HospitalInspections.org

Based on review of the facility 2016 Quality Assurance/Performance Improvement Plan (QAPI), review of facility contracted services list, and interview, it was determined the facility failed to ensure quality data collection was performed and program improvement opportunities identified for all contracted facility services. This had the potential to affect all patients treated at the facility.

2016 Quality Assurance/Performance Improvement Plan
Revision Date 12/21/2015

I. Mission/Goals
"...To provide high quality patient and acute care in a rural setting...
II. Vision
...3. Establish a culture that fosters safety as a priority...
III. Goals
A. Incorporate the performance improvement process into the structure of all departments and services existing quality programs...
B. Improve safety and quality of care and utilization of hospital resources through the incorporation of best practices...
E. Continue to perform monitoring to comply with requirement of...regulatory agencies and standards.
F. Coordinate and integrate medical staff, hospital committee, and departmental monitoring and evaluation activities.
I. To provide a system for managing the data required to improve quality and safety of patient care...
IV. Principles of Performance Improvement
...B. Measuring these process and their outcomes...
C. Assess, aggregate and analyze collected data to identify key areas for improving patient care...

I. Maintain accurate records on all activities.

X. Annual Program Evaluation Plan
...The PI (performance improvement) Director is responsible for coordinating the presentation of the annual review..."

Findings include:

A review of the QAPI program was conducted on 4/12/16 at 1:00 PM and revealed no documentation of participation by contracted services for Pharmacy, Laboratory, Radiology or Therapy Services.

An interview was conducted on 4/13/16 at 8:15 AM with Employee Identifier (EI) # 3, Registered Nurse (RN) Director of Nursing, confirmed the facility failed to ensure contracted services and services provided under arrangement participated in and demonstrated evidence of the QAPI program.

Based on review of the medical records and interviews with facility staff it was determined the facility failed to ensure physician orders were followed and completed as ordered for 2 of 7 active records reviewed. This affected MR # 8 and # 10 and had the potential to negatively affect all patients served by the facility.

Findings include:

1. MR # 8 was admitted to the facility on 3/25/16 with Dementia with Agitation.

Review of the 3/27/16 Physician's Order revealed the following orders for the Skilled Nurse (SN):
1. Increase Coumadin to 4.5 milligram (mg) by mouth (PO) at bedtime.
2. INR (International Ratio) in 3 days.

Review of the 3/30/16, 4/1/16, 4/2/16, 4/3/16, and 4/4/16 SN notes revealed no documentation lab work was obtained to check the patient's INR as ordered.

Further review of the 4/4/16 SN notes revealed documentation the patient fell and was sent to emergency room (ER) for evaluation. The patient was returned to the facility with a Physician's Order to hold Coumadin for 2 days (INR 4.3). Repeat INR on 4/6/16.

Review of the 4/6/16 SN note revealed documentation the staff unsuccessfully attempted to obtain a blood specimen at 5:05 AM and 7:00 AM. There was no documentation the physician was notified the blood was not obtained and no further attempts were made to obtain the blood.

Review of the 4/7/16 resulted lab report revealed the patient's Protime (PT) 25.5 and INR 2.6. There were no further orders for the SN to obtain labs to monitors the patient's Coumadin.

Review of the 4/11/16 Interdisciplinary- Progress Note revealed documentation of blood in urine.

Review of the 4/11/16 6:00 AM Physician's Order revealed the orders to include an INR STAT... and the results were INR 6.7 and PT 71.0.

The patient was transferred to the ER on 4/12/16 at 9:00 AM and later admitted.

In an interview conducted on 4/13/16 at 8:05 AM with Employee Identifier (EI) # 3, Director of Nursing (DON), verified the staff did not follow physician orders and coordinate the care of the patient.




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2. MR # 10 was admitted to the hospital 3/31/16 with an Axis I (major mental) diagnosis, Bipolar Affective Disorder manic phase severe without psychotic features and Axis III (medical conditions) diagnosis Moderate Obesity.

Review of 4/8/16 physician orders revealed a Tegretol level and Basic Metabolic Profile were ordered.

There were no results of the above lab tests in the medical record on 4/13/16.

Written questions were submitted to facility staff on 4/13/16 at 9:15 AM. EI # 3's written responses received on 4/13/16 at 10:45 AM confirmed lab work was not obtained as ordered.

Based on review of medical records (MR), policies and procedures and interviews, the hospital staff failed to:

1. Document the anatomical location of medication injection sites.

2. Document medications administered on the Medication Administration Record (MAR).

3. Document all PRN (as needed) medications on the MAR.

4. Ensure the physician's history and physical included the date and time the document was authenticated.

This affected MR's # 8, # 4, # 6, # 12 # 10 and # 11, 6 of 12 records reviewed and 2 unsampled records # 13 and # 15. This had the potential to affect all patients served by this facility.

Findings include:


Policy: Medical Records Content

"2. Records of pertinent nursing observations of the patient and the patient's response to treatment.

3. The reasons for the use of and the response of the patient to PRN medication administered and justification for withholding scheduled medications...

a. Progress notes including the patient's response to medication and treatment rendered and observation(s) of patient by all members of treatment team providing services to the patient."

Policy # 6008: Medication Administration
Revised: 12.19.11

Policy:
It is the policy of U.S.A. Healthcare Psychiatric Services, LLC that medications shall be administered in a timely manner and as prescribed by the patient's ...physician...

Procedure:
6. The nurse administering the medication shall ensure that the right patient...
7. The individual administering the medication shall initial the patient's MAR (medication administration record) on the appropriate line and date for that specific day...
10. If a patient refuses medication...the nurse must contact the physician...The nurse administering medications shall initial and circle the MAR space provided for that particular drug.
11. When medications are administered...record in the patients' medical record:
a. The date and time the medication was administered;
b. The dosage;
c. The route of administration;
d. The injection site, if applicable;
f. Any results achieved and the time such results were observed; and
g. The signature and title of the person administering the drug.
...14. "NOW" orders will be given within 1 hour from time order is received by the nurse.
15. Medications that are ordered on a PRN (as needed) basis are not eligible for scheduled dosing time; these must be administered as ordered...Medications that are ordered on a PRN basis must only be used for indications prescribed.
20. Any explanatory note in the progress Notes shall be entered when drugs are withheld, refused or given other than scheduled time.
25. The patients' continuous need and use of PRN medications shall be evaluated by the Interdisciplinary Care Planning Team and the attending physician on a weekly basis..."


Medical Record Findings:

1. MR # 4 was admitted to the facility 1/7/16 with a diagnosis of Major Depressive Disorder.

A review of the MAR dated 1/13/16 through 1/26/16 revealed an order for Toradol 30 mg (milligrams) IM (Intramuscular) x 1 dose. The nurse initialed 1/14/16 at 9:00 AM the medication was administered. The nurse failed to document where/location of the injection, response to the medication and the reason the patient received the injection.

A review of the MAR dated 1/13/16 through 1/26/16 revealed an order for Rocephin 1 Gram x 3 days UTI (Urinary tract infection). The nurse initialed 1/14/16, 1/15/16 and 1/16/16 at 9:00 AM the medication was administered.

There was no documentation of the an anatomical injection site where the IM medications were administered.

In an interview 4/13/16 at 8:30 AM with Employee Identifier (EI) # 3, Director of Nursing confirmed the nurse failed to document appropriately.

2. MR # 6 was admitted to the facility 3/24/16 with a diagnosis of Dementia with Associated Agitation, Paranoia and Suspicion.

The order for the PPD is as follows: PPD on Admission, read in 72 hours and give 2nd PPD- read 2nd PPD in 72 hours.

A PPD (purified protein derivative) skin test for tuberculosis (TB) was administered 3/24/16 into the left forearm. There was no time documented when the test was administered.

A 2nd PPD was administered 3/27/16 to the right forearm.

There was no documentation on the MAR of the first test results being read and no time the 2nd test was administered.

The 3/30/16 date on the MAR indicates read -- no documentation is present on the MAR regarding reading either test.

An entry is present on the Interdisciplinary- Progress notes dated 3/31/16 at 11:10 AM by the CRNP (Certified Registered Nurse Practitioner), " Nursing staff states area of TB skin test with induration... skin right inner arm with induration (raised, hardened area ~ 1 cm (centimeter) mild irritation to site. + TB skin test, obtain CXR (chest X-ray)..."

A late entry is present on the Interdisciplinary- Progress notes dated 3/31/16 11:40 AM, " PPD skin test red and firm. CXR obtained tolerated well."

The nurse failed to document observation of the PPD and failed to confirm the test was repeated 72 hours later.

In an interview 4/13/16 at 8:30 AM with EI # 3, confirmed the above information.




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3. MR # 8 was admitted to the facility on 3/25/16 with Dementia with Agitation.

During the observation of a medication pass conducted on 4/12/16 at 8:15 AM and review of the April 2016 Medication Administration Record (MAR) revealed no documentation the patient's 4/11/16 9:00 AM medications were administered by the Skilled Nurse (SN) as ordered for the following medications:

Calcium 600 mgs + Vitamin D every day.
Ferrous Sulfate 325 mg every day.
Lasix 40 mg every day.
Diltiazem 120 mg every day.

Further review of the MAR revealed Vitamin K 4 mg subcutaneous (SQ) was admininisted at 8:55 AM. There was no documentation of the location the medication was administered.

In an interview conducted on 4/13/16 at 8:15 AM with EI # 3, the aforementioned findings were verified the staff failed to document administering the medications or location of the injection site.

***

Review of the MAR on 4/12/16 at 9:00 AM revealed the following documentation:

Review of the MAR for MR # 15, an unsampled patient. There was no documentation (initials of the nurse) the following medications were administered at 9:00 AM as ordered.

Ultram 2 tabs 50 mg (100 mg total) po BID (twice a day).
Plaquenil 200 mg daily.
Xanax 0.5 mg BID.

Facility staff failed to document medications were administered as ordered.

An interview was conducted on 4/13/16 at 8:15 AM with EI # 3, and verified the above findings.




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4. MR # 10 was admitted to the hospital 3/31/16 with an Axis I (major mental) diagnosis, Bipolar Affective Disorder manic phase severe without psychotic features and Axis III (medical conditions) diagnosis Moderate Obesity.

Record review revealed the following documents without dates and times completed and/or reviewed:

Psychiatric History and Physical- (dictated/transcribed 4/1/16). There was no date and time the physician reviewed and signed the evaluation.

Medical History and Physical-(dictated/transcribed 4/1/16). There was no date and time the nurse practitioner and physician reviewed and signed the evaluation.

Review of the 4/2/16 nursing documentation revealed Haldol, Benadryl and Ativan IM was administered at 9:50 AM.

There was no documentation of the an anatomical injection site where the IM medications were administered.

Review of the 4/5/16 11:25 AM nursing documentation revealed Humalog 5 units subcutaneous was administered.

There was no documentation of an anatomical injection site where the insulin was administered.

Review of MR's # 10 MAR included Refresh eye drops 2 drops both eyes every shift, start 4/1/16 and Trazadone 400 mg po at bedtime, start 3/31/16.

There was no initials of the nurse who administered Refresh eye drops on 4/10/16 at 10:00 PM and no documentation MR # 10 refused Refresh eye drops.

There was no initials of the nurse who administered Trazadone on 4/8/16 at 9:00 PM and no documentation MR # 10 refused Trazadone.

Facility staff failed to document medications were administered as ordered.

In an interview with EI # 3 on 4/13/16 at 10:56 AM after written questions were submitted 4/13/16 at 8:45 AM, EI # 3 confirmed the above findings.

*****

Review of the facility MAR on 4/11/16 at 1:30 PM revealed the following:

Review of MR # 12's MAR included Prilosec 20 mg po (by mouth) daily at 7:00 AM, start 3/29/16. There was no initials of the nurse who administered Prilosec and no documentation MR # 12 refused Prilosec on 3/29/16 at 7:00 AM.

Review of the MAR for MR # 13, an unsampled patient, included Amlodipine 5 mg po daily at 9:00 AM, start 3/31/16. There was no initials of the nurse who administered Amlodipine on 4/9/16 at 9:00 AM and no documentation MR # 13 refused Amlodipine.

Facility staff failed to document medications were administered as ordered.

An interview with EI # 3 on 4/13/16 at 10:56 AM was conducted after written questions were submitted on 4/13/16 at 8:45 AM. EI # 3 confirmed the above findings.

3. MR # 11 was admitted on 4/4/16 at 5:40 PM with diagnoses Axis I, Major Depressive Disorder, severe with dangerous suicidal impulses.

Record review revealed the following documents without dates and times completed and/or reviewed:

Psychiatric History and Physical- (dictated 4/5/16; transcribed 4/6/16). There was no date and time the physician reviewed and signed the evaluation.

Medical History and Physical-(dictated 4/5/16; transcribed 4/6/16). There was no date and time the nurse practitioner and physician reviewed and signed the evaluation.

Written questions were submitted to the facility staff on 4/13/16 at 8:45 AM. On 4/13/16 at 10:55 AM, EI # 3 confirmed staff failed to document date and times of document review and completion.

Based on review of medical records (MR) and interview it was determined in 3 of 12 records reviewed the physician failed to sign and date orders promptly. (The Merriam-Webster online dictionary defines 'Prompt' as performed readily or immediately.) This affected MR's # 3, #, 10 and # 11 and had the potential to affect all patients served in this facility.

Findings include:

1. MR # 3 was admitted to the facility 1/6/16 with diagnoses of Major Depression and Axis III diagnosis of Diabetes Mellitus and LBKA (left below the knee amputation).

The patient was discharged 1/18/16 to a medical facility. During review of the medical record an order was present in the medical record dated 1/18/16 at 1650 (4:50 PM) which was not signed by the physician.

In an interview on 4/13/16 at 8:30 AM with Employee Identifer (EI) # 3, Director of Nursing confirmed the above information.




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2. MR # 10 was admitted to the hospital 3/31/16 with an Axis I (major mental) diagnosis, Bipolar Affective Disorder manic phase severe without psychotic features and Axis III (medical conditions) diagnosis Moderate Obesity.

Record review revealed the following document without dates and times completed and/or reviewed:

Geriatric Admission Orders and Preliminary Treatment Plan: The document was signed by the physician, but no date and time documented.

3. MR # 11 was admitted on 4/4/16 at 5:40 PM with diagnoses Axis I, Major Depressive Disorder, severe with dangerous suicidal impulses.

Record review revealed the following document without dates and times completed and/or reviewed:

Adult Admission Orders and Preliminary Treatment Plan: The document was signed by the physician, but no date and time documented.

Written questions were submitted to the facility staff on 4/13/16 at 8:45 AM. On 4/13/16 at 10:55 AM, EI # 3 confirmed staff failed to document dates and times of review and completion of orders.

Based on review of the facility 7/1/2010 Pharmacy Consultant Agreement, Pharmacy & Therapeutics Committee Policy and Procedure, 2014, 2015 and 2016 Pharmacy & Therapeutics Committee Meeting Minutes and interviews, it was determined the facility failed to ensure:

a) The consulting pharmacist participated in quarterly Pharmacy and Therapeutics Committee Meeting Minutes per facility policy.

b). The Pharmacy and Therapeutics Committee submitted annual summaries to the facility Program Improvement Planning Committee per facility policy.

Findings include:

Policy # 13000: Pharmacy & Therapeutics Committee
Effective: 07.01.10

Purpose
To provide a standardized format and rules by which the Pharmacy and Therapeutics Committee will function.

Policy

The Pharmacy & Therapeutics Committee will be composed of at least one physician or one psychiatrist, the Administrator, the Director of Nursing or representative, and the Consulting Pharmacist of USA Healthcare Psychiatric Services, LLC.

"Procedure

1. The Pharmacy & Therapeutics Committee will have the following responsibilities:
a. Utilize clinical evidence from appropriate organizations as needed.
b. Establishing and maintaining the Drug Formulary...
c. Defining and monitoring medications which are determined to be experimental.
d. Implement a drug utilization evaluation (DUE) program.
e. Implement prior approval guidelines for medication utilization.
f. Implementing product withdrawal...based on FDA (federal drug administration) decisions or other safety safety considerations.
g. Makes recommendations concerning drugs to be stocked...

2. The Pharmacy & Therapeutics Committee meets at least quarterly and reports to the governing board by a written report.

Record Keeping

Minutes of Committee meeting and activities will be kept...approved at the next meeting and be available upon request.

Reporting

The Committee sends a summary of the past 12 months of activities to the Program Improvement Planning Committee annually."

An interview with Employee Identifier (EI) # 9, Pharmacy Consultant was conducted on 4/11/16 from 2:50 PM to 3:20 PM.

The surveyor asked EI # 9 if he conducted Pharmacy and Therapeutics Meetings at the facility. EI # 9 responded he did not participate in the facility Pharmacy & Therapeutics Committee meetings.

The surveyor asked EI # 9 what quality assurance/performance improvement (QAPI) activities were conducted to monitor pharmacy activities and services? EI # 9 reported he was not aware of any current pharmacy QAPI activities.

On 4/13/16 at 7:45 AM, a written request for the facility Pharmacy & Therapeutics Committee Meeting Minutes for 2014, 2015 and 2016 and Pharmacy QAPI documentation for 2015 and 2016 was submitted by EI # 3, Director of Nursing.

On 4/13/16 at 10:35 AM, EI # 2, Administrator presented the surveyor with The Pharmacy & Therapeutics Committee meetings documentation.

Review of the 2015 and 2016 Pharmacy & Therapeutics Committee meetings documentation revealed there was no Pharmacist/Consultant Pharmacist present at quarterly meetings on 3/2/15, 6/11/15, 12/22/15 and 3/24/16.

The facility failed to follow its Pharmacy & Therapeutics Committee responsibility to include the Consultant Pharmacist in quarterly meetings.

There was no documentation in the 2014 and 2015 Pharmacy & Therapeutic Meeting minutes the Committee submitted annual summaries of activities to the facility Program Improvement Planning Committee per policy.

In an interview conducted on 4/13/16 at 11:00 AM, EI # 2 confirmed the aforementioned findings.

Based on observation, review of medical record (MR) documentation, facility policy and staff interviews, it was determined the facility failed to follow its own policy and procedure for home medication administration.

This did affect MR # 14, unsampled patient and had the potential to affect all patients treated at the facility.

Findings include:

Policy # 6009; Medication Brought in By The Patient

Policy:
"...It is also policy that medications brought in by the patients are stored appropriately until time of discharge and establish guidelines for the appropriate action to be taken with medication brought into the hospital by the patient.

Procedure:

2. All medication should be sent home with family on admission when possible, unless unusual medication or the medication is not readily available. A physician's order must be obtained to use the patient's medications from home. The home medication must be inspected and properly identified before being dispense by staff the Charge Nurse..."

Observations of care were performed on 4/11/16 at 1:15 PM in the Adult unit medication room with Employee Identifier (EI) # 1, Registered Nurse, Supervisor.

The surveyor observed one bottle of Ampyra 10 mg (milligram) tab (tablet) ER (extended release) 1 po (by mouth) BID (twice daily) in a home medication container for MR # 14 who was, admitted to the facility 3/15/16 with diagnoses including "Suicidal Depression".

In an interview with EI # 1 at 1:20 PM on 4/11/16, the surveyor asked EI # 1 what was the facility's process to validate the authenticity of home medications administered by staff?

EI # 1 reported to the surveyor "we get a doctor's order to use a home med (medication) before we administer it". The surveyor asked EI # 1 if the pharmacist verified the home medications given to patients by staff? EI # 1's response was "No".

Review of MR # 14 failed to reveal documentation Ampyra 10 mg was inspected and properly identified before being dispensed by the Charge Nurse per facility policy. There was no physician's order to use MR # 14's home medication.

In an interview on 4/13/16 at 11:30 AM, EI # 3, RN, Director of Nursing and EI # 2, Administrator confirmed the above findings.

Based on observations and interview, it was determined the facility failed to ensure all medications / supplies available for patient use were not expired. This had the potential to negatively affect patients receiving care at this facility.

Findings include:

1. During a tour of the of the adult medication room conducted on 4/11/16 at 10:45 AM. The following medications/ supplies were observed to be expired:

3 vials of Eye Lubricant 0.5 milliliter (ml) expired on 1/16.
60 - Guaifenesin Extended Release 600 milligrams (mg) tablets expired on 3/4/16.
96 - Loperamide Hydrochloride 2 mg tablets expired on 2/19/16
40 - Purple top vacutainer vials expired on 1/16.

Found in the emergency cart was the following:
1 bag, 1000 ml Dextrose 5 %, expired 1/January 2015.
1 bag, 1000 ml Dextrose 5 %, expired 1/January 2016.
1 tube, 5 grams Actidose-AQ, expired 6/9/2015.
1 tube, 5 gram Actidose-AQ, expired 3/31/2016.
12 Ammonia AROM (aroma) inhalants, expired 3/25/2014.
1 Glucogen Hypokit 1 mg, expired 3/12/2016.

The above mentioned medications/ supplies were verified at the time of observation with Employee Identifier (EI) # 1, Registered Nurse (RN) Supervisor.

2. During a tour of the geriatric medication room conducted on 4/11/16 at 12:35 PM the following medications were observed to be expired:

28 - Nexium 24 20 mg Caplets revealed the pharmacy label with the expiration date of 3/10/16 and the manufacters expiration date on the box was 11/15.
96 - Lopermide Hydrochloride 2 mg tablets expired 2/19/16.
100- Aspirin Enteric Coated 325 mg tablets expired 1/14/16.
100- Vitamin E 100 soft gels expired 2/16.

The following wound care dressing supplies were observed to be expired:
2 - Duoderms expired 1/16.
2 - Hydrofera Blue expired 6/14.
3 - Derma Gran Hydrophilic expired 11/15.

The above mentioned medications/ supplies were verified at the time of observation with Employee Identifier (EI) # 6, Registered Nurse (RN) Supervisor.





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A tour of the Rehabiliation Therapy department on 4/12/16 at 11:10 AM was conducted with EI # 5, Licensed Physical Therapist Assistant, Rehabilitation Director.

In a locked cabinet available for patient use was one 5 liter container of Omnisound Gel, expired December 2012.

In an interview on 4/12/16 at 11:20 AM, EI # 5 confirmed the above.

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety. This had the potential to affect all patients served by the hospital.

Findings include:

Refer to Life Safety Code violations for findings.

Based on observations, review of facility policy, Centers for Disease Control (CDC) Healthcare Hand Hygiene recommendations and interviews, it was determined the facility failed to ensure:

a) Staff followed and performed hand hygiene and used gloves per facility policy and procedure and CDC recommendations.

b) Staff performed and documented active infection control surveillance for compliance with hand hygiene.

c) Hand Soap was available to staff and patients in all areas.

This affected medical record (MR) # 10 had the potential to negatively affect all patients and staff at this hospital.

Findings include:

Facility Policy # 450: Hand Hygiene-Handwashing
Effective: 06.01.10

Policy

Handwashing/hand hygiene is regarded by this facility as one of the single most important means of preventing the spread of infections.

"Procedure
1. Check for adequate paper towels before starting the hand washing procedure. Wet hands with water.
2. Apply soap to hands...for at least 20-25 seconds.
3. Rinse well without touching the inside of the sink or the faucet (these are always considered soiled). Leave the water running.
4. Dry hands well. When finished, turn off faucet with a clean paper towel.
Discard the towel...

A. When to Wash Hands
...7. Before and after each patient contact.
8. After touching a patient...
10. After contact with any body fluids.
11. After handling any contaminated items...


CDC
MMWR
Recommendations and Reports
October 25, 2002/51
"...Recommendations
1. Indications for handwashing and hand antisepsis...
Decontaminate hands after contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings if hands are not visibly soiled (IA) (400).
Decontaminate hands if moving from a contaminated-body site to a clean-body site during patient care (II) (25,53).
Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient (II) (46,53,54).
Decontaminate hands after removing gloves (IB) (50,58,321)..."


Observations of care were performed on 4/11/16 at 11:00 AM in the medication room on the Adult Unit that included blood glucose testing on MR # 10.

Employee Identifier (EI) # 1, Registered Nurse (RN), Supervisor performed hand hygiene using soap and water at the sink and dried her hands with paper towels. EI # 1 then turned off the faucet using clean bare hands, not a clean paper towel per facility policy and procedure.

EI # 1 donned gloves, performed blood glucose testing on MR # 10, removed/discarded gloves then completed hand hygiene using hand sanitizer.

EI # 1 opened the medication record administration, documented the test results.

EI # 1 then donned gloves without first performing hand hygiene, cleaned with glucometer with a disposable Super Sani Wipe disinfectant cloth and removed and discarded gloves.

EI # 1 failed to perform hand hygiene prior to and immediately after glove removal.

In an interview on 4/11/16 at 11:10 AM, EI # 1 confirmed the above observations.




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A tour of the facilities Adult Unit was conducted on 4/11/16 at 9:30 AM. During the tour of the Patient Laundry Room, the surveyor observed there was no soap found in the wall dispenser above the sink for patients and staff to wash hands with after placing dirty laundry in the washing machines.

The surveyor also observed empty soap dispensers in the Clean and Dirty Utility rooms.

The staff had no means of applying soap to wash hands if their hands were visibly soiled.

In an interview conducted on 4/13/16 at 9:50 AM with EI # 4, who verified the above mentioned findings. EI # 4 stated, "The staff have hand sanitizer in their pockets to clean their hands with."

---. During the observation of a medication pass conducted on 4/11/16 at 11:30 AM. EI # 1, was observed to wash hands at sink, turn off the water with clean hands, and then dry with paper towels. EI # 1 then began preparing patient medications for administration.

An interview was conducted on 4/13/16 at 9:50 AM with EI # 4, and the aforementioned findings were verified.

---. During the observation of a medication pass conducted on 4/11/16 at 12:35 PM. EI # 6, was observed to wash hands in the geriatric kitchen area with soap and water, rinse hands, and turn off faucet. There were no paper towels available in the dispenser to dry hands with.

In an interview conducted on 4/13/16 at 9:50 AM with EI # 4, verified the staff did not follow hand washing policy.

Based on medical record (MR) review and interviews, it was determined the facility failed to ensure psychiatric evaluations included a complete psychiatric history.

This affected MR # 11, 1 of 5 active records reviewed on the Adult Unit and had the potential to affect all patients treated at the hospital.

Findings include:

MR # 11 was admitted on 4/4/16 at 5:40 PM with diagnoses Axis I, Major Depressive Disorder, severe with dangerous suicidal impulses.

Review of the Psychiatric History and Physical documentation revealed the following: "...Past Psychiatric History...was treated at this hospital four years ago...was lost to follow up after that time..."

The Psychiatric History and Physical did not include documentation of MR # 11's past psychiatric diagnosis resulting in hospitalization nor did it include prior precipitating factors, if MR # 11's past hospitalization was due to similar symptoms, signs and behaviors.

This would be necessary in order to address and treat MR # 11, ensuring a favorable impact on MR # 11's future psychiatric course.

Written questions were submitted to facility staff on 4/13/16 at 8:45 AM. On 4/13/16 at 10:55 AM, Employee Identifier # 3, Director of Nursing verified via written response MR # 11's psychiatric evaluation failed to include all requirements necessary in the Psychiatric History and Physical.

Based on medical record (MR) review and interview, it was determined the facility failed to ensure all psychiatric evaluations included documentation of the patient's past medical history.

This affected MR # 10, 1 of 7 active records reviewed in the Adult unit and had the potential to affect all patients treated at the hospital.

Findings include:

MR # 10 was admitted to the hospital 3/31/16 with an Axis I (major mental) diagnosis, Bipolar Affective Disorder manic phase severe without psychotic features and Axis III (medical conditions) diagnosis Moderate Obesity.

Review of the Psychiatric History and Physical dictated 4/1/16 included the following documentation: "...Past Medical/Surgical History...has only routine chronic medical problems..."

Medical record review revealed MR # 10 had Diabetes Mellitus and Hypertension, both co-morbid medical conditions to be identified and addressed in MR # 10's past medical history documentation.

Written questions were submitted to hospital staff on 4/13/16 at 8:45 AM. On 4/13/16 at 10:55 AM, Employee Identifier # 3, Director of Nurses confirmed the psychiatric evaluation documentation did not include MR # 10's past medical history.

Based on review of medical records (MR), policy and procedures and interviews, it was determined the facility failed to document achievement of short and long term goals and ensure short term goals were met as documented.

This affected MR's # 3 and # 5, 2 of 5 discharge records reviewed and 1 of 7 active records reviewed on the Adult Unit, MR # 11. This had the potential to affect all patients treated at the hospital.

Findings include:

Policy: Interdisciplinary Treatment Plan

" Each patient admitted to the hospital shall have a written treatment plan that is appropriate to the patient's specific assessed needs. The treatment plan will be revised and maintained based on the patient's response to identified interventions. The treatment plan shall be individualized to meet the patients' unique needs and circumstances as identified through assessment data and patient/family in-put to the extent possible and shall be appropriate to the patient's needs, strengths, limitations and goals...

Procedure:
1. Within eight hours of patient admission, the admitting RN (Registered Nurse) shall initiate the Interdisciplinary Treatment Plan...

3. At least every 7 days as indicated by the acuity and treatment issues, the Treatment Plan shall be reviewed and updated on the unit...

5. The Master Interdisciplinary Treatment Plan shall:

a. Be initiated for each active problem (psychiatric, behavior, medical)
b. Contain long-term goals which identify specific behaviors anticipated to be accomplished by the time of discharge.
c. Contain short term goals that are individualized, specific, measurable, attainable and reasonable and include target dates...
e. Contain discharge criteria necessary for the individual patient to achieve..."


1. MR # 3 was admitted to the facility 1/6/16 with diagnoses of Major Depression and Axis III diagnosis of Diabetes Mellitus and LBKA (left below the knee amputation).

The Interdisciplinary Master Treatment Plan documented Master Problem List as:
Suicidal Thoughts no plan, Hypertension, High Cholesterol and Folliculitis.

Short term goal dated 1/7/16 documented:
1. Will deny any suicidal ideation (SI) in 7 days (Met 1/14/16)
2. Will have decrease in depression in 7 days.

Long term goal dated 1/7/16 documented:
No self harm, increased mood.

Short term goal dated 1/8/16 documented:
Will verbally report a decrease depression, decrease anxiety, increase gaining coping skills prior to discharge.

The goal was continued from projected due date of 1/15/16 and then marked goal met: 1/18/16. The patient was transferred to a medical hospital and admitted on 1/18/16. The goal was not achieved prior to emergent transfer to the hospital.

Short term goal dated 1/17/16 documented:
1. No signs and symptoms of folliculitis times 5 days. (Met 1/18/16)

Long term goal dated 1/17/16 documented:
Resolution of folliculitis.

The patient was transferred to a medical hospital and admitted on 1/18/16. The goal was not achieved prior to emergent transfer to the hospital.

2. MR # 5 was admitted to the facility 2/2/16 with diagnosis of Rule out Major Depressive Disorder with Psychotic Features and Muteness as in partial Cacatonia.

The Interdisciplinary Master Treatment Plan documented Master Problem List as:
Presented to ... ER (Emergency Room) with depression and anxiety and he/she had picked up a knife to harm self or others...
Hypertension and Constipation.

Short term goal dated 2/2/16 documented:
1. Will not attempt to self harm for 7 days (met 2/9/16)
2. Will deny suicide ideations x 7 days
3. Will deny anxiety x 7 days
4. Will report an increase in mood x 7 days.

Short term goals # 2, 3 and 4 were not met but continued 2/9/16, 2/16/16, and 3/1/16.

Short term goal dated 2/3/16 documented:
1. Will self report having no SI/HI (homicidal ideation) for 7 consecutive days prior to discharge (met 2/26/16)
2. Will deny having any anxiety for 7 consecutive days prior to discharge (met 2/26/16)

The patient was transferred to a psychiatric hospital unit 2/26/16 for possible ECT (Electroconvulsive therapy) and admitted on 2/26/16. The goal was not achieved prior to transfer to the hospital.

In an interview 4/13/16 at 11:00 AM with Employee Identifier (EI) # 3, Director of Nursing confirmed the goals were not met the dates were entered from the discharge date.



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3. MR # 11 was admitted on 4/4/16 at 5:40 PM with diagnoses Axis I, Major Depressive Disorder, severe with dangerous suicidal impulses.

Review of the 4/5/16 Multidisciplinary Treatment Plan revealed the following"...Problem # 1: Suicidal Ideations with plans to shoot... self..."

Further review revealed short term goal # 2, dated 4/5/16 that included the following documentation: "...Pt (patient) will state 2 reasons to live x (by) 7 days. Timeframe 4/11/16..."

Review of the medical record from 4/5/16 to 4/10/16 including nursing, therapy and physician progress notes did not include documentation MR # 11 verbalized 2 reasons to live as required to achieve short term goal # 2.

Written questions were submitted to the facility staff 4/13/16 at 8:45 AM. On 4/13/16 at 10:55 AM, EI # 3, verified via written response there was no documentation the goal was met on 4/10/16 as staff documented.

Based on medical record (MR) review and interview, it was determined the hospital failed to ensure:

a) Staff performed and documented 1:1 individualized therapy ordered by the Multidisciplinary Treatment Team.

b) Social Services Progress Note documentation included specific patient progress for identified problems.

This affected MR # 10 and # 11, 2 of 7 active records reviewed on the Adult Unit.

Findings include:

1. MR # 10 was admitted to the hospital 3/31/16 with an Axis I (major mental) diagnosis, Bipolar Affective Disorder manic phase severe without psychotic features and Axis III (medical conditions) diagnosis Moderate Obesity.

Review of Multidisciplinary Treatment Team dated 4/1/16 included interventions for "1:1 (individualized therapy) 2x's (two times) Q (every) 15 minutes about me, what I like". Target date 4/8/16. Responsible person was named but no documented title.

Record review on 4/12/16 revealed a 4/7/16 Social Worker individual therapy note. Staff failed to provide 1:1 therapy 2x a week as per interventions/target date.

Written questions submitted to hospital staff on 4/13/16 at 9:00 AM and written responses were received on 4/13/16 at 10:50 AM. Employee Identifier # 3, Director of Nursing confirmed staff failed to conduct and document 1:1 therapy as ordered.

2. MR # 11 was admitted on 4/4/16 at 5:40 PM with diagnoses Axis I, Major Depressive Disorder, severe with dangerous suicidal impulses.

Review of Multidisciplinary Treatment Team dated 4/5/16 revealed short term goals for attendance of two 30 minute activities daily, target dates/timeframe 4/12/16. Interventions for "1:1 (individualized therapy) 2x's (two times) Q (every) wk (week) 15 minutes, Spiritual Share 2 x q wk 30 min. (minutes) to express Spiritual needs and Creative Expressions-2 x q wk 30 min. to express self.

Review of the Social Services Group Progress Note dated 4/5/16 for Art Therapy: Communication/Self Care. Problems addressed were communication and identify what is needed to be mentally healthy.

The Social Worker documentation revealed MR # 11's mood was depressed, affect flat, thought disturbances none expressed, interaction with peers cooperative and passive.

The Social Worker failed to document MR # 11's response to the 4/5/16 Group session, if insight was improved, if MR # 11 shared experiences, or expressed self or needs.

Review of the Social Services Group Progress Note dated 4/7/16 for Anger Management/Coping Skills. Problems addressed were anger management and coping skills.

The Social Worker documentation revealed MR # 11's mood was depressed, affect flat, thought disturbances none expressed, interaction with peers cooperative and passive.

The Social Worker failed to document MR # 11's response to the 4/7/16 Group session, if insight was improved, if MR # 11 shared experiences, grasped concepts or expressed self or needs.

Written questions were submitted to hospital staff on 4/13/16 at 9:00 AM and written responses were received on 4/13/16 at 10:50 AM. EI # 3 confirmed staff failed to document patient response to ordered group therapy interventions.