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Based on record review, policy and procedure review, staff and patient interviews the facility's governing body failed to appoint a Chief Executive Officer (CEO), failed to notify the Department of CEO changes, failed to assure that patient rights were not violated and failed to assure that the Quality Assurance and Performance Improvement (QAPI) committee montiored and implemented plans of action for eight (8) patients (#3, 8, 10, 14, 17, 18, 19, and 20) of the twenty (20) sampled and all patients admitted to the facility since

Cross Reference for details:

A0115- Patient Rights and;
A0263- Qapi.

Based on record review and staff interview, the facility failed to have evidence of a continuously appointed Chief Executive Officer (CEO) from 5/19/12 to 6/18/12 and from 12/5/12 through 2/17/13.

Findings include:

Interview on 6/2/2014 during the entrance meeting revealed a different governing body appointed CEO than the administrator on file with the Department.

Review of the facility's organization chart dated May 2014, revealed the governing body appointment of the current CEO on 3/13/13.

Review of the CEO personnel record revealed a hire date of 2/18/13.

The previous CEO's were employed as followed:
Employee #2 -- hire date is 6/19/12 and termination date is 12/04/2012
Employee # 3-- hire date was 8/19/07 and termination date was 5/18/12.

Record review revealed no evidence of an appointed CEO for 5/19/2012 through 6/18/2012 and 12/5/12 through 2/17/2013

Interview with the current CEO, she stated she has been in the position for over a year. She also stated the regional vice president provided oversight for the facility in the periods there was not a CEO appointed. There was no evidence in the governing body minutes of the current CEO appointment

Based on record review, and staff interview the facility failed to protect the rights of patients by failing to communicate patient rights adequately, indentifying safety hardards and environmental risk, failing to prevent harm and/or death, failed to implement, monitor the use of physical restraints for six (6) patients (8, 14, 17, 18, 19, and 20) of the twenty (20) sampled patients.

Cross reference for details:

A0117- Patient Rights: Notice of Right
A0144- Patient Rights: Care in a Safe Setting
A0145- Patient Rights: Free from Abuse/Harassment
A0167- Patient Rights: Restraints Or Seclusion

Based on record review and interview, the facility failed to communicate patient's rights one (1) patient (#14) who did not communicate in English of the twenty (20) patient sampled.

Findings include:

1. Record review for patient #14 revealed the patient was admitted on 5/26/14 with a diagnosis of psychosis. Review of the pre-admission forms revealed patient #14 only spoke Spanish. . Patient rights are available in Spanish; however, there was no evidence that patient #14, received the Spanish version of the patient rights.

In addition on 5/29/14 patient #14 used a wooden chair to break the exterior window of the bedroom and eloped from the facility. Facility staff notified the police and patient #14 was returned to the facility later that morning.

Observation of the video dated 5/29/14 revealed patient #14 threw a chair through the window in a bedroom. In less than a minute, patient #14 exited through the window, climbed the opposite corner wall and on the roof. Patient #14 disappeared over the roof just before three (3) staff exited the door to the courtyard.

Continued review of the record revealed that translation services were not provided for patient #14. On 5/28/14, review of the psychological and history and physical exams revealed a 'translator was needed' for the exam. On 5/29/14 at 3:55 p.m. revealed the patient's sister was the translator.

Patient #14 was not informed of patient rights due to a lack of communication/interpreter, thus could not understand the instructions given by the facility and could not participate in group therapy. The lack of communication increased the likelihood of decompensation in his psychosis and place patient #14 at risk for harm as evidenced by the patient's elopement.

Review of Policy Number: R1.006 titled "Communication/ Interpreters" revealed that "The Language Line is available 24 hours a day, 7 days a week. Additional interpreter services or other acceptable translation services will be provided as soon as possible."

Interview on 6/5/14 at 9:00 a.m., the Executive Nurse confirmed the above.

Based on observation, record review and staff interview the facility failed to identify safety hazards and environmental risks in fifty-six (56) patient rooms and common areas including electric outlets, electrical cords, two-hundred-five (205) non-secured wooden chairs that could increase the likelihood of patient self-harm or harm to others for two (2) patients (# 8, and 14) of the twenty (20) sampled.
This systematic failure increased the likelihood for self-harm and/or death for all patients admitted to the one-hundred-twenty (120) bed facility. The exposed electrical sockets increased the likelihood of electrocution, fire hazard, the unsecured cords presented a ligature hazard for potential looping, or hanging ability that could be used for choking, asphyxiation, or strangulation. The 205 non-secured wooden chairs could be used as a weapon, barricade device, or potential hanging device in patient care areas and bedrooms.

Findings include:
1. Record review for patient #8 revealed the patient was admitted to the Supportive Care Unit on May 21, 2013 with a primary diagnosis of Major Depression. Patient #8 was placed on a every fifteen (q 15) minute checks. Continued review revealed that on May 24, 2013 at 6:30 p.m. patient #8 was found on the floor in the bedroom hanging from the bed frame with a pant cord tied around the neck. Emergency Medical Services (911) was notified. Facility staff cut the cord with scissors, chest compressions and CPR were initiated. Patient #8 was pulseless and was transferred to an acute care facility and expired.
2. Record review for patient #14 revealed the patient used a wooden chair to break the exterior glass window of the bedroom and eloped from the facility on 5/29/14.

Observation on 6/3/2014 8:15 a.m. revealed safety hazards and environmental risks as follows:
1. The Supportive Care Unit with thirteen (13) patient rooms with unprotected electrical outlets, 13 patient rooms with hospital bed cords greater than three (3) feet in length, and nine (9) patient rooms with Air Conditioning (AC) unit cords greater than 3 feet in length and 13 non-secured wooden chairs in the common area.

2. The Assisted Care Unit with eight (8) patient rooms with unprotected electrical outlets and three (3) rooms with exposed hospital bed cords. and sixteen (16) non-secured wooden chairs in the Television area, sixteen 16 chairs in the dining area and fifteen (15) chairs in the group therapy room.

3. The Start Care Unit with thirteen (13) rooms with AC cords greater than 3 feet in length. Forty-four (44) electrical sockets unprotected in the bedrooms and forty-two (42) electrical sockets unprotected in the bathrooms.

4. The C Hall Unit with fourteen (14) AC units below the patients bedroom windows with cords of varying lengths extending across the floor/wall to the electrical outlets. Twenty two (22) unprotected outlets in the bedrooms and 14 unprotected outlets in the bathrooms.

5. The E Hall Unit with twelve (12) unprotected electrical outlets in the bathrooms.

6. The A and B Unit which includes the Start Unit, with thrifty-three (33) chairs in the common area, seventeen (17) chairs in group room 1, eighteen (18) chairs in group room 2, and forty-four (44) chairs in patients rooms.

7. The C Hall with seventeen (17) chairs in the group therapy room.

8. E hall with sixteen (16) chairs in the common area.

Review of policy #E.C.006 titled, "Safety and Hazard Surveillance" indicated that the facility safety officer conducts a monthly safety surveillance report to identify facility safety, and environmental hazards. This report is reviewed monthly with the Safety/Environment of Care Committee.

A review of the facility monthly safety surveillance report from 6/1/2013 to 6/1/2014 revealed no documentation of facility safety, and environmental hazards checks to prevent patient use of heavy furniture as a weapon.

A review of the facility Safety/Environment of Care Committee meeting minutes from 6/1/2013 to 6/1/2014 revealed, no evidence which identified the exposed electrical outlets, AC unit cords, and hospital bed cords as safety hazards.

The Safety Environment of Care Committee failed to identify risk even with the death of patient #8 and the elopement of patient #14.

Interview on 6/3/2014 at 10:30 a.m. and on 6/5/14 at 3:00 p.m. with the facility safety officer confirmed the above findings.

Based on record reviews, video review, interview and observation, the facility failed to provide proper translation services, safe chairs and monitoring necessary to avoid physical harm in two (2) patients (#8 and #14) of the twenty (20) sampled patients.

Findings include:

1. Record review for patient #8 revealed the patient was admitted to the Supportive Care Unit on May 21, 2013 with a primary diagnosis of Major Depression. Patient #8 was placed on a every fifteen (q 15) minute checks. Continued review revealed that on May 24, 2013 at 6:30 p.m. patient #8 was found on the floor in the bedroom hanging from the bed frame with a pant cord tied around the neck. Emergency Medical Services (911) was notified. Facility staff cut the cord with scissors, chest compressions and CPR were initiated. Patient #8 was pulseless and was transferred to an acute care facility and expired.
2. Record review for patient #14 revealed the patient was admitted on 5/26/14 with a diagnosis of psychosis. Review of the pre-admission forms revealed patient #14 only spoke Spanish. Patient #14 used a wooden chair to break the exterior window of the bedroom and eloped from the facility on 5/29/14. Facility staff notified the police and patient #14 was returned to the facility later that morning.

Observation of the video dated 5/29/14 revealed patient #14 threw a chair through the window in a bedroom. In less than a minute, patient #14 exited through the window, climbed the opposite corner wall and on the roof. Patient #14 disappeared over the roof just before three (3) staff exited the door to the courtyard.

Interview with the Quality Assurance Performance Improvement Manager on 6/5/14 at 11:01 a.m. confirmed that the video mechanism is not monitored in the facility, but is recorded for later viewing as needed.

Observation on 6/6/14 at 10:20 a.m. of A and B Halls revealed one-hundred-twelve (112) available chairs of the same approximate size used in the elopement of patient #1, located as follows:

1. Unit A with ten (10) Unit A patient rooms with two (2) chairs a total of twenty (20) chairs;
2. Unit B with twelve (12) patient rooms with (2) chairs a total of twenty-four (24) chairs;
3. A and B group room number one (1) with seventeen (17) chairs;
4. A and B group room number two (2) with eighteen (18) chairs;
5. A Hall common areas with nineteen (19) chairs and:
6. B Hall common areas with fourteen (14) chairs.

Based on record review and staff interview, the facility failed to implement the use of restraints for four (4) patient (#17, 18, 19 and 20) of the twnety (20) sampled pateints.

Findings include:

1. Patient #17 had a physican order dated 5/2/14 to apply restraints and/or seclusion for a maxuim of four (4) hours. Review of the physican orders revealed no evidence that the physican had signed/authicnated the verbal order.

2. Patient #18 had a physican order dated 1/12 and 1/13/14 for the use of restraints revealed to apply restraints. Review of the physican orders revealed no evidence that the physican had signed the order and no evidence of a time limit for the use of the restraint. In addition, there was no record of observation/monitoring during the use of the restaints, no evidence of a Face-to-Face Assessment to identify patient #18 physican/emotional condition during and post restraint applcation.


3. Patient #19 had a physican order to apply restraints with every fifteen (q 15) minute patient assessments. Review of the flow sheet for the q 15 minutes assessments revealed that the a 15 minutes were not completed. There was no evidence a Face-to-Face Assessment was conducted and no evidence of the patient debriefing.

4. Patient #20 had a physican order dated 6/29/13 revealed to apply restraints for a maxuimum of 4 hours. Review of the record revealed no evidence of patient #20 actions during the restraint application and no evidence of patient education.

Review of policy # PC094 dated 01/2014 entitled, " Specialty Restraints: Protective and Supportive Devices " revealed:

a. That the nurse or designated Register Nurse initiates a seclusion/restraint flow sheet;
b. Nursing staff checks the patient overall physical condition every fifteen minutes and level of care provided on the seclusion and/restraint flow sheet;
c. Records patient ' s education regarding safety measures and;
d. Authentication (Signing) of any verbal/telephone order, including the date and time of signature.

Interview on 6/6/2014 at 10:30 a.m. the Assistant Administrator in the conference room confirmed the above findings.

Based on record review and staff interview, the Quality Assurance and Performance Improvement (QAPI) failed to analyze, implement a plan of action, monitor or evaluated a plan of action to assure patient rights were not violated for eight (8) patients (#3, 8, 10, 14, 17, 18, 19, and 20) of the twenty (20) sampled patients.
The facility failure to implement a plan of action after patient #8 committed suicide on 5/24/2013 placed all patients admitted to the facility at risk of serious injury and/or death. As a result of this failure an Immediate Jeopardy (IJ) was identified on 6/3/2014.
On 6/3/2014 at 4:00 p.m., the Chief Executive Officer (CEO) was notified that an immediate jeopardy (IJ) was identified, related to Patient Rights Care in a Safe Setting 482.13(c)2. It was identified that the facility failed to identify safety hazards and environmental risks in fifty-six (56) patient rooms and common areas throughout the facility which included the following:

· Unprotected electrical sockets in patient rooms and bathrooms
· Hospital Beds with cords that presented a ligature risk
· Air Conditioning (AC) Units with cords that presented a ligature risk
· Unsecured wooden chairs that patients have used as weapons
Cross Reference:
A-0043-Governing Body
A-0115-Patient Rights

Findings include:

Record review for patient #8 revealed an admission to the Supportive Care Unit on May 21, 2013 with a primary diagnosis of Major Depression. Patient #8 was placed on a every fifteen (q 15) minute checks. Continued review revealed that on May 24, 2013 at 6:30 p.m. patient #8 was found on the floor in the bedroom hanging from the bed frame with a cord (removed from the pants) tied around the neck. Emergency Medical Services (911) was notified. Facility staff cut the cord with scissors, chest compressions and CPR were initiated. Patient #8 was pulseless and was transferred to an acute care facility and expired.
Review of Plan of Action Risk Reduction strategies, dated 5/24/2013, and the Senior Leadership meeting dated June 5, 2013 revealed a facility plan was to remove all hospital beds, revise the nursing assessment flow sheet to include a revised contraband list and all staff would receive training in recognizing of suicide risk factors.

Review and comparison of two (2) Nursing Assessments, after the implementation plan revealed the revision date on the bottom of both sheets were the same, with no evidence of a revision of the contraband list.

Interview on 6/5/2014 at 2:30 p.m. the Assistant Nursing Director confirmed the findings.

Based on record review and staff interview, the facility failed to ensure that hygiene needs were completed for one (1) patient #3 of the twenty (20) sampled patients.

Findings include:

Record review of patient #3 medical record revealed that the patient was involuntarily (1013) admitted to the facility's supportive care unit (SCU) on May 14, 2014 with a primary diagnosis of Psychosis and discharged on May 17, 2014. A Physician Note and Initial Psychiatric Evaluation was performed on admission which included that patient #3 was well groomed, wheelchair bound requiring total assistance with Activities of Daily Living (ADL ' s).

Review of physician daily progress note dated May 18, 2014 revealed patient #3 to be poorly groomed.

Review of the Nursing staff daily flow sheets revealed no evidence of appropriate hygiene on May 18, 2014.

Review of policy #PC.091 titled, "Personal Hygiene Assistance" indicates that the nursing staff are to assist patients daily with personal hygiene to ensure cleanliness.

Interview on 6/4/2014 at 3:00 p.m. the System Nurse Executive confirmed the above findings.

Based on observation, record review and staff interview, the facility failed to assure controlled drugs change of shift count was correct.

Findings include:

Observation on 6/2/2014 at 3:45 p.m. of the narcotic count between two registered nurses on C Hall unit revealed that the Controlled Substance Drug Record, Shift Change Accountability sheet ( record of the remaining drugs at the end of the shift) for June 2, 2014 7:00 a.m. -11:00 p.m. could not be located.

Review of policy entitled "Controlled Substances", date reviewed/revised 01/2014 revealed, "An audit of all formulary schedule II, III, IV, and V drugs would be performed at the end of each shift by the off-going and on-coming medication nurses and recorded on the Controlled Substance Record".

Interview on 6/2/2014 at 3:45 p.m. Registered Nurse (RN) #4 verbalized, that the sheet was missing and the off-going nurse said it was in the narcotic book, RN #4 confirmed that the sheet was not available and that the 7:00 a.m. count had not been recorded.

Based on record review and staff interview, the facility failed to appoint a Director of Dietary services qualified by education and training.

Findings include:

A review of the facility organizational chart dated May 2014 revealed, no evidence of a Director of Dietary Services.

A review of the facility Medical Executive Committee meeting minutes dated May 19, 2014 revealed the appointment of the Director of Integrated Services to an interim position over Dietary Services while the vacant position is source to be filled.

A review of employee records revealed, the Director of Integrated Services was governing body appointed as the Director of Dietary services on May, 16, 2014. The employee record revealed no evidence of education and or training for competence in that position. Review of the appointee's application/resume revealed a High School Diploma, and technical training in the field of automotive, security, and home inspections.

Interview on 6/4/2014 at 2:55 p.m. the Interim Director of Dietary services confirmed the above findings.

Based on record review and staff interview the facility failed to provide a therapeutic diet for 1 (one) patient (#10) of 20 (twenty) patients sampled.

Findings include:

Record review for patient #10 revealed an admission date of 5/6/2014 with a primary diagnosis of Bipolar I, and a recent medical history of weight loss of greater than twenty (20) pounds.

A nutritional consult assessment was completed on 5/7/2014 by the Dietician who recommended a Regular diet, double meat lunch, with extra starch, vegetables, and/or fruit.

Review of physician orders revealed no evidence of implementation of the recommended diet by the Dietician for patient #10.

Review of policy #PC.084 titled Diet Orders, revealed, the Dietician is responsible for ensuring that any new diet orders, or amended diet orders are to be written as needed.

Interview on 6/4/2014 at 2:10 p.m. the Dietician confirmed the above findings.

Based on observation and interview the facility failed to provide for the safety and well being of patients in three (3) of three (3) patient accessible restrooms near the lobby waiting room and in the assessment area of admissions.

Findings include:

Observation on 6/5/14 at 2:00 p.m. revealed three (3) restrooms utilized for patients prior to the admission of patients, including one (1) restroom in the assessment area of admissions and two (2) restrooms in the hall behind the front lobby.

The restrooms had two (2) pendant type sprinklers each for a total of six (6). These sprinkler heads hang down from the ceiling and could be used a ligature (a hanging or strangling device such as a cord from sports pants or a belt) to hang themselves from the sprinkler.

Interview on 6/5/14 at 2:00 p.m. the Chief Executive Officer confirmed that he/she and the supervisor of the maintenance department were aware of the dangers of these sprinkler heads and that these needed to be changed in these three patient accessible restrooms.

Interview on 6/6/14 at 11:30 am with the Life Safety Code team member confirmed that for psychiatric hospitals, the sleeve/recessed protected type of pendant sprinkler is to be used in patient accessible areas.

Review of policy titled "Safety and Hazard Surveillance's" revealed the facility safety officer conducts a monthly safety surveillance report to identify facility safety and environmental hazards. Minutes from the meeting dated 5/29/14 revealed no evidence of identifying the sprinklers.

Based on observation, record review and interview, the facility failed to provide assessments in a timely manner for one (1) patient (#15) of twenty (20) sampled patients.

Findings include:

Observation of surveillance video dated 5/9/14 of patient #15, revealed the patient being escorted to the assessment waiting area at 11:30 a.m. and leaving twice for smoking breaks and receiving meals during the three and one half (3.5) hour wait for assessment.

Record review of the assessment log revealed patient #15 arrived on 5/9/14 at 11:30 a.m. for a walk-in assessment. Patient #15 left the facility without being assessed. The facility notified the emergency contact for the patient. Two days later the patient was fatally injured after being struck by a car.

Review of policy ARS-017 revealed a registration form should be completed by the patient or family in the reception area. The assessment counselor will review the information. An assessment is performed within thirty (30) minutes inside an assessment room.

Based on record review and interview, the facility failed to communicate patient's rights one (1) patient (#14) who did not communicate in English of the twenty (20) patient sample.

Findings include:

1. Record review for patient #14 revealed the patient was admitted on 5/26/14 with a diagnosis of psychosis. Review of the pre-admission forms revealed patient #14 only spoke Spanish. . Patient rights are available in Spanish; however, there was no evidence that patient #14, received the Spanish version of the patient rights.

In addition on 5/29/14 patient #14 used a wooden chair to break the exterior window of the bedroom and eloped from the facility. Facility staff notified the police and patient #14 was returned to the facility later that morning.

Observation of the video dated 5/29/14 revealed patient #14 threw a chair through the window in a bedroom. In less than a minute, patient #14 exited through the window, climbed the opposite corner wall and on the roof. Patient #14 disappeared over the roof just before three (3) staff exited the door to the courtyard.

Continued review of the record revealed that translation services were not provided for patient #14. On 5/28/14, review of the psychological and history and physical exams revealed a 'translator was needed' for the exam. On 5/29/14 at 3:55 p.m. revealed the patient's sister was the translator.

Patient #14 was not informed of patient rights due to a lack of communication/interpreter, thus could not understand the instructions given by the facility and could not participate in group therapy. The lack of communication increased the likelihood of exacerbating his psychosis and placed patient #14 at risk for harm as evidenced by the patient's elopement.

Review of Policy Number: R1.006 titled "Communication/ Interpreters" revealed that "The Language Line is available 24 hours a day, 7 days a week. Additional interpreter services or other acceptable translation services will be provided as soon as possible."

Interview on 6/5/14 at 9:00 a.m., the Executive Nurse confirmed the above.