given the proper diet as per physician order and the plan of care. The findings include:


Patient #20 was admitted to the facility on 10/29/92 with diagnoses that included schizoaffective disorder, bipolar type and major vascular neurocognitive disorder. Review of the patient's Integrated Treatment Plan dated 1/4/17 identified that the patient was at risk for aspiration and that the patient would demonstrate cooperation with dietary restrictions. A Physician Order dated 1/10/17 directed in part, a low potassium diet; pureed consistency with nectar thick liquids; 1:1 supervision with all meals; upright 90 degrees as tolerated; aspiration precautions. During tour of the W1S unit on 1/30/17, an observation was made of Patient #20 who was being fed by MHA #1. The macaroni and cheese on the patient's tray had been partially eaten. Review of hospital documentation and interview with the Unit Director on 1/30/17 identified that the macaroni and cheese should not have been on the tray or it should have been pureed in a blender.



4. Based on a review of clinical records, staff interviews and a review of hospital policies and procedures for one of 3 patients reviewed on constant observation (Patient #52), the facility failed to prevent a foreign body from being ingested and/or inserted into a body cavity while constantly supervised by staff in accordance with the plan of care. The finding included:


Review of the clinical record identified Patient #52 was admitted to the hospital on 3/6/13 with diagnoses that included bipolar disorder, borderline personality disorder and an extensive history of foreign body ingestion and insertion. The multidisciplinary treatment plan dated 12/28/16 identified ingesting and inserting foreign bodies into internal cavities as a problem with interventions that included continuous observation, brief and casual conversations with a family member, stuffed animals, breathing techniques, cool and warm compresses, aromatic scents, soft music, watching movies, television, yoga and meditation. Physician's orders dated 1/21/17 directed constant observation for the protection of self and others for behaviors that included swallowing of objects such as pens and paper clips, assaulting staff, head banging or insertion of objects into internal body parts, the mouth or skin. Physician orders further directed that the patient's hands and face were to be visible at all times and a sitter would be assigned to sit outside of the patient's room for the safety of staff.

Review of the clinical record dated 1/21/16 at approximately 6:30 PM identified Patient #52 was in bed "digging" at his/her rectum complaining of a stomach ache and was taken to the bathroom. Further review of the clinical record indicated while in the bathroom Patient #52 continued to manipulate his/her rectum and blood was noted. An emergency code was initiated and it was determined that Patient #52 had inserted the lens of his/her eyeglasses into his/her rectum. Patient #52 was transferred to Hospital #2 on 1/21/17 at approximately 7:30 PM. Review of the hospital documentation from Hospital #2 identified Patient #52 broke the temporal sides of his/her eyeglasses and swallowed both pieces then the patient took apart the framework and inserted the glass lens into his/her rectum. Imaging was conducted that identified evidence of a foreign body in the stomach. Further review of the hospital documentation from Hospital #2 indicated that due to the patients rectal bleeding and concerns of tearing and perforation the patient required further surgical evaluation and was transferred to an alternate hospital for tertiary care on 1/22/17. Review of the hospital documentation from Hospital #3 identified the lenses from the patient's rectum was manually removed in the Emergency Department and the glass frames were removed by the department of gastroenterology via an esophagogastroduodenoscopy. Patient #52 was transferred back to Hospital #1 on 1/23/17.

Interview with MHA #5 on 2/5/17 at 10:00 AM identified she was responsible for constant observation of Patient #52 on 1/21/17 from 5:15 PM-6:15 PM. MHA #5 indicated at 6:15 PM when she handed off her assignment to LPN #1 Patient #52 was standing in the hallway after returning from the bathroom with her eyeglasses intact and on his/her face.

Interview with LPN #1 on 2/2/17 at 1:30 PM indicated at approximately 6:15 PM she received Patient #52 in his/her bed absent eyeglasses with his/her hands under the bed covers. LPN #1 identified she directed the patient to remove his/her hands from under the bed covers however the patient did not comply. LPN #1 indicated Patient #52 jumped out of bed and ran to the bathroom. LPN #1 called for assistance and the patient was escorted into the bathroom tugging at his/her rectum, blood was identified and the emergency code was initiated.

Interview with Nursing Supervisor #3 on 2/2/17 indicated the hospital had not completed the investigation however revised the plan of care on 1/23/17 when the patient returned to the facility.

The hospital policy entitled special observation directed in part that continuous observation is implemented when the patient requires ongoing monitoring to ensure his/her safety and/or the safety of others. The nursing staff assigned ensures a clear view and unimpeded access to the patient at all times.

The hospital policy entitled Integrated Treatment Planning Process directed in part the treatment plan was interdisciplinary and would be consistent with recovery principles. The nursing plan of care would list key information and services for nursing staff related to the psychiatric and medical care of the individual. This may include specific prompts related to treatment approaches and individual triggers including psychiatric and medical treatment interventions required by the individual. The treatment plan is reviewed on a regular basis to ensure the effectiveness of the individual receiving care. Any new risk identified or other reasons for a review would be considered by the team. The team reviews the treatment plan achievement of goals and objectives, and progress towards discharge criteria with the individual.



5. Based on review of the clinical record, interview with staff and review of policy and procedures for one of 3 patients reviewed for the use of seclusion (Patient #15), the facility failed to ensure that the treatment plan was comprehensive to identify coping strategies, techniques or methods that assist patients in maintaining control. The findings include:

Patient #15 was admitted on 12/15/16 with diagnoses that included schizoaffective disorder.

Review of restraint/seclusion records from 12/19/16 through 1/24/17 identified that on eight occasions, restraint and/or seclusion had been applied to Patient #15 for the imminent risk of physical assault to staff or patients. Five of those eight episodes resulted in four point restraints for a period that ranged from twenty eight minutes to one hour and fifty five minutes the patient with the remaining three resulting in seclusion, although it is not clear in the restraint/seclusion records why four point restraints are selected. Therapeutic interventions included re-direction, providing emotional support, watching television, voluntary time out, and talking to staff.

Although integrated treatment plans dated 1/4/17 and 1/18/17, indicated that Patient #15 is able to participate in patient education, preferred methods of de-escalation have not been identified. Additionally, review of integrated treatment plans dated 1/11 and 1/25/17 also failed to identify that de-escalation methods had not been reviewed with Patient #15.

Although review of the Restraint Use for the Management of Violent or Self Destructive Behavior policy and procedure directed, prior to the initiation of restraint, therapeutic interventions are employed considering patient specific triggers as a means to help the patient regain control of his/her behavior, review of the clinical record failed to identify specific triggers for Patient #15 had been identified to assist in de-escalation.



29049

1. Based on clinical record review, observations, interviews with staff, and review of hospital documentation for 1 of 3 patients reviewed for safe medication administration (Patient #13), nursing staff failed to ensure that the right patient received the correct medications, resulting in a finding of Immediate Jeopardy. The findings include:


Patient #57 was admitted with diagnoses of schizophrenia, hypertension, and Type II diabetes. Patient #57's 8:00 PM scheduled oral medications were identified as Clozaril 525 mg, Depakote 1,500 mg, Valium 10 mg, Metformin 850 mg, Vasotec 20 mg, Haldol 7.5 mg, Inderal 40 mg, Cogentin 1 mg, Lipitor 40 mg, Colace 200 mg, Senna 2 tabs, and Miralax 17 gm's.

RN #10 was on duty on 11/1/16 on the evening shift, had floated from another unit to DS2, and was responsible for administering evening medications to all patients on DS2 (21 patients). In accordance with nursing practice at this hospital, RN #10 had pre-prepared (pre-poured) all evening medications for every patient prior to the 8:00 PM medication pass. Each patient's prepackaged labeled unit dose medications were retrieved from an electronic medication dispensing system, placed in a medication cup, and placed on a tray in alphabetical order with a corresponding label with the patient's name and date of birth.

On 11/1/16 at approximately 8:00 PM, Patient #57 presented to the medication administration room requesting his/her evening medications. At that time, RN #10 identified that Patient #57's medication card was there but the medications were not. RN #10 identified that 2 patients (Patients #13 and #60) had already received medications and it was presumed that one of those patients received Patient #57's medications in error. Interview with RN #10 on 2/1/17 at 3:02 PM identified that RN #10 was unable to determine with certainty who received Patient #57's medications. In addition, RN #10 could not recall when in the medication administration process he/she reviewed and/or signed the medication kardex for Patient's #13, #57 and #60.

Patient #13 was admitted with diagnoses of impulse control disorder and mild intellectual disabilities. Standing evening medications included Metformin 1,000 mg, Vasotec 5 mg, Zetia 10 mg, Clonazepam 1.0 mg, and Trazadone 100 mg.

Patient #60 was admitted with diagnoses of paranoid schizophrenia and left cerebral vascular accident (CVA) with aphasia. Standing evening medications included Ezetemibe 10 mg, Atrovastatin 40 mg and Coreg 3.125 mg.

Once RN #10 realized that either Patient #13 or Patient #60 received Patient #57's medications, he/she notified the Head Nurse (RN #12). Staff obtained the vital signs of Patients #13 and #60, which included blood pressure, pulse, respirations and oxygen saturation (O2 sat) levels and RN #12 notified MD #6 of this medication error. During this phone call, MD #6 identified that Patients #13 and #60 would need to be evaluated at an acute care hospital for any potential adverse drug reaction.

MD #6 arrived on the unit at approximately 8:45 PM. According to clinical record review and interview with MD #6 on 2/6/17 at 1:00 PM, MD #6 discussed the medication error with nursing staff in an attempt to identify who received the medications. Patient #13 who was in his/her bedroom when MD #6 assessed the patient as being more sedated than baseline. Patient #60 was in the unit hallway and assessed by MD #6 as alert. Staff requested 2 ambulances for transport and MD #6 assisted in completing discharge paperwork. During this time, the nursing supervisor (RN #3) was on the unit and requested that staff obtain vital signs. Vital signs for Patient #13 were obtained at 8:15 PM (Blood pressure 104/70, pulse 75, respirations 18, O2 sat 94%); 8:30 PM (blood pressure 94/60, pulse 68), 9:00 PM (blood pressure 124/84, pulse 70, respirations 16, O2 sat 88%); and again prior to 9:46 PM (blood pressure 60/40, 47, pulse 16, O2 sat 82%, blood glucose 136, mental status more sleepy). At 9:46 PM, Patient #13 was identified as obtunded and a medical emergency was called. Oxygen was administered at 15 liters with an O2 sat increase to 98%. Review of the clinical record failed to identify that mental status changes and/or other physical assessments were performed or documented.

Emergency Medical Responders arrived at 9:50 PM and Patient #13 was transported to an acute care hospital. On arrival at the acute care hospital, Patient #13 was diagnosed with medication toxicity and was placed on a ventilator for breathing assistance. Following treatment in the ICU Patient #13 recovered and returned to the facility.

Interview with RN #3 on 2/6/17 at 11:45 AM identified that prior to 9:30 PM he/she observed Patient #13 in bed, dentures had fallen out of the patient's mouth, and the patient was difficult to arouse. Vital signs were obtained and MD #6 was called to the room to re-assess the patient. Oxygen was administered and when Patient #13 was moved to a sitting position in the bed, Patient #13 vomited. RN #3 identified that he/she was not aware of the type or strength of medications that Patient #13 or Patient #60 may have been administered. RN #3 identified that had he/she known, Patients #13 and #60 would have been sent out (to the hospital) sooner.

Review of Patient #60's clinical record identified that on 11/1/16 between 8:00 PM and 10:00 PM, the patient was monitored and vital signs were stable. Patient #60 was evaluated at an acute care hospital, showed no signs of receiving the wrong medications, and returned to the facility without incident.

Following the 8:00 PM medication error, RN #10 proceeded to administer the remaining pre-prepared medications to the remaining 18 patients on the unit without evidence that the remaining 18 pre-prepared medications were checked for accuracy.

Surveyor observations made between 1/30/17 and 2/2/17 identified that medications were pre-prepared in advance of medication administration on multiple patient care units. The hospital policy for medication management identified that medication packets were to be placed in a medication cup and the cup placed in a labeled medication tray. The policy also identified that at the time of medication administration, staff would identify the correct patient by using 2 forms of identification (name and photograph) and check the medication and kardex for the correct medication, correct dosage, correct time, correct route, and discontinuance of an order.




2. Based on review of the clinical record, review of facility policy and procedures and interviews with facility for one of 3 patients reviewed for medication administration (Patient #42), the facility failed to ensure that medication was administered in accordance with facility policy and procedure. The findings include:


Patient # 42 was admitted to the facility with diagnoses that included severe depression, anxiety and suicidal ideation. A physician order dated 1/20/17 directed Metformin 500 milligrams every 8:00 AM and every 5:00 PM. A special observation review/assessment conducted 1/20/17 identified that the patient remains hopeless, helpless and is having suicidal ideations. Review of nursing and physician progress notes dated 1/27/17 characterized the patient as remaining on continuous observation for self-harm and it was identified the patient had taken Metformin and hid it on his/her person. Further review of the progress notes identified that the patient indicated s/he "hid it to see if I could get away with it".


During an interview with Director of Nurses #3 on 1/30/17 at 2:00 PM, s/he stated that it is the expectation that mouth checks are done after medication administration to ensure that medications are swallowed.
Review of the policy and procedure for Medication Management identified in part, ensure that the patient has properly taken the medication. Whiting: a nursing staff member will instruct the patient to open his/her mouth to verify that the medication has been swallowed.

Based on medical record reviews, review of facility policies and interviews the facility failed to maintain accurate and/or complete records for 1 of 3 patients. The finding includes:


a. Patient #B2N10's diagnoses included COPD. The monthly integrated treatment plan dated 1/26/17 identified that the Patient will utilize O2 therapy as prescribed to maintain O2 level above 90% and documentation will be found in the nursing notes. Physician orders initiated on and dated 12/22/16 directed O2 at 1-4 liters/minute titrate as needed to keep O2 saturations > 90%. The order failed to reflect parameters for the titration of the Oxygen. An additional physician's order initiated on and dated 12/22/16 directed O2 saturation levels every shift. The vital sign sheet dated 1/14/17 through 1/30/17 indicated that although documentation of O2 saturation levels that were performed, the amount of O2 the patient received at the time the level was obtained was only documented three times (2 liters/minute on 1/17, 1/18, and 1/20/17). Observation on 1/31/17 at 10:15 AM noted Patient #B2N10 with O2 via nasal cannula at 2liters/minute. Interview with the B2N Unit Director on 1/31/17 at 10:35 AM noted that flow rate of the O2 was not consistently documented. The facility medical record policy identified medical records are maintained in compliance with current existing standards which include all medical records are complete.


b. In addition, Patient #B2N10's physician's order initiated on and dated 12/22/16 directed O2 saturation levels every shift (3 times a day). Observation on 1/31/17 at 10:15 AM noted Patient #B2N10 with O2 via nasal cannula at 2 liters/minute. A review of the Patient's record was conducted on 1/31/17 with the B2N Unit Director. The vital sign sheet dated 1/14/17 through 1/30/17 noted that O2 saturation level monitoring was not performed in accordance with the written treatment plan. O2 saturation monitoring was only obtained/documented once on 1/14, 1/15, 1/16, 1/18, 1/19, 1/23 and 1/26/17 and twice on all other days, not every shift as stated in the treatment plan. Interview with the Director of Regulatory Compliance on 2/3/17 at 12:45 PM indicated that the facility had three 8 hour nursing shifts.


c. In addition, Patient #B2N10's diagnoses included Schizophrenia. The monthly integrated treatment plan (ITP) identified that staff would encourage to attend recommended treatment groups. Group notes dated 1/23/17 through 1/27/17 identified that the patient attended a cognitive orientation group on 1/25/17 on the day shift. The Engagement progress note dated 1/25/17 at 8:30 AM indicated that the Patient participated in community meeting. Although the engagement note dated 1/25/17 at 7:00 PM identified that the patient attended a group activity, the note lacked the specific group activity that the patient attended. Interview the Unit Director on 1/31/17 at 10:38 AM noted that he/she did not know which group the patient attended as there were two groups held on the evening shift for 1/25/17. The facility policy for documentation of patient progress and care identified that a progress note should be completed after each individual or group intervention.

Based on medical record reviews, review of facility policies and interviews for two of six patients who resided on the Batell psychiatric units (Patients #B2S4 and #39), the facility failed to ensure that nursing and/or physician documentation was complete and/or accurate. The finding includes:


a. Patient # B2S4 was readmitted to the B2S unit on 1/18/17 and diagnoses included sleep apnea and chronic obstructive pulmonary disease. Physician orders dated 1/18/17 directed CPAP (continuous positive airway pressure) when in bed. Nursing narratives incorrectly dated 1/26/17 instead of 1/28/17 identified that the Patient had trouble breathing and was sent to the acute care hospital per the physician orders dated 1/28/17. Undated transfer documentation (W10) to the acute care hospital for 1/28/17 noted the diagnosis of sleep apnea and lacked the treatment for the CPAP. Interview with RN #8 on 1/31/17 at 2:03 PM identified that patient #B2S4 was transferred to the hospital on 1/28/17, the nursing narrative was incorrectly dated 1/26/17 and O2 and CPAP treatment orders should be written on the W10 prior to the Patient's transfer. Subsequently, the Battell readmitting physician spoke with Patient #B2S4 and the CPAP was placed on hold due to the patient's wishes for a repeat sleep study evaluation to ascertain the CPAP requirement(s).
Review of hospital CPAP policy identified that an order for treatment shall be written which includes the mode, pressures, and as applicable the respiratory rate and supplemental oxygen if indicated. The policy entitled Patients Requiring Admission to an Acute Care hospital identified that for admissions to the acute care hospital, the following documentation is required and includes a completed W10. The facility medical records policy identified that medical records are complete and all medical record documentation is legible, authenticated, dated and timed.



b. Patient #39 was admitted on 9/26/16 and diagnoses included Schizoaffective Disorder, Bipolar Type. The quarterly integrated treatment plan (ITP) dated 1/24/17 identified that the patient had aggressive behaviors, discharge criteria included that the patient will create effective coping skills, and interventions included, in part, music therapy. The monitoring sheets dated 1/31/17 from 3:30 PM to 4:45 PM indicated that Patient #39 was yelling and screaming and the intervention was engagement. The monitoring sheets dated 1/31/17 at 5:00 PM noted that Patient #39 was threatening and throwing a blanket and the intervention was engagement. Observation on 2/1/17 at 10:38 AM identified that there was a "Blue Room" on Patient #39's unit (B4N) with a mattress on the floor and crumpled blanket, washcloth and tissues. Interview with the Unit Director on 2/1/17 at 10:55 AM noted that Patient #39 exhibited threatening behavior on 1/31/17 between 4:00 PM and 4:30 PM, went into the "Blue Room" voluntarily, with the door left opened, and eventually calmed down. Review of Patient #39's record and interview with the Unit Director on 2/1/17 at 10:55 AM identified that the Patient's record to include the every 15 minute monitoring sheet lacked documentation for the use of the "Blue Room". He/she indicated that although the patient's use of the Blue Room could be documented in the nurse notes, the use of the Blue Room documented on monitoring sheets was done only if the patient was confined to the Blue Room. The facility medical records policy identified that medical records are complete and all medical record documentation is legible, authenticated, dated and timed.

Based upon a tour of the hospital, the facility failed to ensure that individual patient nutritional needs were met in accordance with recognized dietary practices at the Behavioral Health Nursing Units in the Merritt Building at Connecticut Valley Hospital.

On 02/01/17 at 11:40 AM, the surveyor, while accompanied by the Plant Facility Engineer 2, the Clinical Manager and the Building Manager observed 16 (sixteen) containers of Vital AF 1.2 nutritional supplement with expiration dates of January 1, 2017 printed on them in the Wing 4D Exam Room, and not taken from service or preventing usage.

1. Based upon a tour of the hospital, the facility failed to ensure that the Behavioral Health Nursing Units in the Battel, Woodward, and Dutcher Buildings at Connecticut Valley Hospital were designed and maintained in such a manner as to promote the safety and well-being of patients.

On 01/31/17 - 02/10/17 at 9:00 AM and times throughout the survey, the surveyor, while accompanied by the Plant Facility Engineer 1 and the Plant Facility Engineer 2 observed that the some patient shower rooms, bathrooms and sleeping rooms throughout the Battel, Woodward, and Dutcher Buildings were provided with non- institutional-style, tamper resistant screws/fasteners in the overhead, lighting fixtures and light lens that appeared breakable that posed a potential hanging or potential injury hazard and were not designed or maintained to psychiatric institutional standards or guides; i.e. internal portions of these lamp units shall be properly safeguarded from patients-permanent measures are required to be
applied.



2. Based upon a tour of the hospital, the facility failed to ensure that the Connecticut Valley Hospital Behavioral Health Nursing Units in the Blue Hills Bloomfield building were designed and maintained in such a manner as to promote the safety and well-being of patients.

On 02/02/17 at 9:00 AM and times throughout the survey, the surveyor, while accompanied by the Plant Facility Engineer 1 observed that the windows for the second floor patient rooms were of ordinary glass that appeared breakable, that posed a potential injury hazard and or elopement hazard and were not designed or maintained to psychiatric institutional standards or guides; i.e. no protective glazing or security screens.
The units shall be properly safeguarded from patients-permanent measures are required to be
Applied.



3. Based upon a tour of the hospital, the facility failed to ensure that the Behavioral Health Nursing Units in the Battel Hall building at the Connecticut Valley Hospital were designed and maintained in such a manner as to promote the safety and well-being of patients.

On 01/31/17 at 9:00 AM and times throughout the survey, the surveyor, while accompanied by the Plant Facility Engineer 1 and the Plant Facility Engineer 2 during tour of the nursing units tested the patient antiligature alarms on top of the room walls on the 4th and 3rd floor north and south wings. The patient care staff in the nursing station were observed to be looking for what was sounding i.e. the alarms. The staff when interviewed stated I don't normally work in this building and didn't know what the alarm was. The Plant Facility Engineering staff were present for theses interviews. The Plant Facility staff notified the unit managers of these observations.




27293

4. Based upon a tour of the hospital, the facility failed to ensure that the Behavioral Health Nursing Units in the Merritt Building at Connecticut Valley Hospital were designed and maintained in such a manner as to promote the safety and well-being of patients.

On 02/01/17 at 9:40 AM, the surveyor, while accompanied by the Plant Facility Engineer 2 and the Building Manager observed that the patient shower rooms, bathrooms and sleeping rooms throughout the Merritt Building were provided with non- institutional-style, tamper resistant screws/fasteners in the overhead, lighting fixtures that posed a potential hanging or potential injury hazard and were not designed or maintained to psychiatric institutional standards or guides; i.e. internal portions of these lamp units shall be properly safeguarded from patients-permanent measures are required to be applied.


5. Based on observations with staff, the hospital failed to ensure that the environment was free from ligature points. The findings include:

Observation of the physical therapy department on 1/30/17 at 11:20 AM identified that treatment room #1 had 3 hot pack towels hanging from metal drying arms that were mounted on the wall. The drying arms protruded approximately 10-12 inches from the wall, creating a potential ligature point.
Interview with the Physical Therapy Supervisor on 1/30/17 at 11:20 AM identified that there could be a time when a patient might be left alone in the room during a treatment. The Physical Therapy Supervisor identified that the drying arms would be moved to a non-patient care area.

Based on a tour of the facility, observations and interviews for three of six seclusion and/or restraint rooms located in the Battell building (B2N, B3N), the facility failed to ensure heating units remained functional to control room air temperatures in patient care areas. The finding includes:


A tour of the B2N Unit was conducted on 1/31/17 with Director #2. Observations on 1/31/17 at 10:00 AM identified that both the restraint and seclusion rooms were very cold. Observation with the maintenance staff on 1/31/17 at 11:35 AM noted that the air temperatures in the restraint and seclusion rooms were 48 and 53 degrees Fahrenheit consecutively. Interview with RN #7 on 1/31/17 at 10:00 AM identified that Patient #25 was placed in the seclusion room on 1/28/17. Interview with maintenance staff on 1/31/17 at 11:35 AM indicated that the rooms were heated via coils in the floor and at times the coils would freeze up. Observation on 1/31/17 at 11:40 AM noted that the seclusion room on B3N was very cold. Interview with maintenance staff on 2/1/17 at 9:41 AM identified that a heating motor (Battell building) needed to be replaced and air temperatures were not routinely monitored unless there was a problem. The facility lacked a mechanism for environmental air temperature monitoring to ensure that comfortable temperatures were maintained in rooms used for patient care.

1. Based on a tour of the facility, review of facility practices, observations, interviews, the facility failed to ensure that the seclusion room/blue room (used for multiple patients) was clean on one of six units in the Battell building. The finding includes:


a. A tour of the B4N unit was conducted with the Unit Director on 2/1/17. Observation on 2/1/17 at 10:38 AM identified that the blue room had padded blue walls, a mattress on the floor, and had a crumpled blanket, washcloth and tissues remaining from prior use. Interview with the Unit Director on 2/1/17 at 10:41 AM noted that Patient #39 went into the "Blue Room" voluntarily on the evening shift yesterday and the room should have been cleaned immediately after use by staff. Interview with the Director of Regulatory Compliance on 2/2/17 at 11:19 AM indicated that the seclusion room was cleaned with Virex spray after use. The facility standard of practice for environmental services identified restraint/seclusion rooms be cleaned after use and tree times per week.



2. Based on a tour of the facility, review of facility policies, observations, and interviews, the facility failed to ensure that proper hair coverage was maintained by dietary staff. The finding includes:


a. A tour of the Battell building dietary department was conducted with Director #2 on 2/1/17 at 9:43 AM. Observations identified two female dietary staff in the kitchen area with long hair, hair nets on and hair exposed at the top of the head and/or side of the forehead. Interview with the Head Cook on 2/1/17 at 9:43 AM indicated that he/she also observed the uncovered hair of the two dietary staff members and identified that hair must be covered. The facility policy for dress codes in the kitchen and dining rooms identified that employees with long hair will be required to wear hair net and visor cap.


3. Based on observations, review of hospital policy, review of hospital documentation and interviews with hospital personnel for patients admitted to the Woodward Units, documentation and interviews failed to reflect that medical equipment was stored as per policy. The findings include:


Tours of WN1 and WS1 identified patients' medical equipment that included oxygen canisters, nebulizers, podiatry treatments and dentures were stored in the storage room. The Code carts, dressings and other clean stock items were also located in the storage rooms. A few of the used nebulizer equipment and one of the suction machines were without the benefit of coverage. Review of the Care of Equipment Policy and interview with the Infection Control Nurse on 2/2/17 identified that the equipment should be cleaned as per manufacturer's recommendation, covered and stored for future use.


29049

4. Based on observation and staff interview in the dental clinic, the facility failed to maintain a sanitary environment. The finding included:


During a tour of the dental clinic on 2/1/17 at 1:30 PM identified dental equipment used for impressions, buffer equipment used for dentures and the cabinets on which the equipment was located was pitted and rusted rendering the equipment and/or cabinetry to be properly sanitized. Interview with Dental Hygienist #1 on 2/1/17 at 1:45 PM identified she used Cavi Wipes to clean all the equipment and surfaces and was unaware that rust could not be cleaned thoroughly with the Cavi Wipes. The manufacturer guidelines for the use of Cavi Wipes directed cleaning procedures included: blood and body fluids must be thoroughly cleaned from surfaces and objects before application of the disinfecting towelette. A Cavi Wipe towelette can be used for this purpose. Thoroughly clean each surface with a new Cavi wipe. Repeat use of the product may be required to ensure that the surface remains visibly wet for two minutes.



5. Based on review of the clinical record, interviews with facility staff and observations for one of two patients that utilized respiratory equipment (Patient # 43), the facility failed to ensure that the respiratory equipment was maintained in accordance with infection control practices and principles. The findings include:


Patient #43 was admitted with diagnoses that included paranoid type schizophrenia. Review of a physician order dated 1/12/17 directed Continuous Positive Airway Pressure (CPAP) at 15 centimeters of water via face mask at bedtime. Observations with Director of Nurses (DNS) #3 and Registered Nurse # (Chris) on 1/31/17 at 10:30 A.M., identified Patient #43's CPAP tubing with the mask connected to the tubing was draped across an examination table in the utility room. During an interview with DNS #3 and RN #14 at that time, they stated that it was the responsibility of the night nurse to clean the tubing and mask and properly store it for future use, although RN # 14 could not explain why it had not been done this particular day.


Review of the CPAP Care of Equipment policy and procedure directed that respiratory therapy equipment will be maintain according to current standard guidelines. Cleaning shall be done per the manufactures' instructions. The mask must be washed daily.

Based on clinical record reviews, review of facility policies and procedures, observations and interviews, for 1 of 3 sampled patients who had respiratory treatment orders (Patient #B2S4), the facility failed to ensure that CPAP (continuous positive airway pressure) and/or nebulizer treatment orders were complete. The finding includes:


a. Patient #B2S4's diagnoses included sleep apnea. The physician's order dated 1/18/17 directed CPAP when in bed. The physician's order lacked specific parameters including the amount of oxygen to be utilized. Review of the patient's treatment record and interview with RN #8 on 1/31/17 at 2:08 PM noted that Patient #B2S4 refused to use CPAP. Review of hospital CPAP policy identified that an order for treatment shall be written which includes the mode, pressures, and as applicable the respiratory rate and supplemental oxygen if indicated.


b. Patient #B2S4's diagnoses included chronic obstructive pulmonary disease (COPD). Physician orders dated 1/28/17 at 11:15 AM and 11:30 AM directed to please give Albuterol nebulizer treatment and the order dated 11/28/17 at 2:40 PM directed Albuterol nebulizer treatment every 8 hours as needed for shortness of breath. The respiratory treatment orders lacked the dose of the Albuterol to be administered. Observation of an Albuterol pack on 1/31/17 at 2:03 PM identified an albuterol dose of 2.5mg/3ml. Interview with RN #8 on 1/31/17 at 2:03 PM noted that he/she was unaware if the facility carried more than one Albuterol dosage for nebulizer treatments. Further interview with RN #8 on 1/31/17 at 2:08 PM indicated that he/she spoke with pharmacy (staff) and the facility carries only the 2.5mg/3ml dose of Albuterol. The facility medical staff rules and regulations identified that physician order components include, in part, the name of the medication, form of the medication and dose.

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

1. Provide active treatment, including alternative interventions, for one (1) of 16 active sample patients (B4N-7). Patient B4N-7 was either not emotionally stable to participate in treatment at times or was not motivated to attend all groups s/he was supposed to attend as listed on the unit activity schedule. Although the treatment plan for this patient included several group therapies, the patient regularly and repeatedly did not attend group. According to unit staff, B4N-7 spent many hours isolated in his/her room without any structured activities. B4N-7's non- participation in assigned treatment modalities negates the clinical effectiveness of the patient's treatment goals and objectives, potentially delaying the patient's improvement. (Refer to B125, Section I)

II. Provide structured individual and/or group activities based on patients' needs for four (4) of 11 patient care units (B2N, B2S, B4N and W2S) where active sample patients were housed. This failure hindered patient's participation in active treatment and resulted in patients roaming the wards, sleeping in chairs and idly sitting around on the units. (Refer to B125, Section II)


III. Provide sufficient numbers of structured therapeutic activities after around 3:00 p.m. on weekdays and/or services by professional personnel on weekends (Saturday-Sunday) to meet the needs of the patient population in 14 of 28 Units (B3N, B4N, M4D, B4S, B2N, B2S, W1S, W1N, W2S, W2N, WH2, D1N, D1S and D3S). The majority of treatment measures/activities on weekends were delegated to and conducted by non-professional staff (Mental Health Technicians). These activities were more leisure-oriented, rather than therapeutic treatment based on individualized needs of the patient population. These failures resulted in lack of active treatment for patients in these units. (Refer to B125, Section III)

Based on document review and interview, the facility failed to assess and estimate memory functioning in a sufficiently descriptive manner to establish baseline parameters for two (2) of 16 active sample patients (WH6-15 and B2S-5). This failure makes it impossible to establish objective baseline functioning for future comparisons and follow changes to adjust treatments as appropriate.

Findings include:

A. Record Review

1. Patient WH6-15's annual psychiatric evaluation dated 7/28/16 had no assessment and documentation of memory functioning.

2. Patient B2S-5's admission psychiatric evaluation dated 12/05/16 had Immediate recall as "intact" and Recent and Remote memory was not evaluated (The pre-printed form sections related to these memory evaluations was left blank).

B. Document Review

The "Health Information Management Policy and Procedures" approved by the "Medical Record Committee" for the facility, under Chapter 2, Procedure 2.3a (Admission Psychiatric evaluation revised 8/26/15) and procedure 2.3b (Annual Psychiatric Review/Annual Psychiatric Progress approved on 6/27/2012) both indicate under documentation requirements, Immediate recall, Recent memory, and Remote memory be assessed and documented.

C. Interview

In a meeting on 1/31/17 at 3:00 p.m., the medical director concurred with the above deficiencies.

Based on document review and interview, the facility failed to provide psychiatric evaluations that included an assessment of patient assets in descriptive fashion for two (2) of 16 active sample patients (B2S-5 and B2N-10). The failure to identify patient assets impairs the treatment team's ability to choose treatment modalities that utilize the patient's attributes in therapy.

Findings include:

A. Record Review

1. Patient B2S-5's admission psychiatric evaluation dated 12/05/16 indicates Patient Strength/Assets and Resources as "I don't know."

2. Patient B2N-10's admission psychiatric evaluation dated 4/08/15 indicates patient's Assets as "Good person and kind."

B. Document Review

The Health Information Management Policy and Procedures Chapter 2, Procedure 2.3a "Admission Psychiatric Evaluation" approved on August 26, 2015, under XI states "Patient Strengths/Assets and Resources documents the patient's personal attributes as well as other resources available to him/her that might be employed to promote recovery".

C. Interview

In a meeting and review of the above deficiencies on 1/31/17 at 3:00 p.m., the medical director concurred with the above deficiencies.

Based on interview and medical record review, there was failure to ensure the identification of nursing interventions based on patient findings, especially for safety issues for seven (7) of 16 active sample patients (W2S-9, B4N-6, B4N-7, WH4-1, WH2-1, W1N-2 and M4D-4). This resulted in the absence of interventions to guide nursing personnel in the implementation and evaluation of care, especially for patients with violence toward self and/or others.

Findings include:

A. Patient Findings:

1. Patient W2S-9--treatment plan dated 1/27/17.

During interview on 1/30/17, at 2:05 p.m. RN W5 reported that Patient W2S-9 challenges new patients that come to the unit and hits them without provocation.

During interview on 1/30/17 at 2:30 p.m. Patient W2S-9 related that s/he was blind except for seeing shadows and shapes. During a follow-up interview on 1/31/17 at 1:45 p.m., Patient W2S-9 reported that s/he got in trouble on the ward yesterday. When asked what happened, s/he responded, "I hit another patient." Patient W2S-9 added "I was coming down the hall and the patient was passing. I was scared."

For problem, "aggressive," the only nursing intervention other than relating to administering medications was "Encourage patient to verbalize when feeling unsafe and having an urge to hit someone...to assist patient to identify methods to navigate those feeling (sic) and identify alternative coping mechanisms." There were no interventions related to specific monitoring based on patients findings and additional interventions related to helping the patient to prevent further violence.

2. Patient B4N-6--treatment plan dated 1/18/17.

For problem, "Psychosis, inability to survive on his own," there were no identified nursing interventions.

3. Patient B4N-7--treatment plan dated 1/27/17.

For problem, "[Patient] has a long history of serious mental illness, medication non-adherence, and assaultiveness to others. S/he has little insight into past aggression, threats, or the significance of s/his mental illness in s/his life." The nursing intervention stated, "Nursing staff will dispense medication as prescribed and will encourage (patient name) to communicate [his/her] needs and wants to staff during daily treatment interventions." This statement is a routine nursing function that would be provided any patient regardless of presenting symptoms.

4. Patient WH4-1-treatment plan dated 1/17/17.

For problem, "aggressive...sexualized behavior,"

The same nursing intervention was identified for both aggressive and sexual behavior. This intervention was stated as "Nursing staff will help [Patient] identify triggers, provide positive feedback for appropriate behavior, speak with [him/her] in a calm, non threatening (sic) manner when directing him towards a task, encourage [him/her] to discuss feelings, fears, and concerns, offer PRN medication when ][Patient] is feeling out of control and help [him] identify at least 3 positive aspects of stating health, RN will also assess [Patient ' s] mental status daily."

As listed these are generic interventions for this patient. For these major safety issues there are no specific monitoring, intervention and prevention directions for nursing personnel working with this patient in the clinical area.

5. Patient WH2-1-treatment plan dated 1/17/17:

For problem, "anger and aggression," there are no specific monitoring, intervention and prevention directions related to this problem to direct nursing personnel working with this patient in the clinical area.

6. Patient W1N-2-treatment plan dated 1/25/17:

For problem, "delusional beliefs that staff are trying to harm [him/her] with medications and treatments...delusional statements that [s/he] is an (sic) doctor or attorney."

The only related nursing intervention was stated as "Encourage compliance with medications". Provide medication teaching at each med (medication) pass. [Patient] will often say "I am a Psychiatrist" and claims responsibility for the care of [his/her] peers. When interacting with [Patient], emphasize expression of feelings rather intellectualization (sic)." This intervention did not direct nursing personnel in responding to the patient's delusional statements other than "emphasize expression of feelings rather than intellectualization." This intervention needed to be more clearly stated for non-professional nursing personnel.

7. Patient M4D-4-treatment plan dated 1/24/17:

For problems, "aggression" and "suicidal ideations," the same nursing intervention was identified for both problems as "Encourage [Patient] to use [his/her] personal preferences (such as cold cloth, prns, walk, pace, read, write, TV, wrap in blanket, call family, Chaplin, friend, eat/drink, music, deep breath) to assist [him/her] with managing [his/her] symptoms when around others and in the community."

There were no monitoring or clearly stated preventive interventions identified based on specific patient findings.

B. In an interview on 2/1/17 at 12:15 p.m. with the Director of Nursing (DON) the missing and generic nursing interventions for sample patients B4N-6 and B4N-7 were reviewed. The DON agreed that the plan for patient B4N-6 had no nursing intervention, and patient B4N-7 nursing intervention was generic. She stated, "Not adequate," and "nursing intervention should be more around management of behavior."

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

I. Provide active treatment, including alternative interventions, for one (1) of 16 active sample patients (B4N-7). Patient B4N-7 was either not emotionally stable to participate in treatment at times or was not motivated to attend all groups s/he was supposed to attend as listed on the unit activity schedule. Although the treatment plan for this patient included several group therapies, the patient regularly and repeatedly did not attend group. According to unit staff, B4N-7 spent many hours isolated in his/her room without any structured activities. B4N-7's non- participation in assigned treatment modalities negates the clinical effectiveness of the patient's treatment goals and objectives, potentially delaying the patient's improvement.

II. Provide structured individual and/or group activities based on patients' needs for four (4) of 11 patient care units (B2N, B2S, B4N and W2S) where active sample patients were housed. This failure hindered patient's participation in active treatment and resulted in patients roaming the wards, sleeping in chairs and idly sitting around on the units.

III. Provide sufficient numbers of structured therapeutic activities after around 3:00 p.m. on weekdays and/or services by professional personnel on weekends (Saturday-Sunday) to meet the needs of the patient population in 14 of 28 Units (B3N, B4N, M4D, B4S, B2N, B2S, W1S, W1N, W2S, W2N, WH2, D1N, D1S and D3S). The majority of treatment measures/activities on weekends were delegated to and conducted by non-professional staff (Mental Health Technicians). These activities were more leisure-oriented, rather than therapeutic treatment based on individualized needs of the patient population. These failures resulted in lack of active treatment for patients in these units.

Findings include:

I: Failure to ensure alternative treatment for a patient refusing to attend assigned treatment:

A. Record review

1. Patient B4N-7 was admitted on 1/10/2013. According to the Psychiatric Evaluation, dated 1/10/13, the patient was admitted from an acute care emergency room in Middletown where the patient was initially seen "due to worsening paranoia and hallucinations." "Patient states she/he wanted to be admitted to be able to quit smoking." "States it was a nice group home but feels safer here."

2. The Master Treatment Plan (MTP), last review 1/27/2017, listed the following interventions for the problem of (called "Barriers to achieving Goals) by this facility" "(Patient name) has a long history of mental illness, medication no-adherence, and assaultiveness to others." S/he has had little insight into pass aggression, threats, or the significance of her/his mental illness in her/his life." Interventions are, "connecting through music," "nursing Interventions -RN," "Community Meeting Information," and "Medication Management" and "Discharge Planning."

3. A review of the "Shift Group Attendance Sheet" for month of December and January the following unit groups was offered, "Community meeting" on the unit Monday to Friday, "coping skills through Art therapy" on Monday and Friday, "effective communication" each Monday and Wednesday, "anger management" on Tuesday's unit." Patient B4N-7 did not attend a single group and no alternative active treatment was provided in the record in the medical record.

4. Progress note dated 12/18/16, the section titled outcome states: "(Patient name) is mostly isolative (avoid people and stays in s/his room mostly talking to her/himself), interact with staff when in need of staff assistance." "to gain assistance." "S/he hardly communicates with peers on the unit." "S/he hardly participates in groups on the unit."

B. Observation

On 1/30/17 there was a census of 22 patients on the B4N unit, at 1:35 p.m. during the unit walk through with the Director of Nursing, 16 patients were observed in bed rooms, including sample patient B4N-7, 10 were in bed covered up and appears to be napping. The schedule 2:15 p.m. CBT (cognitive behavioral therapy) group was cancelled as the therapist had to go home for an emergency, there was no alternative activity offered. Sample patient B4N-7 was on the schedule to attend the 3:15 p.m. discharge readiness group on the unit, patient was not in attendance the nurse stated s/he refused to attend.

C. Interviews

1. On 1/30/17 at 3.15 p.m. the lack of active treatment for sample patient B4N-7 was discussed unit nursing station in the presence of the unit psychiatrist, unit social worker and the charge nurse. Unit psychiatrist stated, "Sample patient name" "just will not go to groups, we have tried a variety of things to encourage s/him." When asked about alternative active treatment program for the patient, RN and Social worker stated, there is none been offered?

2. In an interview on 1/31/17 at 2:00 p.m. with B2N Unit Director, SWD1 and Charge Nurse, RND4, the lacked of active treatment for Sample patient B4N-7 was discussed. The unit Director stated "we have tried a variety of things such as nursing staff reminders of scheduled activities, group leaders going to up and down the unit encouraging patients to attend groups, but patients refuse to attend." The Charge Nurse stated "(patient name) has refractory behaviors and like to isolate her/himself and don't like to be in groups are socialize with others." When asked about alternative program activities for the patient, charge nurse stated "there is none but he spend 5 minutes time listening to the patient, which the patient enjoys."

3. In an interview on 2/1/17 at 10:00 a.m. with the Director of Nursing (DON) Sample patient B2N-7 active treatment was discussed. The DON agreed stating "yes I see."

4. In an Interview with B4N-7 on 1/31/17 at 2.40 p.m. the patient states, "the team wants me to attend group, I am not very social, like been alone, I don't attend the groups, it would be nice if rehab take me on a trip as they do with others." S/he then stated, "I want to end the interview."

II. Failure to offer groups/activities to meet the majority of patient needs on the unit:

A. Observations on Unit B2N on 1/30/17 at 1:30 p.m. revealed that an arts and crafts activity was held on the unit. At 1:35 p.m. there were two (2) patients working with the Rehabilitation staff member. The remainder of the patients were sitting in adjoining rooms idle, including active sample Patient B2N-10, listening to music on the television or walking in the hallways. The staff member worked with 1-3 patients at a time for a total of six (6) of the 22 patients present on the unit during this activity period.

During interview with the COO at this time, she agreed that this activity failed to meet the majority of the patients' needs.

B. Observations on Unit W2S on 1/31/17 at 1:40 p.m. revealed that three (3) of 15 patients were taken to an off unit activity by rehabilitation staff leaving 12 patients on the unit without an alternative structured group/activity. These patients remaining on the unit, including active sample Patient W2S 9, were roaming the hallways, lying in bed or sitting in the dayrooms.

The COO verified the above documented findings.

C. Observation on 1/30/17-- there was a census of 22 patients on the B4N Unit, at 1:35 p.m. during the unit walk through with the Director of Nursing, 16 patients were observed in bed rooms, including sample patient B4N-7, 10 were in bed covered up and appears to be napping. The schedule 2:15 p.m. CBT (cognitive behavioral therapy) group was cancelled as the therapist had to go home for an emergency, there was no alternative activity offered. On 1/31/17 at the 3:15 Connecting Through Music group activity on the unit there were six (6) of the 22 patients in attendance. The remaining 16 patients were in bedrooms including sample patient B4N-7.

D. Observation 0n Unit B2S on 1/31/17, the census was 15 patients. At 1:00 - 3:00 Recovery Through Recreation group activity held off unit-- there were three patients in attendance. The DON accompanied the surveyor to the group.

III. Failure to offer adequate numbers of groups/activities on evenings and weekends to meet the needs of the patient population by qualified staff:

A. Review of all unit schedules provided by the COO revealed the following information:

1. Unit D1S:

No structured activities scheduled after 3:30 p.m. on Thursday and Friday and all services offered by nursing personnel on Saturday after 10:00 a.m. and on Sunday after 2:30 p.m.

2. Unit B3N:

No structured activities scheduled after 2:30 p.m. on Monday, Wednesday and Friday and all services offered by nursing personnel on Saturday and Sunday after 11:30 a.m.

3. Unit B4N:

All services offered by nursing personnel on Saturday after 11:00 a.m. and on Sunday all day.

4. Unit M4D:

No structured activities scheduled after 5:00 p.m. on Wednesday and Friday and all services offered by nursing personnel after on Saturday and Sunday after 2:00 p.m.

5. Unit B4S:

No structured activities scheduled after 4:00 p.m. on Monday and Friday and all services offered by nursing personnel on Saturday and Sunday after 10:00 a.m.

6. Unit B2N:

All services offered by nursing personnel on Saturday and Sunday after12:30 pm.

7. Unit B2S:

No structured activities scheduled after 2:30 pm on Monday, Thursday, and Friday and all services offered by nursing personnel on Saturday and Sunday all day.

8. Unit W1S:

No structured activities scheduled after 2:30 pm on Monday and Friday and all services offered by nursing personnel on Saturday and Sunday after 10:00 am.

9. Unit W1N:

No structured activities scheduled after 2:00 pm on Monday and Friday and all services offered by nursing personnel on Saturday and Sunday after 12:00 noon.

10. Unit W2S:

No structured activities scheduled after 4:00 p.m. on Monday and Tuesday and 2:00 p.m. on Thursday and Friday and all services offered by nursing personnel on Saturday and Sunday all day.

11. Unit W2 N:

All services offered by nursing personnel on Saturday and Sunday after 10:00 a.m.

12. Unit WH2:

No structured activities scheduled after 4:00 p.m. on Monday, Tuesday, Wednesday, and Thursday and all services offered by nursing personnel on Saturday and Sunday after 10:30 a.am.

13. Unit D1N:

All services offered by nursing personnel on Saturday and Sunday after 2:00 pm.

14. Unit D3S:

No structured activities scheduled after 3:30 p.m. on Thursday and Friday and all services offered by nursing personnel on Saturday and Sunday after 2:00 p.m.

A. Interviews:

1. During interview on Unit B2N on 1/30/17 at 1:05 p.m. when asked what s/he did on week-ends, non-sample active Patient B2N-8 responded, "We chill out. I do go to church on Sundays."

2. During interview on 1/30/17 at 3:40 p.m., when asked what activities s/he attending on weekends, active sample Patient WH6-15 responded "We are allowed to stay in bed. I do go to church."

3. During interview with review of all Unit schedules on 2/1/17 at 10:30 a.m., the COO and the Director of Rehabilitation Services verified the above documented findings.

Based on record review and staff interview the medical director failed to ensure that;

I. The Psychiatric Evaluations included an assessment of patients' memory for 2 (WH6-15 and B2S-5) of the 16 active sample patients (refer to B116).

II. The Psychiatric Evaluations included an inventory of patients' assets for 2 (B2S-5 and B2N-10) of 16 active sample patients (refer to B117).

III. Active treatments including alternative treatments are provided to 1 of 16 active sample patient B4N -7(Refer to B125).

IV. Provide structured individual or group activities based on patients' needs in 4 of 11 patient care units B2N, B2S, B4N and W2S (refer to B125) and

V. Provide sufficient numbers of structured therapeutic activities after around 3:00 p.m. on weekdays and/or services by professional personnel on weekends (Saturday-Sunday) to meet the needs of the patient population in 14 of 28 Units (B3N, B4N, M4D, B4S, B2N, B2S, W1S, W1N, W2S, W2N, WH2, D1N, D1S and D3S) (refer to B125).

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

I. Ensure the identification of nursing interventions based on patient findings, especially for safety issues for seven (7) of 16 active sample patients (W2S-9, B4N-6, B4N-7, WH4-1, WH2-1, W1N-2 and M4D-4). I. Ensure that specific interventions to guide personnel in the provision of nursing care were documented on the treatment plans of eight (8) of eight (8) sample patients (1E, 1F, 2B, 2D, 3C, 3H, 4D and 4G). This resulted in the absence of interventions to guide nursing personnel in the implementation and evaluation of care, especially for patients with violence toward self and/or others.
(Refer to B122)

II. Ensure correct, timely documentation of safety checks for two (2) of two (2) non-sample active patients B2N-1 and B2N-19 who were on constant observation for safety issues in the B2N Unit. This failure results in a safety risk for all patients on this unit.

Findings include:

A. During walking rounds of the B2N Unit on 1/20/17 at 1:05 p.m., a review of monitoring sheets revealed that the 15-minute safety checks for Patients B2N-1 and B2N-19 had not been documented since 12:15 p.m.

B. During interview at this time, MHT W9 stated that the monitoring sheets were kept at the nursing station and that he documented the 15-minute monitoring checks for safety every hour rather than in a timely manner (every 15 minutes).

C. During interview on 2/1/17 at 12:15 p.m., the DON stated "That is not appropriate (referring to the untimely documentation of the safety checks."

D. Review of policy, "Special Observation," dated 10/8/15 revealed the following statement: "The nursing staff member assigned to the patient documents the patient's clinical status every 15 minutes on the positive Behavioral Support Plan and/or Special Observations form (CVH-665)."

The staff failed to follow this policy requirement.