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Based on medical record reviews, review of facility documentation, review of facility policies/practice and interviews, the governing body failed to ensure that medical staff were accountable for the quality of care/services for patients who tested positive for tuberculosis. Please refer to A49, A438, and A748.

Based on medical record reviews, review of facility documentation, review of facility policies/practice and interviews for 7 of 7 patients (Patients #18, #19, #20, #21, #22, #23, #24) who had a positive test result (Quantiferon (QFT)) for tuberculosis (TB), clinicians failed to perform and/or timely perform a post positive QFT assessment of the patient and/or provide for follow-up and/or timely follow-up treatment for latent TB infection and/or update/timely update the patient's medical treatment plan. The finding includes:

a. Patient #18 had a diagnosis of paranoid schizophrenia and was admitted to the B3S unit on 2/15/12. Discharge paperwork from Acute Care Hospital #2 identified that the patient had a positive TB skin test. Blood work results dated 2/17/12 indicated a positive QFT. The chest x-ray (CXR) ordered by MD #3 and performed on 2/22/12 noted no focal infiltrates and emphysema. Although nursing narratives dated 2/23/12 identified that MD #3 was informed of the CXR results, integrated progress notes dated 2/21/12 to 3/19/12 lacked an assessment of the patient by MD #3 or another clinician for potential active TB symptoms, possible exposure to TB and/or evaluation for prophylactic therapy. The patient was assessed by APRN #2 on 3/20/12 and 3/26/12, and the patient subsequently began treatment for a latent TB infection on 3/27/12 (lapse of greater than 1 month after the first positive QFT).
In addition, the medical clinicians failed to update the medical problem list to include the latent TB infection until 3/27/12, resulting in a lack of revision to the patient's integrated treatment plans (ITP) dated 2/24/12, 3/6/12 and 3/20/12. Interview with MD #5 on 4/24/12 at 9:40 AM noted that the medical clinician should update the problem list portion of the history and physical to ensure that the problem was noted on the patient's next treatment plan.

b. Patient #19 had diagnoses of substance abuse and schizoaffective disorder and was admitted to the B4N unit on 1/9/12. Blood work results dated 1/12/12 indicated a positive QFT. Although the CXR result performed on 1/13/12 noted no symptoms for positive QFT and no acute pulmonary disease, integrated progress notes dated 1/12/12 through 1/18/12 lacked an assessment of the patient by the covering clinician for active TB symptoms, possible exposure to TB and/or evaluation for prophylactic therapy. The patient was subsequently assessed by APRN #2 on 3/13/12 (1 month after the positive QFT) and subsequent QFT ordered by APRN #2 and collected on 3/15/12 and 3/19/12 noted negative results. Interview with MD #5 on 4/24/12 at 9:30 AM noted that it was not uncommon to get an initial false positive QFT, which may be due to drugs in the patient's system interacting with the test, and that the clinician needed to find out if the patient was symptomatic and obtain a history after a QFT was reported as positive.
c. Patient #20 had a diagnosis of substance abuse and was admitted to Addiction Services on 2/24/12. Blood work ordered on 2/24/12 and collected on 3/2/12 due to the patient's prior refusals indicated a positive QFT which was reported on 3/5/12. The patient was assessed by the clinician with no signs and symptoms of active TB on 3/1/12, had no cough, fever, chills, and had a reported past history of a positive TB skin test documented by the clinician on 3/5/12. The CXR ordered by MD #4 on 3/5/12 and performed on 3/6/12 noted no focal infiltrates. The CXR results lacked a clinician's initials and/or date to indicate that a clinician was made aware of the CXR results. Although MD #4 met with the patient on 3/9/12, discussion for evaluation for prophylactic therapy was not documented. Patient #20 was discharged on 4/4/12. Interview with MD #5 on 4/27/12 at 10:30 AM noted that the decision to treat Patient #20 for latent TB infection would depend on the patient's history and continuity of medical oversight after discharge. S/he further indicated that s/he was not sure why MD #4 did not start Patient #20 on prophylactic treatment as the reasoning was not documented. Interview with MD #5 on 4/27/12 at 11:00 AM identified that s/he spoke with MD #4 and MD #4 did not recall seeing the patient's CXR. Interview with Director of Regulatory Compliance on 4/27/12 at 9:30 AM noted that per facility practice, results of x-rays are posted on the unit's medical board and either the psychiatrist or medical physician needs to sign the results and the results are then filed. The facility medical record maintenance policy identified that laboratory reports/tests must be initialed and dated by the appropriate psychiatrist and physician or ambulatory care service clinician prior to filing in the medical record.
d. Patient #21 had a diagnosis of substance abuse and was admitted to Addiction Services on 2/7/12. The history and physical dated 2/7/12 identified that the patient had a latent TB infection, a history of a past positive TB test, and was not treated. Blood work results reported on 2/10/12 indicated a positive QFT. Although the CXR result performed on 2/8/12 to rule out active TB noted no active disease, integrated progress notes dated 2/8/12 through discharge on 2/13/12 lacked an assessment of the patient by the clinician for possible exposure to TB and/or evaluation for prophylactic therapy. The CXR result also identified that the physician viewed the results of the x-ray on 2/28/12, after the patient was discharged. In addition, Patient #21's integrated treatment plan dated 2/10/12 lacked the problem of the patient's latent TB infection to include goals and/or interventions for monitoring and/or treatment. The patient's discharge summary dated 2/7/12 completed by the physician indicated that the patient would have discharge follow- up at Acute Care Hospital #1 and did not include the medical diagnosis of latent TB infection.
e. Patient #24 had a diagnosis of substance abuse and was admitted to Addiction Services on 2/15/12. Blood work results reported on 2/17/12 indicated a positive QFT and the 2/21/12 CXR was negative. Integrated progress notes dated 2/17/12 through discharge on 2/13/12 lacked an assessment of the patient by the clinician for active TB symptoms, possible exposure to TB and/or evaluation for prophylactic therapy. In addition, the medical clinicians failed to document the latent TB infection and the problem was not identified on the patient's integrated treatment plans dated 2/21/12, 3/6/12 and 3/19/12.
f. Patient #22 had a diagnosis of substance abuse and was admitted to Addiction Services on 3/12/12. The client face sheet noted that the patient lived at home and the home phone number was documented. The history and physical and initial nursing assessment dated 3/12/12 did not indicate that the patient had a history active or latent TB infection. Nursing narratives noted that the patient was discharged to home on 3/16/12 at 9:30 AM. Blood work results identified that blood for an ordered QFT was collected on 3/13/12 and was reported as positive for latent TB infection on 3/16/12 at 1:45 PM after the patient had been discharged. The discharge after care plan indicated that the Patient had a QFT and results were pending. The patient's medical record lacked documentation that the clinician attempted to notify the patient of the positive results after discharge.
g. Patient #23 had a diagnosis of substance abuse and was admitted to Addiction Services on 2/6/12. The client face sheet noted that the patient lived at home, did not have a home phone number and the name and phone number of a family member was listed as a collateral contact. The history and physical and initial nursing assessment dated 2/6/12 did not indicate that the patient had a history active or latent TB infection. Nursing narratives noted that the patient was discharged to home on 2/10/12 at 8:30 AM. Blood work results identified that blood for an ordered QFT was collected on 2/8/12 and was reported as positive for latent TB infection on 2/10/12 at 1:20 PM after the patient had been discharged. The discharge after care plan dated 2/10/12 noted that the plan was given to the patient and was incomplete to identify that a QFT had been performed, the results of the QFT or that attempts were made by the clinician to notify the patient of the positive results after discharge.
Interview with MD #5 on 5/8/12 indicated that the clinicians would notify the patient's known community provider of pending test results after the patient was discharged.
The hospital medical staff rules and regulations identified that the Attending Psychiatrist shall be responsible, in part, for assuring continuity of care after discharge.
The facility policy for infection prevention identified that a physical examination and history will be done to assess for symptoms of active TB disease and any possible exposure to TB after a positive QFT. The policy further noted that persons with a new positive QFT will have a CXR to rule out active disease and if the CXR is negative, the person should be evaluated for prophylactic therapy for 6-12 months with Isoniazid (INH).
The facility documentation of patient progress policy identified that progress notes are written, in part, to document results or to communicate any changes in the patient's condition.
The facility integrated treatment planning process policy identified that the treatment plan is reviewed on a regular basis to ensure that it effectively addresses the needs of the individual receiving care. The review begins with a Present Status assessment to identify interval changes that have occurred to include any new risk, medical or diagnostic issue.
The medical staff rules and regulations identified that the integrated problem list and master treatment plan shall be completed under the direction of the Attending Psychiatrist and shall be based on the assessments completed by all members of the treatment team including Ambulatory Care Services.

Based on personnel file reviews, review of hospital policy and interviews for two of three RN Infection Preventionists (RN #9, RN #11), the hospital failed to ensure that RN performance/competency evaluations were conducted annually. The finding includes:

Review of personnel files was conducted with the Director of Human Resources on 5/8/12 at 10:15 AM. The review identified that although RNs #9 and #11 were currently employed by the facility, RN #9's last competency evaluation was performed on 8/22/08 and RN #11's last competency evaluation was performed on 9/30/09. Interview with the Director of Human Resources on 5/8/12 at 10:15 AM indicated that although RN #11 retired on 5/9/11 and was "hired back" on 4/1/12, RN #11 should have had a performance evaluation no later than 9/30/10. Interview with the Nursing Director of Ambulatory Care Services on 5/8/12 at 10:40 AM noted that s/he was responsible for the yearly evaluations of the Infection Preventionist and usually kept track of when the evaluations were due. The hospital policy entitled Performance Management System identified that it is the responsibility of the Unit Director/Discipline Supervisor to keep competency based job descriptions current. The competency- based job description is the basis for the employee- performance appraisal. Annual performance appraisals must be completed by September 30th.

For nine of fourteen patients, Patients #1, #2, #3, #4, #6, #9, #10, #11, and #12, the facility failed to ensure that an assessment for the risk of victimization was completed and or accurate and/or conducted in a manner consistent for each patient. The findings were based on review of clinical records, review of facility policies, and interviews, and include the following:
a. Patient #1 was admitted to the facility with diagnoses that included Bipolar Disorder with manic and psychotic features. Review of the admission nursing assessment dated 12/21/11 identified that an assessment for the risk/vulnerability for victimization during the hospitalization was initiated and that Patient #1 reported witnessing serious injuries due to physical assault against a family member, friend, or significant other person. Although the victimization risk assessment process directed that based on a "yes" answer to these questions, further assessment was required, the assessment was not completed.
b. Patient #2 was admitted to the facility with diagnoses that included Bipolar Disorder and Borderline Personality. Review of the annual nursing reassessment dated 4/27/11 identified that Patient #2 refused to participate in the annual assessment and refused to answer any questions related to the assessment. The documentation identified that although Patient #2 refused to answer question related to his/her risk for victimization during the assessment process, it was determined and subsequently documented, that the patient was in need of further assessment in determining his/her risk for victimization. Review of the clinical record lacked documentation to reflect that further assessment was completed.
c. Patient #3 was admitted to the facility with multiple psychiatric disorders that included Schizoaffective Disorder, Antisocial Personality Disorder, and mild mental retardation. Review of the clinical record dated 5/9/11 through 3/5/12 identified that Patient #3 was involved in multiple altercations that resulted in physical assaults with peers and staff members. Review of the annual nursing reassessment dated 7/30/11 identified that Patient #3 was not at risk for victimization though failed to identify the components of the assessment that were used to make the determination.
d. Patient #4 was admitted to the facility with diagnoses that included Schizophrenia/Paranoid Type and Alcohol Abuse. Review of the clinical record dated 4/27/11 through 3/5/12 identified that Patient #4 was involved in multiple altercations that resulted in physical assaults with peers and staff members. Review of the annual nursing reassessment dated 8/26/11 identified that Patient #4 was not at risk for victimization though failed to identify the components of the assessment that were used to make the determination.
e. Patient #6 was admitted to the facility with diagnoses that included Schizoaffective Disorder and polysubstance dependence. Review of the annual nursing reassessment dated 3/2/12 identified that Patient #6 refused to answer questions related to his/her risk of victimization although the assessment was unclear as to what questions were asked. The documentation identified that although Patient #6 refused to answer question related to his/her risk for victimization during the assessment process, it was determined and subsequently documented, that the patient was not in need of further assessment.
f. Patient #9 was admitted to the facility with multiple diagnoses that included Schizophrenia and dementia. Review of the annual nursing reassessment dated 1/13/12 lacked documentation to reflect that a risk for victimization was completed.
g. Patient #10 was admitted to the facility with diagnoses that included Schizoaffective Disorder. Review of the annual nursing reassessment dated 6/2/11 identified that Patient #10 was not at risk for victimization though failed to identify the components of the assessment that were used to make the determination.
h. Patient #11 was admitted to the facility with diagnoses that included Schizophrenia/Disorganized Type and polysubstance abuse. Review of the clinical record dated 5/11/11 through 3/5/12 identified that Patient #11 was involved in multiple altercations that resulted in physical altercations with peers. Review of the annual nursing reassessment dated 9/11/11 identified that Patient #11 was at risk for violence and had a significant history of physical assault on staff and peers. However, the assessment further identified that Patient #11 was not at risk for victimization though failed to identify the components of the assessment that were used to make the determination.
i. Patient #12 was admitted to the facility with diagnoses that included Delusional Disorder. Review of the annual nursing reassessment dated 12/10/11 identified that Patient #12 refused to participate in the annual assessment and/or answer questions related to his/her risk of victimization although the assessment was unclear as to what questions were asked. The documentation identified that although Patient #12 refused to answer question related to his/her risk for victimization during the assessment process, it was determined and subsequently documented, that the patient was not in need of further assessment.
In an interview with the Unit Director on 3/7/12 at 9:30 AM, the Unit Director stated that patients would not be considered at risk for victimization if they could report abuse/mistreatment by peers and/or defend themselves. The clinical records of Patients # 1, #2, #3, #4, #9, #10, #11, and #12 were reviewed with the Unit Director on 3/23/12 at 10:00 AM. Interview with the Unit Director on 3/23/12 at 10:00 AM identified that patients are assessed for their risk for victimization by their peers upon admission and annually thereafter. The Unit Director stated that the intent of the victimization risk assessment was to determine a patient's risk to be victimized by their peers but did not include considerations of the risk of victimization by caretakers and/or other persons based on the patient's vulnerability to be victimized, and/or behavioral health status and/or fears of retaliation for reporting. The Unit Director stated that he/she was unable to explain how staff determined a patient's risk for victimization if the patient refused to cooperate with the assessment but that he/she would expect that the assessment nurse would review the patient's individual information at the time of the annual assessment. The Unit Director stated that the facility did not currently have a policy in place to direct the purpose and/or components of the victimization risk assessment.

Based on a review of clinical records, review of facility documentation, review of facility policies, and interview, the facility failed to ensure that medical records were complete, released in a timely fashion, and/or that the discharge plan was accurate for six of eleven patients (Patients #15, #19, #20, #21, #23, #24). The finding includes:
a. Patient #15 was admitted to the facility on 9/9/11 for rehabilitation and was subsequently discharged on 10/28/11. Review of facility documentation identified that an appropriate authorization request dated 12/20/11 was made to have Patient #15's clinical records be released to a named government agency. A second request by the same government agency dated 1/3/12 identified that Patient #15's records were not sent until 2/25/12, more than two months after the initial request. Interview with the Director of Medical Records on 3/23/12 at 11:00 AM identified that facility policy directed that barring specific limitations for the release of clinical records, records are released with the proper authorization within thirty days. The Director of Medical Records stated that although he/she believed that Patient #15's records, at the patient's request, were mailed to the named government agency before the second request on 1/3/12, he/she could not provide proof of the mailing. The Director of Medical Records was unable to provide an explanation for the delay in releasing Patient #15's records from the time of the second request on 1/3/12 to 2/25/12 when the records were sent.
b. Review of Patient #15's clinical record identified that although the patient was discharged on 10/28/11, the discharge summary was not completed until 1/25/12. Interview with the Director of Medical Records identified that he/she was working with facility staff to ensure that discharge summaries were completed within thirty days after discharge to remain in compliance with facility policies.
c. Patient #23 had a diagnosis of substance abuse and was admitted to Addiction Services on 2/6/12. Blood work results identified that blood for an ordered QFT was collected on 2/8/12 and was reported as positive for latent TB infection on 2/10/12 at 1:20 PM after the patient had been discharged. The discharge after care plan dated 2/10/12 noted that the plan was given to the patient and was incomplete to identify that a Quantiferon test QFT had been performed and/or that results were pending. The hospital medical staff rules and regulations identified that each member shall be responsible for maintaining complete and legible records for his/her patients.

d. Patients #19, #20, #21 and #24 were admitted to the facility during the period of time from 1/9/12 to 2/15/12. Patient #19 had a chest x-ray (CXR) dated 1/13/12. Review of the CXR report with the Director of Compliance on 5/8/12 at 1:30 PM noted that the CXR report was initialed as viewed by one practitioner and lacked the date that the practitioner reviewed and initialed the report. Patient #20 had a CXR dated 3/5/12. Review of the CXR report with the Director of Compliance on 5/8/12 at 1:30 PM indicated that the CXR lacked provider initials to indicate that the report was reviewed by the medical and psychiatric practitioner. Patient #21 had a QFT performed on 2/8/12. Review of the QFT report with the Director of Compliance on 5/8/12 at 1:30 PM identified that the QFT report was initialed as viewed by one practitioner. Patient #24 had a CXR performed on 2/21/12. Review of the CXR report with the Director of Compliance on 5/8/12 at 1:30 PM noted that the CXR report was initialed as viewed by one practitioner. The hospital policy for medical record maintenance identified that laboratory reports, other diagnostic/special tests (i.e. x-ray, EEG, etc.) and consultations must be initialed and dated by the appropriate Psychiatrist and Physician or Ambulatory Care Service Clinician prior to filing in the medical record.




15888

Based on observation, review of the clinical record, and interviews for one patient who utilized the tub as a therapeutic intervention, (Patient #9), the facility failed to ensure that the tub was easily accessable and that water temperatures were within acceptable limits. The findings include:
a. Patient # 9 was admitted to the Hospital in 01/21/1972. Current diagnoses included dementia, schizoaffective disorder, bipolar type, borderline intellectual functioning, and abnormality of gait. An Integrated Treatment Plan (ITP) dated 01/13/12 identified Patient #9's was not able to articulate a life goal; however, the current recovery goal was to transfer to a less restrictive, geriatric unit. Barriers to achieving the goal include, in part, poor frustration tolerance, impulsivity, and assaultive behavior which seemed to be focused on staff; increased frustration with deteriorating medical condition and requirement for 1:1 assistance that resulted in cursing, spitting, and striking out with staff especially when assisting with activities of daily living (ADL's). R #9's ability to benefit from psycho educational groups was limited by both borderline intellectual functioning and general psychiatric disorganization. Interventions included, in part, cue to use personal preferences when distressed. A 01/13/12 annual Nursing Re-Assessment documented by Registered Nurse (RN) #8 identified personal preferences for what helped when not feeling well, that included additional/extra medication, taking a bath or shower and listening to music.
A tour of the shower room on 03/05/12 at 10:00 AM identified 2 walk-in showers and a large, elevated bath tub approximately thirty inches in height. No step stool, handrail, mechanical lift, or other assistive device to enable entrance to the tub was visible in the shower room.
Interview with RN #4 on 03/06/12 at 11:15 AM identified that three patients, including Patient #9, used the tub and that, for Patient #9, it was used as a therapeutic intervention for agitation based upon the Patient's personal preferences. Interview with RN #5, Supervisor, on 03/06/12 at 11:20 AM identified that the use of the tub was part of Patient #9's Personal Preference for soothing. Transfer would be accomplished by assistance of 2 staff and the patient would be monitored by one staff while in the tub.
During interview with Patient #9 on 03/05/12 at 3:30 PM the patient stated "no more big tub, too cold. I love my shower."
Interview with MHA #10 on 3/6/12 at 3:30 PM identified that two patients on the unit that included Patient #9, utilized the tub for bathing. MHA #10 stated that the lift for the tub was missing since his/her transfer to the unit and demonstrated to the surveyor how Patient #9 was lifted into the tub. In addition, MHA #10 stated that the water temperature was sometimes difficult to adjust and that although the tub was filled before the patient got transferred in, sometimes additional water is run and that it was possible for the water to be initially cold before warming up. Although MHA #10 denied that transfer was difficult, the demonstration observed was shared as a concern with the facility for safe transfer of patients into the tub in the absence of a lift. Based on MHAs #10's demonstration of the transfer of Patient #9 into the tub and the potential for a stream of cold water to enter the tub before the water warmed up, the facility chose to restrict further use of the tub until the lift and faucets could be examined/repaired and/or a new tub could be purchased.

Based on medical record reviews, review of facility documentation, review of facility policies/practice and interviews, the hospital failed to ensure for the prevention, control, and investigation of infections and communicable diseases related to patients who tested positive for tuberculosis.
Please refer to A748.

Based on medical record reviews, review of facility documentation and interviews, the facility failed to ensure that infection control policies governing the control of tuberculosis (TB) infection were implemented for 7 of 7 patients (Patients #18, #19, #20, #21, #24) who had positive TB testing. The finding includes:

a. Patient #18 had a diagnosis of paranoid schizophrenia and was admitted to the B3S unit on 2/15/12. Discharge paperwork from Acute Care Hospital #2 identified that the patient had a positive TB skin test. Blood work results dated 2/17/12 indicated a positive QFT. The chest x-ray (CXR) ordered by MD #3 and performed on 2/22/12 noted no focal infiltrates and emphysema. Although nursing narratives dated 2/23/12 identified that MD #3 was informed of the CXR results, integrated progress notes dated 2/21/12 to 3/19/12 lacked an assessment of the patient by MD #3 or another clinician for potential active TB symptoms, possible exposure to TB and/or evaluation for prophylactic therapy. The patient was assessed by APRN #2 on 3/20/12 and 3/26/12, and the patient subsequently began treatment for a latent TB infection on 3/27/12 (lapse of greater than 1 month after the first positive QFT).
In addition, the medical clinicians failed to update the medical problem list to include the latent TB infection until 3/27/12, resulting in a lack of revision to the patient's integrated treatment plans (ITP) dated 2/24/12, 3/6/12 and 3/20/12. Interview with MD #5 on 4/24/12 at 9:40 AM noted that the medical clinician should update the problem list portion of the history and physical to ensure that the problem was noted on the patient's next treatment plan.

b. Patient #19 had diagnoses of substance abuse and schizoaffective disorder and was admitted to the B4N unit on 1/9/12. Blood work results dated 1/12/12 indicated a positive QFT. Although the CXR result performed on 1/13/12 noted no symptoms for positive QFT and no acute pulmonary disease, integrated progress notes dated 1/12/12 through 1/18/12 lacked an assessment of the patient by the covering clinician for active TB symptoms, possible exposure to TB and/or evaluation for prophylactic therapy. The patient was subsequently assessed by APRN #2 on 3/13/12 (1 month after the positive QFT) and subsequent QFT ordered by APRN #2 and collected on 3/15/12 and 3/19/12 noted negative results. Interview with MD #5 on 4/24/12 at 9:30 AM noted that it was not uncommon to get an initial false positive QFT, which may be due to drugs in the patient's system interacting with the test, and that the clinician needed to find out if the patient was symptomatic and obtain a history after a QFT was reported as positive.
c. Patient #20 had a diagnosis of substance abuse and was admitted to Addiction Services on 2/24/12. Blood work ordered on 2/24/12 and collected on 3/2/12 due to the patient's prior refusals indicated a positive QFT which was reported on 3/5/12. The patient was assessed by the clinician with no signs and symptoms of active TB on 3/1/12, had no cough, fever, chills, and had a reported past history of a positive TB skin test documented by the clinician on 3/5/12. The CXR ordered by MD #4 on 3/5/12 and performed on 3/6/12 noted no focal infiltrates. The CXR results lacked a clinician's initials and/or date to indicate that a clinician was made aware of the CXR results. Although MD #4 met with the patient on 3/9/12, discussion for evaluation for prophylactic therapy was not documented. Patient #20 was discharged on 4/4/12. Interview with MD #5 on 4/27/12 at 10:30 AM noted that the decision to treat Patient #20 for latent TB infection would depend on the patient's history and continuity of medical oversight after discharge. S/he further indicated that s/he was not sure why MD #4 did not start Patient #20 on prophylactic treatment as the reasoning was not documented. Interview with MD #5 on 4/27/12 at 11:00 AM identified that s/he spoke with MD #4 and MD #4 did not recall seeing the patient's CXR. Interview with Director of Regulatory Compliance on 4/27/12 at 9:30 AM noted that per facility practice, results of x-rays are posted on the unit's medical board and either the psychiatrist or medical physician needs to sign the results and the results are then filed. The facility medical record maintenance policy identified that laboratory reports/tests must be initialed and dated by the appropriate psychiatrist and physician or ambulatory care service clinician prior to filing in the medical record.
d. Patient #21 had a diagnosis of substance abuse and was admitted to Addiction Services on 2/7/12. The history and physical dated 2/7/12 identified that the patient had a latent TB infection, a history of a past positive TB test, and was not treated. Blood work results reported on 2/10/12 indicated a positive QFT. Although the CXR result performed on 2/8/12 to rule out active TB noted no active disease, integrated progress notes dated 2/8/12 through discharge on 2/13/12 lacked an assessment of the patient by the clinician for possible exposure to TB and/or evaluation for prophylactic therapy. The CXR result also identified that the physician viewed the results of the x-ray on 2/28/12, after the patient was discharged. In addition, Patient #21's integrated treatment plan dated 2/10/12 lacked the problem of the patient's latent TB infection to include goals and/or interventions for monitoring and/or treatment. The patient's discharge summary dated 2/7/12 completed by the physician indicated that the patient would have discharge follow- up at Acute Care Hospital #1 and did not include the medical diagnosis of latent TB infection.
e. Patient #24 had a diagnosis of substance abuse and was admitted to Addiction Services on 2/15/12. Blood work results reported on 2/17/12 indicated a positive QFT and the 2/21/12 CXR was negative. Integrated progress notes dated 2/17/12 through discharge on 2/13/12 lacked an assessment of the patient by the clinician for active TB symptoms, possible exposure to TB and/or evaluation for prophylactic therapy. In addition, the medical clinicians failed to document the latent TB infection and the problem was not identified on the patient's integrated treatment plans dated 2/21/12, 3/6/12 and 3/19/12.
f. Patient #22 had a diagnosis of substance abuse and was admitted to Addiction Services on 3/12/12. The client face sheet noted that the patient lived at home and the home phone number was documented. The history and physical and initial nursing assessment dated 3/12/12 did not indicate that the patient had a history active or latent TB infection. Nursing narratives noted that the patient was discharged to home on 3/16/12 at 9:30 AM. Blood work results identified that blood for an ordered QFT was collected on 3/13/12 and was reported as positive for latent TB infection on 3/16/12 at 1:45 PM after the patient had been discharged. The discharge after care plan indicated that the Patient had a QFT and results were pending. The patient's medical record lacked documentation that the clinician attempted to notify the patient of the positive results after discharge.
g. Patient #23 had a diagnosis of substance abuse and was admitted to Addiction Services on 2/6/12. The client face sheet noted that the patient lived at home, did not have a home phone number and the name and phone number of a family member was listed as a collateral contact. The history and physical and initial nursing assessment dated 2/6/12 did not indicate that the patient had a history active or latent TB infection. Nursing narratives noted that the patient was discharged to home on 2/10/12 at 8:30 AM. Blood work results identified that blood for an ordered QFT was collected on 2/8/12 and was reported as positive for latent TB infection on 2/10/12 at 1:20 PM after the patient had been discharged. The discharge after care plan dated 2/10/12 noted that the plan was given to the patient and was incomplete to identify that a QFT had been performed, the results of the QFT or that attempts were made by the clinician to notify the patient of the positive results after discharge.
Interview with MD #5 on 5/8/12 indicated that the clinicians would notify the patient's known community provider of pending test results after the patient was discharged.
The hospital medical staff rules and regulations identified that the Attending Psychiatrist shall be responsible, in part, for assuring continuity of care after discharge.
The facility policy for infection prevention identified that a physical examination and history will be done to assess for symptoms of active TB disease and any possible exposure to TB after a positive QFT. The policy further noted that persons with a new positive QFT will have a CXR to rule out active disease and if the CXR is negative, the person should be evaluated for prophylactic therapy for 6-12 months with Isoniazid (INH).
The facility documentation of patient progress policy identified that progress notes are written, in part, to document results or to communicate any changes in the patient's condition.
The facility integrated treatment planning process policy identified that the treatment plan is reviewed on a regular basis to ensure that it effectively addresses the needs of the individual receiving care. The review begins with a Present Status assessment to identify interval changes that have occurred to include any new risk, medical or diagnostic issue.
The medical staff rules and regulations identified that the integrated problem list and master treatment plan shall be completed under the direction of the Attending Psychiatrist and shall be based on the assessments completed by all members of the treatment team including Ambulatory Care Services.

Based on medical record reviews, review of facility documentation and interviews the hospital failed to ensure that the identified problem of initial false positive Quantiferon testing (QFT) was addressed in the quality assurance program. The finding includes:

Patient #19 was admitted to the facility on 1/9/12 with a diagnosis of substance abuse. Physician orders dated 1/9/12 directed a QFT for tuberculosis screening. The QFT collected on 1/10/12 was reported as positive on 1/12/12. The chest x-ray dated 1/13/12 identified no acute pulmonary disease. Subsequent QFT testing results dated 3/15/12 and 3/19/12 were negative. Interview with MD #5 (Infectious Disease physician) on 4/24/12 at 9:43 AM and/or on 5/8/12 at 10:55 AM noted that the patient's QFT result of 1/10/12 was a false positive, initial false positive results were first observed approximately 6 months to 1 year ago and may be related to the change in laboratory technique. Interview with the Nursing Director of Ambulatory Care Services on 5/8/12 at 10:55 AM indicated that the laboratory performance was routinely reported as part of Quality Assurance and that s/he meets with laboratory staff weekly. Further interview with MD #5 on 5/8/12 at 10:55 AM noted that the problem of initial false positive QFT results had not been discussed with the laboratory department however; clinicians had been informed of the problem an instructed to repeat the QFT in 1 to 2 weeks. The governing body bylaws identified that a responsibility of the Director of Ambulatory Care Services responsibilities was to oversee contracted medical support services to include laboratory services.

Based on medical record reviews, review of facility documentation, review of facility policies/practice and interviews for 7 of 7 patients (Patients #18, #19, #20, #21, #22, #23, #24) who had a positive test result (Quantiferon (QFT)) for tuberculosis (TB), clinicians failed to perform and/or timely perform a post positive QFT assessment of the patient and/or provide for follow-up and/or timely follow-up treatment for latent TB infection and/or update/timely update the patient's medical treatment plan. The finding includes:

a. Patient #18 had a diagnosis of paranoid schizophrenia and was admitted to the B3S unit on 2/15/12. Discharge paperwork from Acute Care Hospital #2 identified that the patient had a positive TB skin test. Blood work results dated 2/17/12 indicated a positive QFT. The chest x-ray (CXR) ordered by MD #3 and performed on 2/22/12 noted no focal infiltrates and emphysema. Although nursing narratives dated 2/23/12 identified that MD #3 was informed of the CXR results, integrated progress notes dated 2/21/12 to 3/19/12 lacked an assessment of the patient by MD #3 or another clinician for potential active TB symptoms, possible exposure to TB and/or evaluation for prophylactic therapy. The patient was assessed by APRN #2 on 3/20/12 and 3/26/12, and the patient subsequently began treatment for a latent TB infection on 3/27/12 (lapse of greater than 1 month after the first positive QFT).
In addition, the medical clinicians failed to update the medical problem list to include the latent TB infection until 3/27/12, resulting in a lack of revision to the patient's integrated treatment plans (ITP) dated 2/24/12, 3/6/12 and 3/20/12. Interview with MD #5 on 4/24/12 at 9:40 AM noted that the medical clinician should update the problem list portion of the history and physical to ensure that the problem was noted on the patient's next treatment plan.

b. Patient #19 had diagnoses of substance abuse and schizoaffective disorder and was admitted to the B4N unit on 1/9/12. Blood work results dated 1/12/12 indicated a positive QFT. Although the CXR result performed on 1/13/12 noted no symptoms for positive QFT and no acute pulmonary disease, integrated progress notes dated 1/12/12 through 1/18/12 lacked an assessment of the patient by the covering clinician for active TB symptoms, possible exposure to TB and/or evaluation for prophylactic therapy. The patient was subsequently assessed by APRN #2 on 3/13/12 (1 month after the positive QFT) and subsequent QFT ordered by APRN #2 and collected on 3/15/12 and 3/19/12 noted negative results. Interview with MD #5 on 4/24/12 at 9:30 AM noted that it was not uncommon to get an initial false positive QFT, which may be due to drugs in the patient's system interacting with the test, and that the clinician needed to find out if the patient was symptomatic and obtain a history after a QFT was reported as positive.
c. Patient #20 had a diagnosis of substance abuse and was admitted to Addiction Services on 2/24/12. Blood work ordered on 2/24/12 and collected on 3/2/12 due to the patient's prior refusals indicated a positive QFT which was reported on 3/5/12. The patient was assessed by the clinician with no signs and symptoms of active TB on 3/1/12, had no cough, fever, chills, and had a reported past history of a positive TB skin test documented by the clinician on 3/5/12. The CXR ordered by MD #4 on 3/5/12 and performed on 3/6/12 noted no focal infiltrates. The CXR results lacked a clinician's initials and/or date to indicate that a clinician was made aware of the CXR results. Although MD #4 met with the patient on 3/9/12, discussion for evaluation for prophylactic therapy was not documented. Patient #20 was discharged on 4/4/12. Interview with MD #5 on 4/27/12 at 10:30 AM noted that the decision to treat Patient #20 for latent TB infection would depend on the patient's history and continuity of medical oversight after discharge. S/he further indicated that s/he was not sure why MD #4 did not start Patient #20 on prophylactic treatment as the reasoning was not documented. Interview with MD #5 on 4/27/12 at 11:00 AM identified that s/he spoke with MD #4 and MD #4 did not recall seeing the patient's CXR. Interview with Director of Regulatory Compliance on 4/27/12 at 9:30 AM noted that per facility practice, results of x-rays are posted on the unit's medical board and either the psychiatrist or medical physician needs to sign the results and the results are then filed. The facility medical record maintenance policy identified that laboratory reports/tests must be initialed and dated by the appropriate psychiatrist and physician or ambulatory care service clinician prior to filing in the medical record.
d. Patient #21 had a diagnosis of substance abuse and was admitted to Addiction Services on 2/7/12. The history and physical dated 2/7/12 identified that the patient had a latent TB infection, a history of a past positive TB test, and was not treated. Blood work results reported on 2/10/12 indicated a positive QFT. Although the CXR result performed on 2/8/12 to rule out active TB noted no active disease, integrated progress notes dated 2/8/12 through discharge on 2/13/12 lacked an assessment of the patient by the clinician for possible exposure to TB and/or evaluation for prophylactic therapy. The CXR result also identified that the physician viewed the results of the x-ray on 2/28/12, after the patient was discharged. In addition, Patient #21's integrated treatment plan dated 2/10/12 lacked the problem of the patient's latent TB infection to include goals and/or interventions for monitoring and/or treatment. The patient's discharge summary dated 2/7/12 completed by the physician indicated that the patient would have discharge follow- up at Acute Care Hospital #1 and did not include the medical diagnosis of latent TB infection.
e. Patient #24 had a diagnosis of substance abuse and was admitted to Addiction Services on 2/15/12. Blood work results reported on 2/17/12 indicated a positive QFT and the 2/21/12 CXR was negative. Integrated progress notes dated 2/17/12 through discharge on 2/13/12 lacked an assessment of the patient by the clinician for active TB symptoms, possible exposure to TB and/or evaluation for prophylactic therapy. In addition, the medical clinicians failed to document the latent TB infection and the problem was not identified on the patient's integrated treatment plans dated 2/21/12, 3/6/12 and 3/19/12.
f. Patient #22 had a diagnosis of substance abuse and was admitted to Addiction Services on 3/12/12. The client face sheet noted that the patient lived at home and the home phone number was documented. The history and physical and initial nursing assessment dated 3/12/12 did not indicate that the patient had a history active or latent TB infection. Nursing narratives noted that the patient was discharged to home on 3/16/12 at 9:30 AM. Blood work results identified that blood for an ordered QFT was collected on 3/13/12 and was reported as positive for latent TB infection on 3/16/12 at 1:45 PM after the patient had been discharged. The discharge after care plan indicated that the Patient had a QFT and results were pending. The patient's medical record lacked documentation that the clinician attempted to notify the patient of the positive results after discharge.
g. Patient #23 had a diagnosis of substance abuse and was admitted to Addiction Services on 2/6/12. The client face sheet noted that the patient lived at home, did not have a home phone number and the name and phone number of a family member was listed as a collateral contact. The history and physical and initial nursing assessment dated 2/6/12 did not indicate that the patient had a history active or latent TB infection. Nursing narratives noted that the patient was discharged to home on 2/10/12 at 8:30 AM. Blood work results identified that blood for an ordered QFT was collected on 2/8/12 and was reported as positive for latent TB infection on 2/10/12 at 1:20 PM after the patient had been discharged. The discharge after care plan dated 2/10/12 noted that the plan was given to the patient and was incomplete to identify tha

Based on a review of clinical records, review of facility documentation, review of facility policies, and interview, the facility failed to ensure that medical records were complete, released in a timely fashion, and/or that the discharge plan was accurate for six of eleven patients (Patients #15, #19, #20, #21, #23, #24). The finding includes:
a. Patient #15 was admitted to the facility on 9/9/11 for rehabilitation and was subsequently discharged on 10/28/11. Review of facility documentation identified that an appropriate authorization request dated 12/20/11 was made to have Patient #15's clinical records be released to a named government agency. A second request by the same government agency dated 1/3/12 identified that Patient #15's records were not sent until 2/25/12, more than two months after the initial request. Interview with the Director of Medical Records on 3/23/12 at 11:00 AM identified that facility policy directed that barring specific limitations for the release of clinical records, records are released with the proper authorization within thirty days. The Director of Medical Records stated that although he/she believed that Patient #15's records, at the patient's request, were mailed to the named government agency before the second request on 1/3/12, he/she could not provide proof of the mailing. The Director of Medical Records was unable to provide an explanation for the delay in releasing Patient #15's records from the time of the second request on 1/3/12 to 2/25/12 when the records were sent.
b. Review of Patient #15's clinical record identified that although the patient was discharged on 10/28/11, the discharge summary was not completed until 1/25/12. Interview with the Director of Medical Records identified that he/she was working with facility staff to ensure that discharge summaries were completed within thirty days after discharge to remain in compliance with facility policies.
c. Patient #23 had a diagnosis of substance abuse and was admitted to Addiction Services on 2/6/12. Blood work results identified that blood for an ordered QFT was collected on 2/8/12 and was reported as positive for latent TB infection on 2/10/12 at 1:20 PM after the patient had been discharged. The discharge after care plan dated 2/10/12 noted that the plan was given to the patient and was incomplete to identify that a Quantiferon test QFT had been performed and/or that results were pending. The hospital medical staff rules and regulations identified that each member shall be responsible for maintaining complete and legible records for his/her patients.

d. Patients #19, #20, #21 and #24 were admitted to the facility during the period of time from 1/9/12 to 2/15/12. Patient #19 had a chest x-ray (CXR) dated 1/13/12. Review of the CXR report with the Director of Compliance on 5/8/12 at 1:30 PM noted that the CXR report was initialed as viewed by one practitioner and lacked the date that the practitioner reviewed and initialed the report. Patient #20 had a CXR dated 3/5/12. Review of the CXR report with the Director of Compliance on 5/8/12 at 1:30 PM indicated that the CXR lacked provider initials to indicate that the report was reviewed by the medical and psychiatric practitioner. Patient #21 had a QFT performed on 2/8/12. Review of the QFT report with the Director of Compliance on 5/8/12 at 1:30 PM identified that the QFT report was initialed as viewed by one practitioner. Patient #24 had a CXR performed on 2/21/12. Review of the CXR report with the Director of Compliance on 5/8/12 at 1:30 PM noted that the CXR report was initialed as viewed by one practitioner. The hospital policy for medical record maintenance identified that laboratory reports, other diagnostic/special tests (i.e. x-ray, EEG, etc.) and consultations must be initialed and dated by the appropriate Psychiatrist and Physician or Ambulatory Care Service Clinician prior to filing in the medical record.




15888

Based on medical record reviews, review of facility documentation and interviews, the facility failed to ensure that infection control policies governing the control of tuberculosis (TB) infection were implemented for 7 of 7 patients (Patients #18, #19, #20, #21, #24) who had positive TB testing. The finding includes:

a. Patient #18 had a diagnosis of paranoid schizophrenia and was admitted to the B3S unit on 2/15/12. Discharge paperwork from Acute Care Hospital #2 identified that the patient had a positive TB skin test. Blood work results dated 2/17/12 indicated a positive QFT. The chest x-ray (CXR) ordered by MD #3 and performed on 2/22/12 noted no focal infiltrates and emphysema. Although nursing narratives dated 2/23/12 identified that MD #3 was informed of the CXR results, integrated progress notes dated 2/21/12 to 3/19/12 lacked an assessment of the patient by MD #3 or another clinician for potential active TB symptoms, possible exposure to TB and/or evaluation for prophylactic therapy. The patient was assessed by APRN #2 on 3/20/12 and 3/26/12, and the patient subsequently began treatment for a latent TB infection on 3/27/12 (lapse of greater than 1 month after the first positive QFT).
In addition, the medical clinicians failed to update the medical problem list to include the latent TB infection until 3/27/12, resulting in a lack of revision to the patient's integrated treatment plans (ITP) dated 2/24/12, 3/6/12 and 3/20/12. Interview with MD #5 on 4/24/12 at 9:40 AM noted that the medical clinician should update the problem list portion of the history and physical to ensure that the problem was noted on the patient's next treatment plan.

b. Patient #19 had diagnoses of substance abuse and schizoaffective disorder and was admitted to the B4N unit on 1/9/12. Blood work results dated 1/12/12 indicated a positive QFT. Although the CXR result performed on 1/13/12 noted no symptoms for positive QFT and no acute pulmonary disease, integrated progress notes dated 1/12/12 through 1/18/12 lacked an assessment of the patient by the covering clinician for active TB symptoms, possible exposure to TB and/or evaluation for prophylactic therapy. The patient was subsequently assessed by APRN #2 on 3/13/12 (1 month after the positive QFT) and subsequent QFT ordered by APRN #2 and collected on 3/15/12 and 3/19/12 noted negative results. Interview with MD #5 on 4/24/12 at 9:30 AM noted that it was not uncommon to get an initial false positive QFT, which may be due to drugs in the patient's system interacting with the test, and that the clinician needed to find out if the patient was symptomatic and obtain a history after a QFT was reported as positive.
c. Patient #20 had a diagnosis of substance abuse and was admitted to Addiction Services on 2/24/12. Blood work ordered on 2/24/12 and collected on 3/2/12 due to the patient's prior refusals indicated a positive QFT which was reported on 3/5/12. The patient was assessed by the clinician with no signs and symptoms of active TB on 3/1/12, had no cough, fever, chills, and had a reported past history of a positive TB skin test documented by the clinician on 3/5/12. The CXR ordered by MD #4 on 3/5/12 and performed on 3/6/12 noted no focal infiltrates. The CXR results lacked a clinician's initials and/or date to indicate that a clinician was made aware of the CXR results. Although MD #4 met with the patient on 3/9/12, discussion for evaluation for prophylactic therapy was not documented. Patient #20 was discharged on 4/4/12. Interview with MD #5 on 4/27/12 at 10:30 AM noted that the decision to treat Patient #20 for latent TB infection would depend on the patient's history and continuity of medical oversight after discharge. S/he further indicated that s/he was not sure why MD #4 did not start Patient #20 on prophylactic treatment as the reasoning was not documented. Interview with MD #5 on 4/27/12 at 11:00 AM identified that s/he spoke with MD #4 and MD #4 did not recall seeing the patient's CXR. Interview with Director of Regulatory Compliance on 4/27/12 at 9:30 AM noted that per facility practice, results of x-rays are posted on the unit's medical board and either the psychiatrist or medical physician needs to sign the results and the results are then filed. The facility medical record maintenance policy identified that laboratory reports/tests must be initialed and dated by the appropriate psychiatrist and physician or ambulatory care service clinician prior to filing in the medical record.
d. Patient #21 had a diagnosis of substance abuse and was admitted to Addiction Services on 2/7/12. The history and physical dated 2/7/12 identified that the patient had a latent TB infection, a history of a past positive TB test, and was not treated. Blood work results reported on 2/10/12 indicated a positive QFT. Although the CXR result performed on 2/8/12 to rule out active TB noted no active disease, integrated progress notes dated 2/8/12 through discharge on 2/13/12 lacked an assessment of the patient by the clinician for possible exposure to TB and/or evaluation for prophylactic therapy. The CXR result also identified that the physician viewed the results of the x-ray on 2/28/12, after the patient was discharged. In addition, Patient #21's integrated treatment plan dated 2/10/12 lacked the problem of the patient's latent TB infection to include goals and/or interventions for monitoring and/or treatment. The patient's discharge summary dated 2/7/12 completed by the physician indicated that the patient would have discharge follow- up at Acute Care Hospital #1 and did not include the medical diagnosis of latent TB infection.
e. Patient #24 had a diagnosis of substance abuse and was admitted to Addiction Services on 2/15/12. Blood work results reported on 2/17/12 indicated a positive QFT and the 2/21/12 CXR was negative. Integrated progress notes dated 2/17/12 through discharge on 2/13/12 lacked an assessment of the patient by the clinician for active TB symptoms, possible exposure to TB and/or evaluation for prophylactic therapy. In addition, the medical clinicians failed to document the latent TB infection and the problem was not identified on the patient's integrated treatment plans dated 2/21/12, 3/6/12 and 3/19/12.
f. Patient #22 had a diagnosis of substance abuse and was admitted to Addiction Services on 3/12/12. The client face sheet noted that the patient lived at home and the home phone number was documented. The history and physical and initial nursing assessment dated 3/12/12 did not indicate that the patient had a history active or latent TB infection. Nursing narratives noted that the patient was discharged to home on 3/16/12 at 9:30 AM. Blood work results identified that blood for an ordered QFT was collected on 3/13/12 and was reported as positive for latent TB infection on 3/16/12 at 1:45 PM after the patient had been discharged. The discharge after care plan indicated that the Patient had a QFT and results were pending. The patient's medical record lacked documentation that the clinician attempted to notify the patient of the positive results after discharge.
g. Patient #23 had a diagnosis of substance abuse and was admitted to Addiction Services on 2/6/12. The client face sheet noted that the patient lived at home, did not have a home phone number and the name and phone number of a family member was listed as a collateral contact. The history and physical and initial nursing assessment dated 2/6/12 did not indicate that the patient had a history active or latent TB infection. Nursing narratives noted that the patient was discharged to home on 2/10/12 at 8:30 AM. Blood work results identified that blood for an ordered QFT was collected on 2/8/12 and was reported as positive for latent TB infection on 2/10/12 at 1:20 PM after the patient had been discharged. The discharge after care plan dated 2/10/12 noted that the plan was given to the patient and was incomplete to identify that a QFT had been performed, the results of the QFT or that attempts were made by the clinician to notify the patient of the positive results after discharge.
Interview with MD #5 on 5/8/12 indicated that the