HospitalInspections.org

Based on record review, and observationthe hospital failed to have an effective Governing Body that is legally responsible for the conduct of the hospital.


Cross Reference:
482.13 Patient Rights
482.21 QAPI
482.41 Physical Enviornment

Based on observation, record review, staff interview, and policy review, the facility failed to protect and promote patient's rights for all actual and potential patients admitted therein.

Cross Reference:
482.13(a) Notice of Rights
482.13(b)(1) Participation in Care Planning
482.13(c)(2) Care in Safe Setting

Based on observation and interview the facility failed to assure that Notice of Patients' Rights was posted in the psychiatric units as directed per facility policy.

Findings include:

Observation on 12/4/2014 at 3:25 p.m. of the adult and geriatric behavioral health units with the Nurse Manager and the Director of Nursing (DON), revealed no evidence of posted patient rights information.

Interview on 12/4/2014 at 3:25 p.m., with the Nurse Manager and DON they each acknowledged that patient rights information was not posted in either unit.

Review of the facility's Patient Rights and Responsibilities provided as a component of the admission packet revealed that -Behavioral Health: A list of patient rights shall be posted on the unit.

Review of policy # 06.04.01, Patient Rights, original date 12/01/11, revealed that the Statement of Rights is posted on the unit.

Based on medical record review, and staff interview, the facility failed to protect the patient's right to participate in the development and implementation of their plan of care on ten (10) patients (#s 1- 10) of ten (10) sampled patients.

Findings include:

Review of ten medical records revealed:

Patient #1:
Admitted on 8/20/2014 at 4:50 p.m. with diagnosis of Psychosis.
Record review revealed:
- A Problems/Plan of Care list was initiated by a nurse as part of the Nursing Admission Assessment which occured within twelwe hours of admission, and which included problems only. No plans were included in the Problems/Plan of Care list.
- A Behavioral Health Initial Treatment Plan initiated by licensed professional counselor which included a master problem list; a statement which read "I/we acknowledge that we have discussed the initial treatment plan with a member of the healthcare team and have been given an opportunity to participate in the treatment planning process. My treatment plan has been reviewed with me. I understand and I agree with my treatment plan."; signature lines for the patient/family, the attending doctor, psychiatrist, RN, social worker, and counselor followed the statements; but, did not contain any signatures

Patient #2:
Admitted on 8/9/2014 at 6:30 p.m. with diagnosis of Psychosis
Record review revealed:
- A Problems/Plan of Care list was initiated by a nurse as part of the Nursing Admission Assessment which occured within twelwe hours of admission, and which included problems only. No plans were included in the Problems/Plan of Care list.
- A Behavioral Health Initial Treatment Plan initiated by licensed professional counselor which included a master problem list; a statement which read "I/we acknowledge that we have discussed the initial treatment plan with a member of the healthcare team and have been given an opportunity to participate in the treatment planning process. My treatment plan has been reviewed with me. I understand and I agree with my treatment plan."; signature lines for the patient/family, the attending doctor, psychiatrist, RN, social worker, and counselor followed the statements; but, did not contain any signatures

Patient #3:
Admitted on 8/23/2014 at 4:00 a.m. with diagnosis of Psychosis.
Record review revealed:
- A Problems/Plan of Care list was initiated by a nurse as part of the Nursing Admission Assessment which occured within twelwe hours of admission, and which included problems only. No plans were included in the Problems/Plan of Care list.
- A Behavioral Health Initial Treatment Plan initiated by licensed professional counselor which included a master problem list; a statement which read "I/we acknowledge that we have discussed the initial treatment plan with a member of the healthcare team and have been given an opportunity to participate in the treatment planning process. My treatment plan has been reviewed with me. I understand and I agree with my treatment plan."; signature lines for the patient/family, the attending doctor, psychiatrist, RN, social worker, and counselor followed the statements; but, did not contain any signatures

Patient #4:
Admitted on 8/11/2014 at 5:00 p.m. with diagnosis of Suicidal Ideations
Record review revealed:
- A Problems/Plan of Care list was initiated by a nurse as part of the Nursing Admission Assessment which occured within twelwe hours of admission, and which included problems only. No plans were included in the Problems/Plan of Care list.
- A Behavioral Health Initial Treatment Plan initiated by licensed professional counselor which included a master problem list; a statement which read "I/we acknowledge that we have discussed the initial treatment plan with a member of the healthcare team and have been given an opportunity to participate in the treatment planning process. My treatment plan has been reviewed with me. I understand and I agree with my treatment plan."; signature lines for the patient/family, the attending doctor, psychiatrist, RN, social worker, and counselor followed the statements; but, did not contain any signatures

Patient #5:
Admitted on 8/19/2014 at 12:25 a.m. with diagnosis of Psychosis.
Record review revealed:
- A Problems/Plan of Care list was initiated by a nurse as part of the Nursing Admission Assessment which occured within twelwe hours of admission, and which included problems only. No plans were included in the Problems/Plan of Care list.
- A Behavioral Health Initial Treatment Plan initiated by licensed professional counselor which included a master problem list; a statement which read "I/we acknowledge that we have discussed the initial treatment plan with a member of the healthcare team and have been given an opportunity to participate in the treatment planning process. My treatment plan has been reviewed with me. I understand and I agree with my treatment plan."; signature lines for the patient/family, the attending doctor, psychiatrist, RN, social worker, and counselor followed the statements; but, did not contain any signatures

Patient #6:
Admitted on 8/18/2014 at 1:05 p.m. with diagnosis of Psychosis.
Record review revealed:
- A Problems/Plan of Care list was initiated by a nurse as part of the Nursing Admission Assessment which occured within twelwe hours of admission, and which included problems only. No plans were included in the Problems/Plan of Care list.
- A Behavioral Health Initial Treatment Plan initiated by licensed professional counselor which included a master problem list; a statement which read "I/we acknowledge that we have discussed the initial treatment plan with a member of the healthcare team and have been given an opportunity to participate in the treatment planning process. My treatment plan has been reviewed with me. I understand and I agree with my treatment plan."; signature lines for the patient/family, the attending doctor, psychiatrist, RN, social worker, and counselor followed the statements; but, did not contain any signatures

Patient #7:
Admitted on 8/5/2014 at 5:17 p.m. with diagnosis Depression, Suicidal Ideations
Record review revealed:
- A Problems/Plan of Care list was initiated by a nurse as part of the Nursing Admission Assessment which occured within twelwe hours of admission, and which included problems only. No plans were included in the Problems/Plan of Care list.
- A Behavioral Health Initial Treatment Plan initiated by licensed professional counselor which included a master problem list; a statement which read "I/we acknowledge that we have discussed the initial treatment plan with a member of the healthcare team and have been given an opportunity to participate in the treatment planning process. My treatment plan has been reviewed with me. I understand and I agree with my treatment plan."; signature lines for the patient/family, the attending doctor, psychiatrist, RN, social worker, and counselor followed the statements; but, did not contain any signatures

Patient #8:
Admitted on 8/12/2014 with diagnosis of Psychosis.
Record review revealed:
- A Problems/Plan of Care list was initiated by a nurse as part of the Nursing Admission Assessment which occured within twelwe hours of admission, and which included problems only. No plans were included in the Problems/Plan of Care list.
- A Behavioral Health Initial Treatment Plan initiated by licensed professional counselor which included a master problem list; a statement which read "I/we acknowledge that we have discussed the initial treatment plan with a member of the healthcare team and have been given an opportunity to participate in the treatment planning process. My treatment plan has been reviewed with me. I understand and I agree with my treatment plan."; signature lines for the patient/family, the attending doctor, psychiatrist, RN, social worker, and counselor followed the statements; but, did not contain any signatures

Patient #9
Admitted on 8/16/2014 at 1:49 p.m. with diagnosis of Psychosis with Suicidal Ideations.
Record review revealed:
- A Problems/Plan of Care list was initiated by a nurse as part of the Nursing Admission Assessment which occured within twelwe hours of admission, and which included problems only. No plans were included in the Problems/Plan of Care list.
- A Behavioral Health Initial Treatment Plan initiated by licensed professional counselor which included a master problem list; a statement which read "I/we acknowledge that we have discussed the initial treatment plan with a member of the healthcare team and have been given an opportunity to participate in the treatment planning process. My treatment plan has been reviewed with me. I understand and I agree with my treatment plan."; signature lines for the patient/family, the attending doctor, psychiatrist, RN, social worker, and counselor followed the statements; but, did not contain any signatures

Patient #10:
Admitted on 8/21/2014 with diagnosis of Psychosis.
Record review revealed:
- A Problems/Plan of Care list was initiated by a nurse as part of the Nursing Admission Assessment which occured within twelwe hours of admission, and which included problems only. No plans were included in the Problems/Plan of Care list.
- A Behavioral Health Initial Treatment Plan initiated by licensed professional counselor which included a master problem list; a statement which read "I/we acknowledge that we have discussed the initial treatment plan with a member of the healthcare team and have been given an opportunity to participate in the treatment planning process. My treatment plan has been reviewed with me. I understand and I agree with my treatment plan."; signature lines for the patient/family, the attending doctor, psychiatrist, RN, social worker, and counselor followed the statements; but, did not contain any signatures

During the closing conference on 12/4/2014 at 6:00 p.m., the DON acknowledged the above findings.

Based on observation and interview, the facility failed to protect the patient's right to receive care in a safe setting affecting not only the ten (10) sampled patients but all patients treated in the facility.

Findings include:

Observation on 12/4/2014 at 3:25 p.m. with the Nurse Manager and Director of Nursing (DON) revealed the following:

1. Geriatric Psychiatric unit:
- The Day room contains eight (8) medium weight office chairs and one (1) light weight rolling
desk chair;
- Handrail next to hall restroom pulled away from the wall on left side (screwed in on right);
- Hall restroom/shower room with one lightweight plastic chair inside, and call light not
working;
- Dining room with fourteen (14) medium weight office chairs;
- Restroom in dining room revealed that the restrooms had not been modified for safety in
behavior health units; contain spring-loaded toilet tissue holders; and, sharp metal edges;
- Rooms 105 and 107: wall air conditioning unit with heavy dust and sharp metal edges
- Room 105: toilet tank cover has been replaced with a piece of wood which has been
turned over and has two (2) large screws extending upward approximately two (2) inches;
spring-loaded toilet tissue holder in use
- Room 111: toilet tank cover has been replaced with a piece of wood which has been
turned over and has one (1) large screw extending upward approximately two (2) inches
and base of toilet has two (2) approximately thirty (30) inch wire cables attached to either
side, and lying on the floor (noted to be securing wood tank cover in other restrooms);
spring-loaded toilet tissue holder in use
- Hallway near room 111: sprinkler ring missing; ceiling panel next to sprinkler with large
brown spot and three (3) holes (sizes approximately 1 inch, 2 inches, 2 inches)
- Snack area near seclusion room: live electrical box coming out of wall; long white computer
cable coming out of wall outlet, lying on floor; open bag of cookies on snack cart
- Restroom in snack area near seclusion room: contains equipment, a wheelchair, cereal,
apple juice and applesauce
- Seclusion room: base board missing; sheetrock damage
- Room 119: one (1) medium weight office chair in room; base board coming off wall

2. Adult Psychiatric Unit:
- Seclusion room: one (1) approximately 6 x 4 inch opening in wall; no mirror or camera;
base boards missing
- Room 129: restroom light not working; three (3) pipes extending from wall, approximately
2.5 inches; four round metal attachments with sharp edges in shower; not modified for
safety in behavior health units; contain spring-loaded toilet tissue holder and sharp metal
edges
- Dayroom: seven (7) medium weight office chairs; one (1) approximately 4 x 4 inch hole in
ceiling; one (1) approximately three (3) inch hole in wall
- Dining room: eight (8) medium weight office chairs; three (3) approximately two (2) inch
screws extending down from ceiling; one (1) approximately two (2) inch hole in ceiling
- TV room: three (3) medium weight office chairs

Interview with the DON on 12/4/2014 at 4:30 p.m. the DON confirmed the findings and revealed that wall outlets were not tamper-proof in either of the behavioral health units; and, call lights were not functional in either of the behavioral health units.

Based on medical record review, observation, policy review, and review of the facility's Patient Rights and Responsibilities, the hospital failed to maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program..

Findings include:

Cross Reference

482.13 Patient Rights
482.41 Physical Environment

Based on medical record review, and staff interview, the facility failed to assure that nursing staff developed, and kept current nursing care plans on ten (10) of ten (10) patients reviewed (#s 1- 10).

Findings include:

Review of ten medical records revealed:

Patient #1:
Admitted on 8/20/2014 at 4:50 p.m. with diagnosis of Psychosis.
Record review revealed:
- A Problems/Plan of Care list was initiated by a nurse as part of the Nursing Admission Assessment which occured within twelwe hours of admission, and which included problems only. No plans were included in the Problems/Plan of Care list.

Patient #2:
Admitted on 8/9/2014 at 6:30 p.m. with diagnosis of Psychosis
Record review revealed:
- A Problems/Plan of Care list was initiated by a nurse as part of the Nursing Admission Assessment which occured within twelwe hours of admission, and which included problems only. No plans were included in the Problems/Plan of Care list.

Patient #3:
Admitted on 8/23/2014 at 4:00 a.m. with diagnosis of Psychosis.
Record review revealed:
- A Problems/Plan of Care list was initiated by a nurse as part of the Nursing Admission Assessment which occured within twelwe hours of admission, and which included problems only. No plans were included in the Problems/Plan of Care list.

Patient #4:
Admitted on 8/11/2014 at 5:00 p.m. with diagnosis of Suicidal Ideations
Record review revealed:
- A Problems/Plan of Care list was initiated by a nurse as part of the Nursing Admission Assessment which occured within twelwe hours of admission, and which included problems only. No plans were included in the Problems/Plan of Care list.

Patient #5:
Admitted on 8/19/2014 at 12:25 a.m. with diagnosis of Psychosis.
Record review revealed:
- A Problems/Plan of Care list was initiated by a nurse as part of the Nursing Admission Assessment which occured within twelwe hours of admission, and which included problems only. No plans were included in the Problems/Plan of Care list.

Patient #6:
Admitted on 8/18/2014 at 1:05 p.m. with diagnosis of Psychosis.
Record review revealed:
- A Problems/Plan of Care list was initiated by a nurse as part of the Nursing Admission Assessment which occured within twelwe hours of admission, and which included problems only. No plans were included in the Problems/Plan of Care list.

Patient #7:
Admitted on 8/5/2014 at 5:17 p.m. with diagnosis Depression, Suicidal Ideations
Record review revealed:
- A Problems/Plan of Care list was initiated by a nurse as part of the Nursing Admission Assessment which occured within twelwe hours of admission, and which included problems only. No plans were included in the Problems/Plan of Care list.

Patient #8:
Admitted on 8/12/2014 with diagnosis of Psychosis.
Record review revealed:
- A Problems/Plan of Care list was initiated by a nurse as part of the Nursing Admission Assessment which occured within twelwe hours of admission, and which included problems only. No plans were included in the Problems/Plan of Care list.

Patient #9
Admitted on 8/16/2014 at 1:49 p.m. with diagnosis of Psychosis with Suicidal Ideations.
Record review revealed:
- A Problems/Plan of Care list was initiated by a nurse as part of the Nursing Admission Assessment which occured within twelwe hours of admission, and which included problems only. No plans were included in the Problems/Plan of Care list.

Patient #10:
Admitted on 8/21/2014 with diagnosis of Psychosis.
Record review revealed:
- A Problems/Plan of Care list was initiated by a nurse as part of the Nursing Admission Assessment which occured within twelwe hours of admission, and which included problems only. No plans were included in the Problems/Plan of Care list.

During the closing conference on 12/4/2014 at 6:00 p.m., the DON acknowledged the above findings.

Based on medical record review and staff interview, the facility failed to assure that telephone/verbal orders be authenticated promptly by the ordering practitioner for ten (10) of ten (10) patients reviewed (#s 1 - 10).

Findings include:

Review of Patient #1 record revealed an admission date of 8/20/2014 at 4:50 p.m.;
Undated/timed Verbal Physician Admission Orders had been hand written on the Physician Order sheet by a receiving nurse; had been read back and verified; but, had not been authenticated by the physician.

Patient #2:
Admitted on 8/9/2014 at 6:30 p.m. with diagnosis of Psychosis
Verbal Physician admission orders dated 8/9/2014 at 6:30 p.m. had been hand written on the Physician Order sheet by a receiving nurse; had been read back and verified; but, had not been authenticated by the physician.

Patient #3:
Admitted on 8/23/2014 at 4:00 a.m. with diagnosis of Psychosis.
Verbal Physician admission orders dated 8/23/2014 at 4:00 a.m. had been hand written on the Physician Order sheet by a receiving nurse; had been read back and verified; but, had not been authenticated by the physician.

Patient #4:
Admitted on 8/11/2014 at 5:00 p.m. with diagnosis of Suicidal Ideations
Verbal Physician admission 8/11/2014 at 5:00 p.m. dated had been hand written on the Physician Order sheet by a receiving nurse; had been read back and verified; but, had not been authenticated by the physician.

Patient #5:
Admitted on 8/19/2014 at 12:25 a.m. with diagnosis of Psychosis.
Verbal Physician admission orders dated 8/18/2014 at 5:00 p.m. had been hand written on the Physician Order sheet by a receiving nurse; had been read back and verified; but, had not been authenticated by the physician.

Patient #6:
Admitted on 8/18/2014 at 1:05 p.m. with diagnosis of Psychosis.
Verbal Physician admission orders dated 8/18/2014 at 10:00 a.m. had been hand written on the Physician Order sheet by a receiving nurse; had been read back and verified; but, had not been authenticated by the physician.

Patient #7:
Admitted on 8/5/2014 at 5:17 p.m. with diagnosis Depression, Suicidal Ideations
Verbal Physician admission orders dated 8/5/2014 3:06 p.m. had been hand written on the Physician Order sheet by a receiving nurse; had been read back and verified; but, had not been authenticated by the physician.

Patient #8:
Admitted on 8/12/2014 with diagnosis of Psychosis.
Verbal Physician admission orders dated 8/12/2014 at 2:52 p.m. had been hand written on the Physician Order sheet by a receiving nurse; had been read back and verified; but, had not been authenticated by the physician.

Patient #9
Admitted on 8/16/2014 at 1:49 p.m. with diagnosis of Psychosis with Suicidal Ideations.
Verbal Physician admission orders dated 8/16/2014 at 4:30 a.m. had been hand written on the Physician Order sheet by a receiving nurse; had been read back and verified; but, had not been authenticated by the physician.

Patient #10:
Admitted on 8/21/2014 with diagnosis of Psychosis.
Verbal Physician admission orders dated 8/21/2014 at 5:00 p.m. had been hand written on the Physician Order sheet by a receiving nurse; had been read back and verified; but, had not been authenticated by the physician.

Interview with the DON on 12/4/2014 at 4:30 p.m. in Dining Room revealed that a verbal admission order is taken and written on the Physician Order sheet by the nurse (with date and time) on the admission day if the physician is not available. The nurse then entered the same orders in the electonic medical record. When the MD arrived, he/she co-signed the Physician Order sheet orders in the electronic medical record only.

Based on observation, interview, and review of the facility's Patient Rights and Responsibilities, the facility failed to be constructed and maintained to ensure the safety of the patients.

Cross Reference
482.41(a) Maintenance of Physical Plant

Based on observation, interview, and review of the facility's Patient Rights and Responsibilities, the facility failed to maintain the overall hospital enviornment in a manner that assured the safety and well-being of patients

Findings include:

During a tour on 12/4/2014 at 3:25 p.m. with the Nurse Director and DON, it was observed
1. Geriatric Psychiatric unit:
- Day room: contains eight (8) medium weight office chairs and one (1) light weight rolling desk
chair
- Handrail next to hall restroom pulled away from the wall on left side (screwed in on right)
- Hall shower room: lightweight plastic chair inside, call light not working
- Dining room: contains fourteen (14) medium weight office chairs
- Restroom in dining room has not been modified for safety; toilet tank cover missing; spring-loaded
toilet tissue holder in use; call light not working
- Rooms 105 and 107: wall air conditioning unit with heavy dust and sharp metal edges
- Room 105: restroom has not been modified for safety; toilet tank cover has been replaced with a piece
of wood which has been turned over and has two (2) large screws extending upward approximately two
(2) inches; spring-loaded toilet tissue holder in use
- Room 111: restroom has not been modified for safety; toilet tank cover has been replaced with a piece of
wood which has been turned over and has one (1) large screw extending upward approximately two (2)
inches and base of toilet has two (2) approximately thirty (30) inch wire cables attached to either side,
and lying on the floor (noted to be securing wood tank cover in other restrooms); spring-loaded toilet
tissue holder in use
- Hallway near room 111: sprinkler ring missing; ceiling panel next to sprinkler with large brown
spot and three (3) holes (sizes approximately 1 inch, 2 inches, 2 inches)
- Snack area near seclusion room: live electrical box coming out of wall; long white computer
cable coming out of wall outlet, lying on floor; open bag of cookies on snack cart
- Restroom in snack area near seclusion room: contains equipment, a wheelchair, cereal, apple
juice and applesauce
- Seclusion room: base board missing; sheetrock damage
- Room 119: one (1) medium weight office chair in room; base board coming off wall

2. Adult Psychiatric Unit:
Per Nurse Director and DON, all rooms are private and have restrooms
- Seclusion room: one (1) approximately 6 x 4 inch opening in wall; no mirror or camera; base
boards missing
- Room 129: restroom has not been modified for safety in behavior health units; restroom light not
working; contain spring-loaded toilet tissue holder; three (3) pipes extending from wall, approximately
2.5 inches; four round metal attachments with sharp edges in shower; not modified for safety in
behavior health units; and sharp metal edges
- Dayroom: seven (7) medium weight office chairs; one (1) approximately 4 x 4 inch hole in
ceiling; one (1) approximately three (3) inch hole in wall
- Dining room: eight (8) medium weight office chairs; three (3) approximately two (2) inch
screws extending down from ceiling; one (1) approximately two (2) inch hole in ceiling
- TV room: three (3) medium weight office chairs

Interview with the DON on 12/4/2014 at 4:00 p.m. revealed that plastic chairs had been ordered to replace some of the existing chairs in the units; an architectural group had been recently consulted for unit modifications and possible addition of beds; wall outlets were not tamper-proof in either of the behavioral health units; call lights were not functional in either of the behavioral health units.

Review of the facility's Patient Rights and Responsibilities provided as a component of the admission packet revealed that the patient has the right to expect safe care related to hospital practices and environment.