HospitalInspections.org

Based on observation, staff interview and document review, the facility failed to ensure each patient received a suicide risk assessment prior to discharge for 4 of 4 patient records reviewed for such assessment [Patients #B1, #B4-B5 and #B10]. These patients were all documented as having suicidal ideation or being actively suicidal upon admission to the facility. This deficient practice had the potential to affect the safety of all patients discharged from the facility.

Findings were:

Facility policy #900.50 entitled "Suicide Risk Assessment / Precautions," last revised 3/18, included the following:
"POLICY: Identification of individuals at risk for suicide during admission and while under the care of a staffed, round-the-clock setting, or following discharge from a high care organization is an important step in preventing suicide and protecting these high risk individuals. Cedar Crest assesses the patient for suicide risk during admission, while in care, and upon discharge from the treatment program. The privileged LIP (licensed independent practitioner) assigns a Level of Observation corresponding with the acuity of the SRA (suicide risk assessment) ...
Discharge a patient from care:
The discharging RN assesses the patient for suicide risk and documents in the Discharge Form.
The RN notifies the physician as needed if there are any safety concerns or an SRA score of Higher than 45 ..."

Facility policy #1000.87 entitled "Discharge of Patients (Routine, AMAs, 15-30 day request for Transfer)," last revised 11/16, included the following:
PROCEDURE:
1 ...All patients are to be assessed by a physician on the day of discharge ..."

Patient #B4 was admitted on 3/12/18 to Cedar Crest Hospital. A Physician/APRN/PA Discharge Note on 3/20/18 at 1:35 p.m. included no Discharge Suicide Risk Assessment Score despite a box being provided for the score. A physician's Comments/Interventions included the following: "Pt is very manipulative, attention seeking, not participating any groups, [illegible] hitting staffs and destroying property, needs to be discharged ..." A review of the Psychiatric Evaluation on 3/13/18 at 1:50 p.m. revealed the following:
"History of Present Illness:
"States she had a lot of "stuff piling up ..." Admits to being sad & mad yesterday and tried to hang self & cut leg multiple times with a "spring from a pen ..." Tried hanging self with sheet ...Admits to wanting to die ..." Admitting diagnoses included: Bipolar I D/O (Disorder) ...ADHD (Attention Deficit & Hyperactivity Disorder), ODD (Oppositional Defiant Disorder) ..."

A Nursing Note on 3/19/18 at 6:45 p.m., the day prior to the discharge of Patient #B4, read as follows:
"Pt. agitated and angry at staff after she attempted to hang self and is being closely monitored at the nurse's station ...Zyprexa 10 mg for severe agitation ordered and administered. Continue 1:1 observation status ...

Patient #B10 was a 14-year-old female admitted on 1/30/18 and discharged on 4/6/18. A Physician/APRN/PA Discharge Note form in the record was completely blank. The form included no Discharge Suicide Risk Assessment Score despite a box being provided for the score. A review of the Psychiatric Evaluation on 1/31/8 at 9:15 a.m. revealed the following:
"[Patient #B10], 14 yrs old WF (white female) was admitted to acute care unit for SI (suicidal ideation), self harming behaviors and risky behaviors ..." A PreAdmission Evaluation / Management form included the following:
"Physician Note
Per staff: Pt presented to [acute care hospital] ED as a 14 y/o female c/o (complaining of) SI (suicidal ideation) and attempt to cut wrists per ED record. Pt endorsed depressed mood per ED record with exacerbating factor being family problems ..."

Patient #B5 was a 10-year-old female admitted to Cedar Crest Hospital on 3/9/18 and discharged on 3/20/18. A review of Patient #B5's Discharge Summary included the following:
"Emma presented for inpatient hospitalization from the emergency room for suicidal ideation ...She began threatening to hurt herself, attempted to jump out of a moving vehicle, and then attempted to strangle herself with seatbelt ..."

A review of the Physician/APRN/PA Discharge Note included no SRA score despite a box being provided for the score on the form. Thus it was unclear if the physician was aware of the patient's suicide risk status. The SRA for the patient's discharge had been conducted by an RN on 3/20/18 with a score of 25, which fell in the "Medium" risk category of 25-41. A box on the form below the score included the following:
"Notification/Action if Med (medium), High or Severe Risk:
Nurse Supervisor Notified?...
Practitioner Notified?..."
Neither of these notifications had been documented as having occurred.

A review of the Precaution/Observation Checklist sheets for Patient #B5 revealed she was on continuous line-of-sight (LOS) precautions while hospitalized at Cedar Crest for suicide and ligature risk. The patient was still on LOS precautions on 3/20/18, the date of her discharge, with "High SRA" (high suicide risk assessment) written at the top of the checklist for that date.

Patient #B1 was admitted on 3/28/18 and discharged on 4/2/18. A review of the Physician/APRN/PA Discharge Note included no SRA score despite a box being provided for the score on the form. Thus it was unclear if the physician was aware of the patient's suicide risk status.

In an interview with Staff #9, the Director of Clinical Services, on the morning of 4/11/18 in her office, she stated, "They're [physicians] are supposed to be writing that SRA (suicide risk assessment) score on there. They're supposed to be reviewing that before a patient is discharged ..."

The above was confirmed in an interview with the CEO, Corporate Vice-President of Clinical Services, Corporate Director of Quality Measures and Corporate Director of Clinical Services on the evening of 4-12-18.




36594

Based on review of facility documents, review of medical records and staff interview, the facility failed to ensure the medical staff was accountable to the governing body for the quality of care provided to patients.

Findings included:

Facility policy number 1000.87 titled "Discharge of Patients" stated in part, "Policy: Patients are discharged only upon the order of the attending physician ..."

Review of the chart for patient #D8 revealed patient #8 was discharged on 2/6/18, no discharge order was found.
Patient #D9 was discharged on 3/30/18 with no discharge order written by a physician.
Review of the medical record for patient #D11 revealed the patient eloped [escaped from the facility] on 3/31/18. The patient was discharged on 4/2/18. There were no doctor's progress notes after the elopement and no evidence the doctor ordered the patient to be discharged.

Patient #D14 was discharged on 4/10/18 with no discharge order written by a physician.

In addition, the facility could provide no documented evidence of patients #B1-#B5 and #B10-#B11 being discharged from the facility by physician order.

The above was confirmed in an interview with the DON on the afternoon of 4/11/18.

The above was also confirmed in an interview with the CEO, Corporate Vice-President of Clinical Services, Corporate Director of Quality Measures and Corporate Director of Clinical Services on the evening of 4-12-18.

The facility was not compliant with the Condition of Participation, as patients did not receive care in a safe setting.

* The director of nursing services failed to review and provide correction action on 69 of 69 incident reports reviewed. The review and corrective action of incident allows a facility the opportunity to be aware of situations and potential problems and possibly prevent their future recurrence (cross refer to A0144).

* A review conducted of a 30-day time period of the child/adolescent unit revealed numerous instances of patient safety violation to include patient to patient aggression, sexual misconduct, self-inflicted injury, suicide attempts, elopement and patient injury (cross refer to A0144).

* Review of observation sheets for 20 of 20 patients revealed no documentation of the patient's activities during each recorded time period. Failure to document patient activities allows no way to ascertain their whereabouts and prevent possible safety issues from occurring (cross refer to A0144).

* Staff #A-21 was instructed to provide direct care to patients on Unit II, despite having a documented work-related injury that stated the staff member's restrictions as "no restraints". The inability of the staff member to restraint a patient prevents the staff member from performing essential job functions that control an aggressive patient and possibly prevent other patients from being injured.

Unit IV (staffing/assignment sheets from 3-11-18 through 4-10-18 were reviewed)
3/11:
*7a-2:45p: 32 patients with four on LOS observation; 1 admission; one RN (two RN's from 2:45-7p), one LVN, four MHAs
*2:45p-11:35p: 31 patients with four on LOS observation; 2 admissions - one RN (two until 7p), one LVN, three MHAs
-two incidents of physical aggression by patients; one at 3:45p and one at 8:55p
-one incident of sexual misconduct at 7:30p
*10:45p-7:15a: 32 patients with four on LOS observation; one RN, one LVN, three MHAs
3/12:
*7-3:15p: 35 patients; 11 discharges, 2 admissions;one RN (2nd RN arrived @ 9am), one LVN; three MHAs (4th MHA arrived at 10 am)
-one incident of patients attacking each other at 12:20p
*2:45p-11:15p: 32 patients with five on LOS observation; only 3 MHAs [1 MHA]
*27 patients with six on LOS observation from 7p-7a; 1 discharge, 2 admissions - one RN, one LVN and 2 MHAs from 10:45p-7:15a
3/13:
*7a-7p: 30 patients with four on LOS observation and one on 1:1 observation, 2 admissions 2 discharges; two RNs, 1 LVN, four MHAs [1 MHA]
*10:45p-7:15a: 31 patients with four on LOS observation and one on 1:1 observation; 4 admissions; one RN, one LVN, 2 MHAs [2 MHAs]
3/14:
*7a-7p: 32 patients with three on LOS observation and one on 1:1 observation; 4 discharges, 1 admission - one RN, one LVN, five MHAs
*7p-7a: 29 patients; 3 discharges - one RN, one LVN, five MHAs until 11:15p then three until 7:15a
3/15:
*7a-7p: 27 patients with 7 on LOS observation and one on 1:1 observation; 4 discharges, 2 admissions/ one RN and one LVN; five MHAs (only 3 MHAs from 11:00 pm to 7:00 am)
-one incident of patient self-inflicted injury
*2:45p-11:15p: 25 patients with five on LOS observation and one on 1:1 observation/ 2 admissions - one RN and one LVN, started the shift with two MHAs, one arrived at 3:30 pm, one arrived at 4:30 pm and one arrived at 6:30 pm
3/16/18 (staffing/assignment sheet missing)
-one incident of patient self-inflicted injury at 8:30p
-one incident at 8:45p where patient acted out, staff abandoned 1:1 and physically abused patient
3/17/18:
*7a-7p: 29 patients with six on LOS observation and one on 1:1 observation; 2 discharges, 2 admissions; one RN, one LVN, three MHAs [2 MHAs]
-one incident at 8:40a that stated in part, "Patient running up and down halls cussing, hitting, and kicking staff ..."
*2:45p-11:15p: 29 patients with seven on LOS observation and one on 1:1 observation; 1 admission - one RN, one LVN and four MHAs
3/18: (staffing/assignment sheet missing)
-one incident at 5:45p where patient punched another patient which required transfer to ER
3/19: (staffing/assignment sheet missing)
-one incident at 1:25p where patient attacked another patient
-one incident at 6:14p of patient suicide attempt
-one incident at unknown time where patient drew on peer's buttock
3/20/18:
*7a-7p: 28 patients with six on LOS observation and one on 1:1 observation; 9 discharges, 1 admission - one RN, one LVN and five MHAs
-one incident at 9:20a where patient attacked staff and had to be restrained/secluded
*2:45-11:15p: 20 patients with four on LOS observation and one on 1:1 observation; 3 admissions; one RN, one LVN, three MHAs
*10:45p-7:15a: 23 patients with four on LOS observation and one on 1:1 observation; 3 admissions; one RN, one LVN, three MHAs
3/21/18:
*7a-3:15p: 26 patients with four on LOS observation; 2 discharges, 1 admission - one RN, one LVN, four MHAs
*2:45p-11:15p: 29 patients with four on LOS observation; 1 discharge, 4 admissions - one RN, one LVN, five MHAs
*10:45p-7:15a: 28 patients with four on LOS observation; 1 admission; one RN, one LVN, three MHAs
3/22/18:
*7:15a-3:15p: 29 patients with two on LOS observation; 2 admissions - two RNs, one LVN, three MHAs [1 MHA]
*2:45p-7:15a: 31 patients with two on LOS observation; 2 RNs (only 1 RN after 7:00 pm with two admissions; 1 at 2:45am and 1 at 5am), one LVN, four MHAs
3/23/18:
*7:15a-3:15p: 33 patients with four on LOS observation; 4 discharges, 2 admissions; one RN, one LVN, four MHAs
*2:45-11:15p: 30 patients with four on LOS observation; 1 discharge, 1 admission; one RN, one LVN, four MHAs (five for the hours of 3p-8:45p)
*11:15p-7:15a: 30 patients with four on LOS observation; 2 admissions; one RN, one LVN, three MHAs
3/24/18:
*7a-3:15p: 31 patients with four on LOS observation; 1 admission, 2 discharges; one RN, one LVN, four MHAs
-one incident at 8:05a where patient attacked another patient
*2:45p-11:15p: 30 patients with four on LOS observation; 2 admissions, 1 discharge; one RN, one LVN, five MHAs
-one incident at 2:55p of patient self-inflicted injury
*11:15p-7:30a: 31 patients with four on LOS observation; 1 admission; one RN, one LVN, three MHAs
3/25/18:
*7a to 3pm: 32 patients with four on LOS observation; 1 admission; one RN, one LVN, four MHAs
*2:45p-11:15p: 33 patients with four on LOS observation; one RN, one LVN, four MHAs
-one incident at 6:45p where patient attacked another patient
*10:45p-7:15a: 33 patients with four on LOS observation; one RN, one LVN, three MHAs (decreasing to two at 1:00 am) [1 MHA]
3/26/18: (staffing/assignment sheet and census missing)
3/27/18: (staffing/assignment sheet missing)
-one incident at 6:00p where patient attacked another patient
3/28/18:
*7a-7p: 32 patients with four on LOS observation; 10 discharges, 4 admissions; one RN, one LVN, three MHAs from 7a-3:15p and five MHAs from 2:45p-11:15p
*7p-7a: 27 patients with four on LOS observation; 4 admissions; one RN, three MHAs
3/29/18: (staffing/assignment sheet and census missing)
-one incident at 9:15p of patient self-inflicted injury that resulted in physical restraint
3/30/18:
*7a-7p: 32 patients with eight on LOS observation; 6 discharges; two RNs (only one RN after 11:30 am, during which time 6 patients were discharged), one LVN, five MHAs from 7a-11:15p
-one incident at 9:50a where pt injured self with piece of broken table
*7p-7a: 26 patients with six on LOS observation; 1 discharge, 2 admissions; one RN, one LVN, four MHAs from 11:15p-7:15a
3/31/18:
*7a-7p: 27 patients with eight on LOS observation; 2 admissions; 1 RN, one LVN, four MHAs from 7a-3:15p (five from 10a-3:15p) and four MHAs from 2:45p-11:15p
-one incident at 11:40a where patient attacked another patient
*7p-7a: 29 patients with ten on LOS observation; 2 admissions; one RN, one LVN, four MHAs
-one incident at 8:13p where patient attacked staff and had to be restrained
-one incident charted at 9:50p that stated in part, "This nurse returned to unit from admissions where she was admitting another pt [patient]. Upon arrival to unit I was informed patient was missing ..." Patient that eloped had an observation status of "LOS".
4/1/18:
*7a-7p: 31 patients with ten on LOS observation; two RNs, one LVN, four MHAs (until 11:15p)
-one incident at 10:15a where patient fell from climbing fence
-one incident at 5:45p where patient struck staff and had to be restrained
*7p-7a: 31 patients with ten on LOS observation; 4 admissions; one RN, one LVN, three MHAs from 10:45p-7:15a
4/2/18:
*7a-7p: 35 patients with 11 on LOS observation, 1 admission, 5 discharges; one RN, one LVN, four MHAs (five from 12:45p-3:15p) and four from 2:45-11:15p
*7p-7a: 31 patients with nine on LOS observation; 2 admissions; 1 discharge - one RN, one LVN, three MHAs from 11:15p-7:15a
4/3/18:
*7a-7p: 31 patients with nine on LOS observation; 2 admissions, 6 discharges; one RN, one LVN, six MHAs until 3:15
*7p-7a: 27 patients with nine on LOS observation; 6 admissions; one RN, one LVN, four MHAs until 11:15p then three MHAs until 7:15a
4/4/18:
*7a-7p: 33 patients with seven on LOS observation, 2 admissions, 6 discharges; two RNs, one LVN, five MHAs until 3:15p, four MHAs from 2:45p-11:15p
-one incident at 10:38a where patient attacked another patient
-one incident at 3:45p where patient attacked another patient
*7p-7a: 29 patients with six on LOS observation; 1 admission; one RN, one LVN, four MHAs from 10:45p-7:15a
-one incident at 8:10p where patient attacked another patient
4/5/18:
*7a-7p: 30 patients with five on LOS observation; 3 discharges, 2 admissions; one RN, one LVN, four MHAs until 11:15p
-one incident at 11:45a where patient attacked another patient
*7p-7a: 29 patients with four on LOS observation; 1 admission; one RN, one LVN, three MHAs from 10:45p-7:15a
-one incident at 7:00p where patient made a suicide attempt
-one incident at 8:30p of patient self-inflicted injury
4/6/18 (staffing/assignment sheet missing)
4/7/18:
*7a-7p: 24 patients with two on LOS observation; 3 admissions, 2 discharges; one RN, one LVN, four MHAs (five MHAs from 3:30p-7:30p)
*7p-7a: 25 patients with three on LOS observation; one RN, one LVN, two MHA from 10:45p-7:15a
4/8/18:
*7a-7p: 25 patients with three on LOS observation; one RN, one LVN, three MHA
*7p-7a: 25 patients with three on LOS observation; one RN, one LVN, four MHAs from 2:45p-11:15p then three MHAs from 10:45p-7:15a
4/9/18:
*7a-7p: 25 patients with four on LOS observation; 2 discharges, 10 discharges; two RNs, one LVN, four MHAs until 3:15p and three MHAs until 11:15p
*7p-7a: 17 patients with three on LOS observation; 6 admissions; one RN, one LVN, four MHAs
4/10/18:
*7a-7p: 24 patients with three on LOS observation; 2 admissions, 4 discharges; one RN, one LVN, three MHAs until 11:15p
*7p-7a: 22 patients with two on LOS observation; 1 admission; two RNs, one LVN, two MHAs from 10:45p-7:15a

***Of the days reviewed for Unit IV, 4 of 24 days were inadequately staffed per the facility's staffing grid. Patient admissions occurred on 22 of the 24 days and patient discharges occurred on 18 of the 24 days.***

***Of the entire 30 day period reviewed for Unit IV, the following incidents were documented:

* Patient aggression - 18 episodes (1 of which required emergency room attention)
* Patient sexual misconduct - 1 episode
* Patient self-inflicted injury - 6 episodes
* Patients attempting suicide - 2 episodes
* Patient elopement - 1 episode
* Patient injury - 1 episode

In an interview with staff #D-1 on 4/12/18 they stated, "We are telling doctors, 'If you're ordering line of sight, we're not going to do it. We don't have staff."

In an interview with staff #A-18 and #A-19 on 4-12-18, both staff were shown the staffing grid verified by staff #A-20 to be the current grid being used to staff the units. Both staff members stated that they had never seen the grid presented to them by the surveyors and shared with the surveyors a staffing grid they had been given by staff #A-20 and told to use to staff the units. The staffing grid given to staff members #A-18 and #A-19 by staff #A-20 allowed less staff members per patient than the grid verified by staff #A-20 as being the current grid. Staff #A-19 stated that [staff #A-19] was to come in each morning and use the midnight census as the number of patients to use to determine staffing, regardless of how many patients might have been admitted to each unit between midnight and the following morning when staffing was determined.

During a tour of Unit 3 on 04/10/17 the following observations and interviews were completed:

In interviews, staff members #C-12, C-13, and C-15 all stated that due to acuity issues on the unit a male patient had to step in and physically re-direct another aggressive male patient on the unit. Staff members #C-14 and C-15 also confirmed that multiple emergency medications were administered on the unit that day.
Staff members on Unit 3 were asked about groups (such as goals groups and Nursing Psych Group) listed on the Unit Schedule being completed by nursing and MHT staff. Staff members #C-12, C-14, and C-15 all confirmed that groups not led by therapists are not being consistently held, but stated that therapist-led groups are being held. Staff member #C-15 stated, "with the high census and acuity we don't have the staff to run groups. Even the therapists can't teach a group at times it's so busy ...We're trying to do the best we can, but with this high acuity most of the time we're just de-escalating patients, giving emergency medications, and breaking up fights."

Review of medical records for Unit 3 on 04/10/18 revealed the following documented incidents:
* Patient #C-10 had a note that stated in part, "Pt assisted staff with de-escalation of a physical altercation among a male and female pt today. Male pt became violent and aggressive towards a female pt."
* Patient #C-11 had a note that stated in part, "[Patient #C-11 name) through [sic] a cup at patient. Both patients started to fight with each other and patient (Patient #C-10 name) grabbed (Patient #C-11) and restrained him from hitting other patient and hitting staff member. (Patient #C-11) was taken outside and eventually calmed down." Another note stated, "Pt was at lunch and was demanding a knife so he could cut his food. Pt lashed out and through [sic] tray across dining hall. Pt stormed out of Dining Room and a code (end of note)".

* The following patients received emergency medications on this date: Patient #C-8 had Haldol 10 mg, Ativan 2mg, and Benadryl 100 mg IM ordered X 1 at 1000. Patient #C-10 had Haldol 5 mg, Benadryl 25 mg, and Ativan 2 mg PO ordered X1 at 0930.
* Patient #C-8 was placed in seclusion from 10:00 AM until 10:30 AM due to "violent/aggressive behavior".
* Review of the "Precaution/Observation Checklist" for Patient #C-8 revealed initials that the monitoring of this patient was completed by staff member #C12 from 1000-1030 during the time of this patient's seclusion.
* Review of the "Precaution/Observation Checklist" for Patients #C-9, C-10, and C-11 revealed initials that the monitoring of these patients was completed by staff member #C12 from 1000-1030. During this half hour time frame this staff member was observing a patient #C-8 in seclusion which requires constant line of sight visualization. This staff member would not be able to perform q 15 minutes checks on other patients simultaneously. During the seclusion of Patient #C-8 the unit would have needed another staff member to assist with the observations of the other 20 patients.

During a review of the staffing variance (census/assignment sheet) for Unit II (adults) for 4-9-18 (review was conducted on 4-11-18), it was noted that the census was 19 patients. The unit was staffed with 1 RN, 1 LVN and 1 MHA (staff #A-21). In an interview with staff #A-21 on 4-11-18, [staff #A-21] stated that [staff #A-21] had recently been injured on the job, was under the care of a physician and had been assigned to work on Unit II, despite the physician's restrictions. At the surveyor's request, staff #A-7 provided the surveyor with the physician's restrictions for staff #A-21, which stated "no restraints". Staff #A-7 was asked if the restrictions had been communicated appropriately to administration and to those who staffed the units. Staff #A-7 provided the surveyor with an email dated 4-6-18 that had been sent to staff #A-18, #A-19 and #A-20, informing those staff members of staff #A-21's restrictions. Staff #A-20 was interviewed and asked if staff #A-20 was aware of staff #A-21's restrictions. Staff #A-20 stated "I think I saw something about that". When asked why staff #A-21 had been scheduled to provide direct patient despite restrictions prohibiting staff #A-21 from doing so, staff #A-20 stated "Oh, I don't do staffing". Staff #A-18 and #A-19 were interviewed and asked why staff #A-21 had been assigned to provide direct patient care on Unit II despite restrictions prohibiting staff #A-21 from doing so. Both staff #A-18 and #A-19 stated that they had been instructed to assign staff #A-21 to Unit II but to tell staff #A-21 "not to respond to any codes".

A review of the precaution/observation checklists for Unit II was conducted on 4-10-18 at 12:05 pm while the surveyor was on the unit. The patients returned to the unit from the cafeteria while the checklists were being reviewed. The checklists had remained on the unit and the last location was documented at 11:00 am.

Facility policy #1800.2 titled "Patient Rights to Care and Treatment" states, in part:
"Procedure:
...
6. Admission staff advises parents of minors of their rights and responsibilities at admission and throughout the continuum of care.
6.1 Parents have the right to be assured that their dependent minor is provided
6.1.1 A safe and comfortable environment."

Facility policy #1000.17 titled "Observation /Precaution Levels states, in part:
"Observation Levels

Q-15 minute checks:
* The unit staff observes the patient a minimum of every 15 minutes and documents the observation on the Patient Observation Monitoring Form.

* Patients at this level may attend activities outside of the unit, i.e., meals at the cafeteria, RT in the Gym, and other on-campus outdoor activities or groups at the RN's discretion.

* The primary RN and/or MHA will document behaviors related to the observation/precautionary level daily in the progress notes.

* The charge nurse will be immediately notified of any patient who cannot be located at the time of check.

Line-of-Sight (LOS)
* The unit staff will provide constant visual observation of the patient at all times. The unit staff may perform line-of-sign observations within a group of patients or milieu group activities. The unit staff documents the observation every 15 minutes in the Patient Observation Monitoring Form.

* Staff will monitor patients on LOS on the unit, unless the physician gives an order, the patient may leave the unit.

* The primary RN and/or MHA will document behaviors related to the observation level daily in the progress notes.

1:1
* One (1) unit staff will provide constant visual observation and remain within arms-length of the patient. This continuous direct visual observation will continue even when patients shower, change clothes or use the bathroom. If/when the patient is asleep, the staff observes patient from a reasonable distance in order to closely observe patient and quickly intervene as necessary.

* Staff will attempt to maintain the patient's privacy as much as possible. However, the safety of the patient must be the main consideration. The unit staff documents the observation every 15 minutes in the Patient Observation Monitoring Form.

* Staff will monitor patients on 1:1 observation on the unit, unless the physician gives an order, the patient may leave the unit.

* The primary RN and/or MHA will chart behaviors related to the observation/precautionary level daily in the progress notes.

* The RN on duty will assess the need for a decrease in observation level each shift. Recommendation should be communicated to the physician/NP if indicated.

* Sleeping patients will be observed at close enough proximity to confirm they are in no physical distress. Staff will observe the patient at a minimum arm's length distance to ensure the ability to clearly see the patient's identity and rise and fall of chest to verify respirations, and make sure patient has moved positions. Staff should use a flashlight to ensure adequate illumination."

Facility policy #1300.1 titled "Nursing Staffing Plan" states, in part:
"The Cedar Crest Department of Nursing Services supports the provision of quality patient care in a safe, cost-effective manner through the utilization of assessed/required staff to patient ratios/levels by qualified and skilled personnel in order to ensure the safety of patients and staff on the unit.

There will be adequate numbers of Registered Nurses (RNs), Licensed Vocational Nurses (LVNs), and Mental Health Associate (MHA) personnel to provide safe and quality care to all patients.
...
D. At a minimum, the staffing levels are based on prescribed staffing standards on the following factors:

1. Patient characteristics and number of patients for whom care is being provided, including:
a. Number of admissions
b. Number of discharges
c. Average daily census (ADC)
d. Scheduled milieu activities

2. Nursing Acuity and population age mix
a. Number of patients on 1:1 or Line-of-sight observation level
b. Consideration for presence of large and/or overly aggressive patients
...
4. Consideration of:
a. Architecture and geography of the unit"


35725

Based on a review of facility documents, staff interview and clinical records review, the facility failed to always review and evaluate incident reports. There was no documentation noted to show follow-up and corrective actions taken by the facility.

Findings were:

Facility based policy titled "Incident Reporting -Risk Management Program" states in part, Policy: "It is the policy of (facility name) to utilize the Risk Management Program techniques to promote safety, pro-actively focus on loss prevention, and detention of hazardous events and circumstances. It must provide a systematic, multi-disciplinary approach to managing and reporting incidents of injury, damage, and loss.
Purpose: The Incident Report is a risk management tool that raises awareness of potential exposure to perils that may/did cause harm. It enables the facility to manage risk, increase safety, and improve the quality of health care provided in the facility through risk control intervention and monitoring the effectiveness of the interventions and corrective action plan.
An "incident" is an unanticipated event which was not consistent with the standard of care and/or operation of the facility and may have occurred due to a violation of policy and procedure. The Incident Report will help the various facility committees and administration in identifying potential areas of risk and implementing measures to improve the overall quality of care throughout the facility.
Procedure: Any facility staff member who witnesses, discovers, or has direct knowledge of an incident must complete and Incident Report before the end of the shift/work day.
3.1 Supervisor will review the incident Report for legibility, completion, signature and date. Supervisor will notify Risk Manager of a serious incident as well as take the lead in investigating Level III and Level IV incidents."

Definitions on Incident Reports Form:
01. Patient Care / Treatment (Includes Restraint/Seclusion)
04. Boundary Violation / Sexual Allegation: "Zero Tolerance" is the policy and practice of not tolerating undesirable behavior based in observing boundaries which are rules that govern the relationship that a healthcare employee has with a patient.
07. Physical Confrontations: Harm to Patient-Using self or an object, patient succeeds in causing physical harm to another.
09. Medication Variance:
11. Falls:

Review of Incident Reports revealed the following number of reports in the specific definition category were turned in to the Risk Manager.
Review of 53 incident reports were turned in from 03/01/2018 to 03/31/2018 revealed the following:
01. Definition = 30 incident reports
04. Definition = 04 incident reports
07. Definition = 12 incident reports
09. Definition = 04 incident reports
11. Definition = 02 incident reports
Review of 16 incident reports were turned in from 04/01/2018 to 04/06/2018 revealed the following:
01. Definition = 08
04. Definition = 01
07. Definition = 06
11. Definition = 01

1. The Nursing supervisor failed review and sign the incident reports. There was no signature/date to indicate that the incident reports were reviewed by a nurse supervisor.
2. The facility failed to review and evaluation incident reports and to document interventions, follow-up, and corrective actions taken by the facility.
The above deficiencies were confirmed by the Risk Manager. In an interview with Staff D27 on the afternoon of 4/12/18 she stated, "incident reports were not review by the nurse supervisor because we didn't have one." Staff D27 said the facility would add acute behavioral indicators to the Performance Improvement Program.


36594

Based on review of facility documents, review of medical records and staff interview, the facility failed to ensure each patient had the right to receive care in a safe setting.


Findings included:

Facility document titled "Precaution/observation checklist" stated in part, "Documentation of activity as witnessed by staff every 15-Minutes."

Review of 20 of 20 medical records (patients D1-D20) revealed the checklist being used with documentation of the location of the patient but no documentation of activity witnessed by staff.

In an interview with the DON and the director of risk management/quality on the morning of 4/12/18, when discussing this form, they stated, "They came from corporate ... We're trying to meet with them. There's a lot of things missing.

With no documentation of activities witnessed, there was no way to tell what patients were doing throughout their stay.

The above was confirmed in the interview with the DON and director of RM/quality the morning of 4/12/18.

The above was also confirmed in an interview with the CEO, Corporate Vice-President of Clinical Services, Corporate Director of Quality Measures and Corporate Director of Clinical Services on the evening of 4-12-18.

The facility failed to provide a sufficient number of licensed and unlicensed staff present to provide appropriate and safe patient care.

* Units were not staffed to facility staffing standards, often resulting in injuries to both patients and staff as well as patient elopement. An inadequate number of staff was provided to observe and carry out physician's orders regarding patient's precaution/observation levels (line of sight and 1:1 patient observation (cross refer to A0392).

* The time period needed to perform admissions, discharges and other administrative tasks was not factored into the staffing allowance, preventing the nursing staff from performing proper patient observation (cross refer to A0392).

* A staff member (#A-21) with an on-the-job injury was instructed to continue to provide patient care, in violation of the staff member's physician's restrictions (cross refer to A0392).

* Patients #C-10 and #C-11 on Unit III assisted with the de-escalation of other aggressive patients, as an adequate number of staff was not available to do so and no staffing considerations had been made for overly-aggressive patients (cross refer to A0392).

Based on interviews, a review of clinical records, facility documentation and tours of the units, the facility failed to provide an adequate number of registered nurses, licensed practical nurses and mental health workers to provide nursing care necessary under each patient's active treatment program and to maintain progress notes on each patient.

Findings were:

Based on interviews, a review of clinical records and tours of the units, the facility failed to provide an adequate number of registered nurses, licensed practical nurses and mental health workers to provide nursing care necessary under each patient's active treatment program and to maintain progress notes on each patient.

Staffing

Staffing variance sheets for Units II & III were reviewed for the time period of 3-27-18 through 4-10-18 and the time period of 3-11-18 through 4-10-18 for Unit IV. Differences between the actual staffing and the appropriate staffing (per the staffing grid verified as current by staff #A-20) were noted. Staff positions noted with [brackets] represent staff positions that should have been scheduled (per the staffing grid) but were not.

Unit 2:
3/27/18:
*7a-7p: 18 patients with two discharges - one RN, one LVN, one MHA [1 MHA]
*7p-7a: 18 patients with two admissions - one RN, one MHA [1 LVN, 1 MHA]
3/28/18:
*7a-7p: 18 patients with two discharges - one RN, one MHA [1 LVN, 1 MHA]
*7p-7a: 18 patients with two admissions - one RN, one MHA [1 LVN, 1 MHA]
3/29/18:
*7a-7p: 18 patients - one RN, one LVN, one MHA [1 MHA]
*7p-7a: 17 patients, one discharge- one RN, one MHA [1 MHA]
3/30/18:
*7a-7p: 17 patients with two discharges - one RN, one LVN, one MHA [1 MHA]
*7p-7a: 17 patients - one RN, one MHA [1 MHA]
3/31/18:
*7a-7p: 15 patients, one discharge - one RN, one LVN, one MHA
*7p-7a: 15 patients, one admission - one RN, one MHA [1 LVN]
4/1/18:
*7a-7p: 16 patients - one RN, one LVN, one MHA [1 MHA]
*7p-7a: 16 patients - one RN, one MHA [1 LVN]
4/2/18:
*7a-7p: 16 patients, two discharges - one RN, one LVN, one MHA [1 MHA]
*7p-7a: 18 patients, four admissions - one RN, one MHA [1 LVN, 1 MHA]
4/3/18:
*7a-7p: 18 patients with four discharges - one RN, one LVN, one MHA [1 MHA]
*7p-7a: 17 patients with three admissions - one RN, one MHA [1 LVN]
4/4/18:
*7a-7p: 17 patients with one discharge and one admissions - one RN, one LVN, one MHA [1 MHA]
*7p-7a: 17 patients with three admissions - one RN, one MHA [1 LVN, 1 MHA]
4/5/18:
*7a-7p: 17 patients with one discharge and two admissions - one RN, one LVN [2 MHAs]
*7p-7a: 17 patients with one admissions - one RN, one MHA [1 LVN, 1 MHA]
4/6/18:
*7a-7p: 19 patients with two discharges - one RN, one MHA [1 LVN, 1 MHA]
*7p-7a: 18 patients with one admission - one RN, one MHA [1 LVN, 1 MHA]
4/7/18:
*7a-7p: 18 patients - one RN, one MHA [1 LVN, 1 MHA]
*7p-7a: 18 patients - one RN, one MHA [1 LVN, 1 MHA]
4/8/18:
*7a-7p: 18 patients - one RN, one MHA [1 LVN, 1 MHA]
*7p-7a: 18 patients - one RN, one MHA [1 LVN, 1 MHA]
4/9/18:
*7a-7p: 18 patients with two discharges, two admissions - one RN, one LVN, one MHA [1 MHA]
*7p-7a: 19 patients with one admission - one RN, one MHA [1 LVN, 1 MHA]
4/10/18:
*7a-7p: 19 patients with two discharges, two admissions - one RN, one LVN, one MHA [1 MHA]
*7p-7a: 19 patients with one admission - ONE RN ONLY [1 LVN, 2 MHAs]

***Of the shifts reviewed for Unit II, 29 of 30 shifts were inadequately staffed per the facility's staffing grid. Patient admissions occurred during 15 of the 30 shifts and patient discharges occurred during 12 of the 30 shifts.***

Unit 3: ("LOS" = Line of Sight precautions, requiring the patient to be within a staff member's line of sight at all times)
(1:1 = requires the patient to have a dedicated staff member that remains within arm's length of the patient)
3/27/18:
*7a-7p: 22 patients; 2 LOS [line of sight]; 1 patient on 1:1; 5 discharges - 1 admission; 1 RN, 1 LVN, 3 MHAs [2 MHAs]
*7p-7a: census: 18 patients; 2 LOS; 1 patient on 1:1; 2 admissions; 1 RN, 1 LVN, 3 MHAs [1 MHA]
3/28/18:
*7a-7p: 21 patients; 1 LOS; 2 discharges - 2 admissions; 1 RN, 1 LVN, 2 MHAs [1 MHA]
*7p-7a: census: 21 patients; 1 LOS; 1 admission; 1 RN, 1 LVN, 4 MHAs until 11pm then down to three until 7a
3/29/18:
*7a-7p: 22 patients; 1 LOS; 4 discharges; 1 RN, 1 LVN, 2 MHAs [1 MHA]
*7p-7a: 18 patients; 1 LOS; 1 discharge; 1 RN, 1 LVN; 1 MHA [1 MHA]
3/30/18:
*7a-7p: 18 patients; 1 LOS; 4 discharges, 1 admission; 1 RN, 1 LVN, 2 MHAs
*7p-7a: 19 patients; 1 LOS; 1 RN, 1 LVN, 2 MHAs
3/31/18:
*7a-7p: 19 patients; 1 LOS; 4 discharges of indeterminate time; 1 RN, 1 LVN, 1 MHA [1 MHA]
*7p-7a: 15 patients; 1 LOS; discharges (see above); 1 RN, 1 LVN, 2 MHAs
4/1/18:
*7a-7p: 15 patients; 1 admission; 1 RN, 1 LVN, 1 MHA [1 MHA]
*7p-7a: 16 patients; 1 RN, 1 LVN, 1 MHA (pulled to another unit from 1930-2300), 1 MHA (listed as 1930 - 2300) unsure if any MHAs were on the unit from 11p-7a [1-2 MHAs]
4/2/18:
*7a-7p: 16 patients; 5 discharges, 4 admissions; 1 RN, 1 LVN; 1 MHA [1 MHA]
*7p-7a: 16 patients; 1 RN, 1 LVN (says " Unit 4"; no time written); 2 MHAs [1 LVN]
4/3/18:
*7a-7p: 15 patients; 2 discharges - 2 admissions; 1 RN, 1 LVN, 1 MHA [1 MHA]
*7p-7a: 15 patients; 1 RN, 1 LVN, 1 MHT
4/4/18:
*7a-7p: 15 patients; 2 discharges; 1 RN, 1 LVN; 1 MHA [1 MHA]
*7p-7a: 13 patients; 2 discharges, 1 admission; 1 RN, 1 LVN , 2 MHTs
4/5/18:
*7a-7p: 14 patients; 1 RN, 1 LVN, 2 MHA
*7p-7a: 14 patients; 1 admission; 1 RN, 1 LVN, 2 MHAs (one listed as "RTC [residential treatment center] 19-2300")
4/6/18:
*7a-7p: 15 patients; 5 discharges; 1 RN, 3 MHAs
*7p-7a: 10 patients; 3 admissions (unknown time); 1 RN, 2 MHAs
4/7/18:
*7a-7p: 13 patients; 1 discharge, 3 admissions; 1 RN, 1 LVN, 2 MHAs
*7p-7a: 15 patients; 1 RN, 2 MHAs [1 LVN]
4/8/18:
*7a-7p: 16 patients; 1 discharge, 6 admissions; 1 RN, 1 LVN, 2 MHAs [1 MHA]
*7p-7a: 21 patients; 3 admissions; 1 RN, 1 LVN, 2 MHAs [1 MHA]
4/9/18: missing
4/10/18:
*7a-7p: 25 patients; 5 discharges; 1 RN, 1 LVN,2 MHTs [1 MHA]
*7p-7a: 20 patients; 1 admission; 1 RN, 1 LVN, 2 MHTs

***Of the shifts reviewed for Unit III, 16 of 26 shifts were inadequately staffed per the facility's staffing grid. Patient admissions occurred during 15 of the 26 shifts and patient discharges occurred during 14 of the 26 shifts.***


Unit IV (staffing/assignment sheets from 3-11-18 through 4-10-18 were reviewed)
3/11:
*7a-2:45p: 32 patients with four on LOS observation; 1 admission; one RN (two RNs from 2:45-7p), one LVN, four MHAs
*2:45p-11:35p: 31 patients with four on LOS observation; 2 admissions - one RN (two until 7p), one LVN, three MHAs
-two incidents of physical aggression by patients; one at 3:45p and one at 8:55p
-one incident of sexual misconduct at 7:30p
*10:45p-7:15a: 32 patients with four on LOS observation; one RN, one LVN, three MHAs
3/12:
*7-3:15p: 35 patients; 11 discharges, 2 admissions;one RN (2nd RN arrived @ 9am), one LVN; three MHAs (4th MHA arrived at 10 am)
-one incident of patients attacking each other at 12:20p
*2:45p-11:15p: 32 patients with five on LOS observation; only 3 MHAs [1 MHA]
*27 patients with six on LOS observation from 7p-7a; 1 discharge, 2 admissions - one RN, one LVN and 2 MHAs from 10:45p-7:15a
3/13:
*7a-7p: 30 patients with four on LOS observation and one on 1:1 observation, 2 admissions 2 discharges; two RNs, 1 LVN, four MHAs [1 MHA]
*10:45p-7:15a: 31 patients with four on LOS observation and one on 1:1 observation; 4 admissions; one RN, one LVN, 2 MHAs [2 MHAs]
3/14:
*7a-7p: 32 patients with three on LOS observation and one on 1:1 observation; 4 discharges, 1 admission - one RN, one LVN, five MHAs
*7p-7a: 29 patients; 3 discharges - one RN, one LVN, five MHAs until 11:15p then three until 7:15a
3/15:
*7a-7p: 27 patients with 7 on LOS observation and one on 1:1 observation; 4 discharges, 2 admissions/ one RN and one LVN; five MHAs (only 3 MHAs from 11:00 pm to 7:00 am)
-one incident of patient self-inflicted injury
*2:45p-11:15p: 25 patients with five on LOS observation and one on 1:1 observation/ 2 admissions - one RN and one LVN, started the shift with two MHAs, one arrived at 3:30 pm, one arrived at 4:30 pm and one arrived at 6:30 pm
3/16/18 (staffing/assignment sheet missing)
-one incident of patient self-inflicted injury at 8:30p
-one incident at 8:45p where patient acted out, staff abandoned 1:1 and physically abused patient
3/17/18:
*7a-7p: 29 patients with six on LOS observation and one on 1:1 observation; 2 discharges, 2 admissions; one RN, one LVN, three MHAs [2 MHAs]
-one incident at 8:40a that stated in part, "Patient running up and down halls cussing, hitting, and kicking staff ..."
*2:45p-11:15p: 29 patients with seven on LOS observation and one on 1:1 observation; 1 admission - one RN, one LVN and four MHAs
3/18: (staffing/assignment sheet missing)
-one incident at 5:45p where patient punched another patient which required transfer to ER
3/19: (staffing/assignment sheet missing)
-one incident at 1:25p where patient attacked another patient
-one incident at 6:14p of patient suicide attempt
-one incident at unknown time where patient drew on peer's buttock
3/20/18:
*7a-7p: 28 patients with six on LOS observation and one on 1:1 observation; 9 discharges, 1 admission - one RN, one LVN and five MHAs
-one incident at 9:20a where patient attacked staff and had to be restrained/secluded
*2:45-11:15p: 20 patients with four on LOS observation and one on 1:1 observation; 3 admissions; one RN, one LVN, three MHAs
*10:45p-7:15a: 23 patients with four on LOS observation and one on 1:1 observation; 3 admissions; one RN, one LVN, three MHAs
3/21/18:
*7a-3:15p: 26 patients with four on LOS observation; 2 discharges, 1 admission - one RN, one LVN, four MHAs
*2:45p-11:15p: 29 patients with four on LOS observation; 1 discharge, 4 admissions - one RN, one LVN, five MHAs
*10:45p-7:15a: 28 patients with four on LOS observation; 1 admission; one RN, one LVN, three MHAs
3/22/18:
*7:15a-3:15p: 29 patients with two on LOS observation; 2 admissions - two RNs, one LVN, three MHAs [1 MHA]
*2:45p-7:15a: 31 patients with two on LOS observation; 2 RNs (only 1 RN after 7:00 pm with two admissions; 1 at 2:45am and 1 at 5am), one LVN, four MHAs
3/23/18:
*7:15a-3:15p: 33 patients with four on LOS observation; 4 discharges, 2 admissions; one RN, one LVN, four MHAs
*2:45-11:15p: 30 patients with four on LOS observation; 1 discharge, 1 admission; one RN, one LVN, four MHAs (five for the hours of 3p-8:45p)
*11:15p-7:15a: 30 patients with four on LOS observation; 2 admissions; one RN, one LVN, three MHAs
3/24/18:
*7a-3:15p: 31 patients with four on LOS observation; 1 admission, 2 discharges; one RN, one LVN, four MHAs
-one incident at 8:05a where patient attacked another patient
*2:45p-11:15p: 30 patients with four on LOS observation; 2 admissions, 1 discharge; one RN, one LVN, five MHAs
-one incident at 2:55p of patient self-inflicted injury
*11:15p-7:30a: 31 patients with four on LOS observation; 1 admission; one RN, one LVN, three MHAs
3/25/18:
*7a to 3pm: 32 patients with four on LOS observation; 1 admission; one RN, one LVN, four MHAs
*2:45p-11:15p: 33 patients with four on LOS observation; one RN, one LVN, four MHAs
-one incident at 6:45p where patient attacked another patient
*10:45p-7:15a: 33 patients with four on LOS observation; one RN, one LVN, three MHAs (decreasing to two at 1:00 am) [1 MHA]
3/26/18: (staffing/assignment sheet and census missing)
3/27/18: (staffing/assignment sheet missing)
-one incident at 6:00p where patient attacked another patient
3/28/18:
*7a-7p: 32 patients with four on LOS observation; 10 discharges, 4 admissions; one RN, one LVN, three MHAs from 7a-3:15p and five MHAs from 2:45p-11:15p
*7p-7a: 27 patients with four on LOS observation; 4 admissions; one RN, three MHAs
3/29/18: (staffing/assignment sheet and census missing)
-one incident at 9:15p of patient self-inflicted injury that resulted in physical restraint
3/30/18:
*7a-7p: 32 patients with eight on LOS observation; 6 discharges; two RNs (only one RN after 11:30 am, during which time 6 patients were discharged), one LVN, five MHAs from 7a-11:15p
-one incident at 9:50a where pt injured self with piece of broken table
*7p-7a: 26 patients with six on LOS observation; 1 discharge, 2 admissions; one RN, one LVN, four MHAs from 11:15p-7:15a
3/31/18:
*7a-7p: 27 patients with eight on LOS observation; 2 admissions; 1 RN, one LVN, four MHAs from 7a-3:15p (five from 10a-3:15p) and four MHAs from 2:45p-11:15p
-one incident at 11:40a where patient attacked another patient
*7p-7a: 29 patients with ten on LOS observation; 2 admissions; one RN, one LVN, four MHAs
-one incident at 8:13p where patient attacked staff and had to be restrained
-one incident charted at 9:50p that stated in part, "This nurse returned to unit from admissions where she was admitting another pt [patient]. Upon arrival to unit I was informed patient was missing ..." Patient that eloped had an observation status of "LOS".
4/1/18:
*7a-7p: 31 patients with ten on LOS observation; two RNs, one LVN, four MHAs (until 11:15p)
-one incident at 10:15a where patient fell from climbing fence
-one incident at 5:45p where patient struck staff and had to be restrained
*7p-7a: 31 patients with ten on LOS observation; 4 admissions; one RN, one LVN, three MHAs from 10:45p-7:15a
4/2/18:
*7a-7p: 35 patients with 11 on LOS observation, 1 admission, 5 discharges; one RN, one LVN, four MHAs (five from 12:45p-3:15p) and four from 2:45-11:15p
*7p-7a: 31 patients with nine on LOS observation; 2 admissions; 1 discharge - one RN, one LVN, three MHAs from 11:15p-7:15a
4/3/18:
*7a-7p: 31 patients with nine on LOS observation; 2 admissions, 6 discharges; one RN, one LVN, six MHAs until 3:15
*7p-7a: 27 patients with nine on LOS observation; 6 admissions; one RN, one LVN, four MHAs until 11:15p then three MHAs until 7:15a
4/4/18:
*7a-7p: 33 patients with seven on LOS observation, 2 admissions, 6 discharges; two RNs, one LVN, five MHAs until 3:15p, four MHAs from 2:45p-11:15p
-one incident at 10:38a where patient attacked another patient
-one incident at 3:45p where patient attacked another patient
*7p-7a: 29 patients with six on LOS observation; 1 admission; one RN, one LVN, four MHAs from 10:45p-7:15a
-one incident at 8:10p where patient attacked another patient
4/5/18:
*7a-7p: 30 patients with five on LOS observation; 3 discharges, 2 admissions; one RN, one LVN, four MHAs until 11:15p
-one incident at 11:45a where patient attacked another patient
*7p-7a: 29 patients with four on LOS observation; 1 admission; one RN, one LVN, three MHAs from 10:45p-7:15a
-one incident at 7:00p where patient made a suicide attempt
-one incident at 8:30p of patient self-inflicted injury
4/6/18 (staffing/assignment sheet missing)
4/7/18:
*7a-7p: 24 patients with two on LOS observation; 3 admissions, 2 discharges; one RN, one LVN, four MHAs (five MHAs from 3:30p-7:30p)
*7p-7a: 25 patients with three on LOS observation; one RN, one LVN, two MHA from 10:45p-7:15a
4/8/18:
*7a-7p: 25 patients with three on LOS observation; one RN, one LVN, three MHA
*7p-7a: 25 patients with three on LOS observation; one RN, one LVN, four MHAs from 2:45p-11:15p then three MHAs from 10:45p-7:15a
4/9/18:
*7a-7p: 25 patients with four on LOS observation; 2 discharges, 10 discharges; two RNs, one LVN, four MHAs until 3:15p and three MHAs until 11:15p
*7p-7a: 17 patients with three on LOS observation; 6 admissions; one RN, one LVN, four MHAs
4/10/18:
*7a-7p: 24 patients with three on LOS observation; 2 admissions, 4 discharges; one RN, one LVN, three MHAs until 11:15p
*7p-7a: 22 patients with two on LOS observation; 1 admission; two RNs, one LVN, two MHAs from 10:45p-7:15a

***Of the days reviewed for Unit IV, 4 of 24 days were inadequately staffed per the facility's staffing grid. Patient admissions occurred on 22 of the 24 days and patient discharges occurred on 18 of the 24 days.***

***Of the entire 30 day period reviewed for Unit IV, the following incidents were documented:

* Patient aggression - 18 episodes (1 of which required emergency room attention)
* Patient sexual misconduct - 1 episode
* Patient self-inflicted injury - 6 episodes
* Patients attempting suicide - 2 episodes
* Patient elopement - 1 episode
* Patient injury - 1 episode

In an interview with staff #D-1 on 4/9/18 when asked about admission assessments, they stated, "It would take about 30 minutes, just for the assessment." When asked about nursing admission assessments on Unit 4 [child adolescent unit] they stated, "The RN leaves the unit and goes to intake to do the nursing assessment." When asked what RN stays on the unit when they have to leave the unit, they stated, "There's not an RN on the unit, then. There are nights when there is no LVN, so if there's an admission and the RN has to leave the unit, there's no nurse on the unit ... We have begged for help."

In an interview with staff #D-2 on 4/9/18 when asked about staffing, they stated, "The weekends, we hurt bad. It's everyday across the board." When asked the most line of sights they've had in one shift, they stated, "Sometimes 12 patients on line of sight and we have to watch the rest of the other patients, too. If they're on 1:1, we'll get extra staff ... They should include more of the line of sights in staffing."

In an interview with staff #D-7 on 4/9/18 when asked how many LOS they had, they stated, "2 LOS and 8 other patients." When what happens when one LOS goes to the restroom, they stated, "I stand in the doorway [of the restroom] so I can watch everyone at once."

In an interview with staff #D-8 on 4/9/18 when asked how many patients they had, they stated, "6 patients, one LOS." When asked if they've ever had multiple LOS at one time, they stated, "Yes." When asked how they watch several at one time, they stated, "That's hard here. If they have to go to the bathroom or something, I'll have them keep the door cracked a little bit and tell them to talk loudly or sing so I know they're OK." When asked if they could remember the most amount of patients they were responsible for, they stated, "All together 15 girls with 6 LOS." When asked if they had to watch a 1:1 with other patients at the same time, they stated, "Multiple times. Once I had one 1:1 with 8 to 12 other patients. It's terrible here. There's no staff. It's not safe ... We're always short staffed. It's stressful."

In an interview with staff #D-28 on 4/10/18 when asked how long admissions take, they stated, "Around an hour." When asked if they get breaks, they laughed and stated, "No, not really."

In an interview with staff #A-22 on 4-10-18, staff #A-22 was asked how many discharges and admissions generally take place during a 12-hour shift. Staff #A-22 replied "Sometimes none, sometimes a lot. Today I have a transfer from another unit and I know I'll be getting an admission aside from the transfer. I've had 1 discharge already and another patient is calling his wife to come pick him up". When asked how long it takes to do an admission, staff #A-22 stated "One and a half to two hours, if I'm not interrupted, but I'm always interrupted, so that's not realistic." When asked how long it takes to prepare a discharge, staff #A-22 stated "Well, I have to do the suicide risk assessment again and do med teaching and some other paperwork, so I'd say 45 minutes".

In an interview with staff #A-23 on 4-10-18, staff #A-23 was asked to name their primary duties. Staff #A-23 stated "Well, I have to give medications, transcribe any new orders, give PRNs [as needed medications] whenever the patients ask for them and obtain consents for psych[oactive] meds. It takes up my whole day".

In an interview with staff #D-6 on 4/10/18 when asked how long their orientation period was, they stated, "I had one day on the unit. I had to teach myself."

In an interview with staff #D-26 on 4/11/18 they stated, "Usually, we're hardly staffed." When asked how long discharges usually take, they stated, "Maybe 15 minutes if everything is OK. You have to get everything in line and make sure doctors and therapists and all the pieces are in place." When asked how long admissions take, they stated, "Way longer. I've never gotten to go through it all at one time. I would say the least amount of time for the initial nursing assessment 30 minutes at a minimum. We do the initial assessment with the parent and child then once we get to the unit, we do the rest. I've never done it straight through, I have never gotten to sit down and get right through it. I guess you can add another 45 minutes for the rest?" When asked what the highest number of admissions and discharges in one shift they could remember, they stated, "11 discharges and 6 admissions." When asked about breaks, they stated, "Breaks. Not really. We can eat really fast sometimes."

In an interview with Staff #D-22 the afternoon of 4/11/2018, staff #D-22 reported that she has work at Cedar Crest for about a year but also did an internship for 2 years at this facility. She stated that she is CPI certified and had completed a refresher CPI course in 6 months. When asked about the staffing on the unit she reported that there was never enough staff. She said she tries not to be involve in the actual restraints or seclusions. She stated, "I do verbal de-escalation, as a therapist getting involved in restraints would hinder my therapeutic process I have with the patients. We hold groups with all the patients. If the milieu is acute about 70% of the patients attend, if the milieu is non acute up to 100% of the patient attend group, sometime it's up to 23-25 patients in group." She was asked if there was another staff member present during group. She stated, "sometimes, maybe half of the time an MHT sits outside the group room. When MHTs are not available and we have acute or actively psychotic patients in the group, I leave the door open in case I need to call for help. This is a 28 bed unit and we are frequently at full capacity with two MHTs. It's outrageous, there is always a fire that needs to be put out. Patients physically intervene because we don't have enough staff on the unit. Sometimes interns are used as subs for staff coverage. The interns are here to learn they shouldn't have to cover the unit because we are short staffed. Psychosocial assessments are due, groups, and patient discharges, everyone is over worked. Sometimes we breakdown and cry, we and make sure the patients don't see us. It's difficult to stay in compliance when you are having to put out fires. The CEO knows what is going on in this hospital. He knows we are understaffed. I've told him our staff are burnt out to the hilt and they are super stretched. I'm also told to clock out for 30 minutes for breaks that I never take. I'm doing notes or some other work during my break. I get in trouble if I don't clock out. I'm told that "Chart Audits" affect my yearly evaluation. They want me to go in later and fix the charts when things are not done or there are incomplete, but I refuse to do it."

In an interview with Staff #D-23 on the afternoon of 4/11/2018, staff #D-23 said she has worked at the facility only a short time but loved her job. When asked about the staffing on the unit she reported that she spends a lot of her time intervening with patients that are upset or aggressive. "There is never enough staff to take care of the patients." She stated, "we are short staffed and everyone is over worked. It is very stressful, I had a breakdown today (staff D23 was tearful during the interview) after being verbally abused by the doctor. The patients don't need to see us breakdown we are supposed to set an example. If patients see us break down, that is a problem. When a "yellow code" is called, staff will come but they don't want to get involved they don't know the patient's history or why they are in the hospital."

In an interview with staff #D-24 on 4/11/18 when asked how staffing was, they stated, "It could be better. Sometimes, it's a little understaffed." When asked on which units, they stated, "Every unit."

In an interview with staff #D-1 on 4/12/18 they stated, "We are telling doctors, 'If you're ordering line of sight, we're not going to do it. We don't have staff."

In an interview with staff #A-18 and #A-19 on 4-12-18, both staff were shown the staffing grid verified by staff #A-20 to be the current grid being used to staff the units. Both staff members stated that they had never seen the grid presented to them by the surveyors and shared with the surveyors a staffing grid they had been given by staff #A-20 and told to use to staff the units. The staffing grid given to staff members #A-18 and #A-19 by staff #A-20 allowed less staff members per patient than the grid verified by staff #A-20 as being the current grid. Staff #A-19 stated that [staff #A-19] was to come in each morning and use the midnight census as the number of patients to use to determine staffing, regardless of how many patients might have been admitted to each unit between midnight and the following morning when staffing was determined.

During a tour of Unit 3 on 04/10/17 the following observations and interviews were completed:

The unit census at the start of the day was 25. Per the Unit Intake Coordinator on the unit, 4 patients had been discharged. At the time of the observation 21 patients were on the unit. The unit was currently staffed with 1 RN, 1 LVN, and 2 MHTS. Per the facility staffing grid (21-25) the unit should have been staffed with 1 RN, 1 LVN, and 3 MHTs. The staff present on the unit did not meet the criteria set by the facility based staffing grid. At the time of the interviews on the unit on 04/10/18 at approximately 3 PM, no additional staff members had been provided to the unit on this date, despite high acuity (including code yellows called for aggressive patients, patient altercations, multiple emergency medications, and a seclusion).

In an interview staff member #C-12 stated that the acuity of the unit was up that day, confirming that two code yellows had been called due to two aggressive patients. "A male and female were going at it and I was trying to keep them apart. One of the male patients stepped in to keep the other male patient away from the female patient. He (male patient) said he'd watch our back." The staff member stated, "we could really use another staff member on days like today." Staff member #C-13 also confirmed that several code yellows were called for that unit and no extra staff had been added to support the acuity. This staff member stated, "we need another staff to assist on days like this". Both staff members reported that Unit 3 is often short staffed.

In an interview with staff member #C-15, they confirmed that the unit had two code yellows and "two silent code yellows, where we will directly call units we know have extra staff to ask for help". This staff member also confirmed the unit is often short staffed, "usually there are only 3 of us working here most days ...sometimes they pull another staff member over". This staff member also confirmed that two patients were involved in a physical altercation and "another male patient grabbed the (other) patient and held him and said to stop it". This staff member verbally re-directed the female down the hallway where "she (the patient) assaulted me." This staff member also confirmed that a patient was placed in seclusion that day.

In interviews, staff members #C-12, C-13, and C-15 all stated that due to acuity issues on the unit a male patient had to step in and physically re-direct another aggressive male patient on the unit. Staff members #C-14 and C-15 also confirmed that multiple emergency medications were administered on the unit that day.
Staff members on Unit 3 were asked about groups (such as goals groups and Nursing Psych Group) listed on the Unit Schedule being completed by nursing and MHT staff. Staff members #C-12, C-14, and C-15 all confirmed that groups not led by therapists are not being consistently held, but stated that therapist-led groups are being held. Staff member #C-15 stated, "with the high census and acuity we don't have the staff to run groups. Even the therapists can't teach a group at times it's so busy ...We're trying to do the best we can, but with this high acuity most of the time we're just de-escalating patients, giving emergency medications, and breaking up fights."

Review of medical records for Unit 3 on 04/10/18 revealed the following documented incidents:
* Patient #C-10 had a note that stated in part, "Pt assisted staff with de-escalation of a physical altercation among a male and female pt today. Male pt became violent and aggressive towards a female pt."
* Patient #C-11 had a note that stated in part, "[Patient #C-11 name) through [sic] a cup at patient. Both patients started to fight with each other and patient (Patient #C-10 name) grabbed (Patient #C-11) and restrained him from hitting other patient and hitting staff member. (Patient #C-11) was taken outside and eventually calmed down." Another note stated, "Pt was at lunch and was demanding a knife so he could cut his food. Pt lashed out and through [sic] tray across dining hall. Pt stormed out of Dining Room and a code (end of note)".

* The following patients received emergency medications on this date: Patient #C-8 had Haldol 10 mg, Ativan 2mg, and Benadryl 100 mg IM ordered X 1 at 1000. Patient #C-10 had Haldol 5 mg, Benadryl 25 mg, and Ativan 2 mg PO ordered X1 at 0930.
* Patient #C-8 was placed in seclusion from 10:00 AM until 10:30 AM due to "violent/aggressive behavior".
* Review of the "Precaution/Observation Checklist" for Patient #C-8 revealed initials that the monitoring of this patient was completed by staff member #C12 from 1000-1030 during the time of this patient's seclusion.
* Review of the "Precaution/Observation Checklist" for Patients #C-9, C-10, and C-11 revealed initials that the monitoring of these patients was completed by staff member #C12 from 1000-1030. During this half hour time frame this staff member was observing a patient #C-8 in seclusion which requires constant line of sight visualization. This staff member would not be able to perform q 15 minutes checks on other patients simultaneously. During the seclusion of Patient #C-8 the unit would have needed another staff member to assist with the observations of the other 20 patients.

During observation on Unit 3 on 04/11/18 the following was noted:
The unit census on that date was 18. The unit was currently staffed with 1 RN, 1 LVN, and 3 MHTS (1 individual staffing as an MHT was the Recreational Therapy Director). Per the facility staffing grid (16-20 patients) the unit should have been staffed with 1 RN, 1 LVN, and 2 MHTs. This unit was appropriately staffed with one extra MHT present.
In an interview with staff member #C-24 they stated that the unit was adequately staffed "today, but usually we don't have enough staff. Half the people working here today don't usually work on this unit."
In an interview with staff member #C-27 confirmed they were the Director of Recreational Therapy, but working as the an MHT on that date. They stated that their interns were running therapy sessions while they worked as an MHT.

During a review of the staffing variance (census/assignment sheet) for Unit II (adults) for 4-9-18 (review was conducted on 4-11-18), it was noted that the census was 19 patients. The unit was staffed with 1 RN, 1 LVN and 1 MHA (staff #A-21). In an interview with staff #A-21 on 4-11-18, [staff #A-21] stated that [staff #A-21] had recently been injured on the job, was under the care of a physician and had been assigned to work on Unit II, despite the physician's restrictions. At the surveyor's request, staff #A-7 provided the surveyor with the physician's restrictions for staff #A-21, which stated "no restraints". Staff #A-7 was asked if the restrictions had been communicated appropriately to administration and to those who staffed the units. Staff #A-7 provided the surveyor with an email dated 4-6-18 that had been sent to staff #A-18, #A-19 and #A-20, informing those staff members of staff #A-21's restrictions. Staff #A-20 was interviewed and asked if staff #A-20 was aware of staff #A-21's restrictions. Staff #A-20 stated "I think I saw something about that". When asked why staff #A-21 had been scheduled to provide direct patient despite restrictions prohibiting staff #A-21 from doing so, staff #A-20 stated "Oh, I don't do staffing". Staff #A-18 and #A-19 were interviewed and asked why staff #A-21 had been assigned to provide direct patient care on Unit II despite restr

Based on a tour of the facility, review of facility documentation and interviews with staff, the facility failed to have services that were directed and staffed by adequate qualified personnel, as the dietary services were not maintained in a clean or safe manner, putting both patients and staff at risk.

* Food (both dry goods and refrigerated food) was improperly labeled and stored. This practice allows for possible food spoilage and bacterial contamination (cross refer to A0620).

* Dishware (to include flatware, all dishes, cooking vessels etc) used by patients and staff were being washed in a dishwasher that did not meet water temperature requirements. These same dishes were being dried in front of a fan, the blades of which were covered in dust that was blowing onto the washed items. This practice allows for bacterial contamination (cross refer to A0620).

* The kitchen equipment and general kitchen area were not being maintained in a clean and sanitary manner (cross refer to A0620).

Based on a tour of the dietary area and a review of documentation, the dietary director failed to be responsible for the daily management of the dietary services.

Findings were:

During a tour of the dietary area on 4-11-18, the following was noted:

* It was observed the kitchen uses Eco Lab Oasis 146 MultiQuat solution for sanitation. According to the product information above this solution should be >200 ppm for food surface sanitation. Staff member #C18 was asked to test the red container of sanitizer solution to check if it was at the correct ppm strength to be effective. Staff member #C18 was not aware of any tests strips and staff member #C17 showed the staff member where the strips were located and how to use them. Staff member #C18 dipped one strip in the solution for a few seconds and it did not change colors. The employee did not appear to know how to correctly test the sanitizer solution for efficacy. The employee then looked at the vial containing test strips and then correctly tested the solution and the strip changed color indicating the solution was over 100 ppm. The surveyor looked at the vial of strips and noted the strips expired on December 2017.

* In a fridge saran wrapped buns and a bowl of broccoli salad were observed with no date present to indicate when the salad was made or the buns were taken out of their original packaging.

* The piercing surface of the facility can opener contained dried, brown, hardened residue.

* The blade of the meat slicer was coated in a brown, gummy residue.

* A yellow-brown, gummy residue was stuck to the underside of the large, kitchen mixer.

* A greasy residue was running down the wall of the food prep area.

* A drawer containing utensils such as spatulas and scoops had an unidentified crumbs and debris present, one spatula had visible food particles present, indicating ineffective cleaning.

* 9 metal warming pans were stacked for storage while wet. When these pans were separated, water droplets were visible. When dishes and pans are not air dried, there is potential for bacterial growth due to the presence of moisture. The FDA Food Code 2017: Annex 3 - Public Health Reasons / Administrative Guidelines - Chapter 4, Equipment, Utensils, and Linens stated in part, "4-901.11 Equipment and Utensils, Air-Drying Required. Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. Cloth drying of equipment and utensils is prohibited to prevent the possible transfer of microorganisms to equipment or utensils." Staff member C#17 stated that staff are trained to make sure the pans are completely dry before storing them.

* In the area where dishes and pans were drying it was observed a large 31" X 31" fan was blowing directly onto these items. The fan had large amounts of visible dust and dirt collected on the wire cage on the front and back of the fan, presenting a risk that these items are being contaminated by this dust and dirt.

* Dust and dirt were visible on the wiring and plugs behind 2 Vulcan ovens.

* Over the three compartment sink a light fixture was observed with one corner that was detached from the ceiling. There was also a large area of the ceiling beside this light fixture with flaking paint noted, presenting a risk of this area to be contaminated by paint chips.

* In the refrigerator in the serving area an open container of almond milk was observe that did not have the date opened noted.

* In the dry goods pantry, 3 of 20 24-ounce cans of grits and 8 of 8 bottles of chocolate syrup had not been marked with the date they were received into the facility.

* Under the shelving unit in the dry goods pantry, the floor was soiled with visible debris to include loose pasta, individual jelly containers, packets of sweetener, crumbs, applesauce containers and ketchup packets.

* Manufacturer signage on the side of the dishwasher stated that the machine was to reach 160 degrees Fahrenheit during the wash cycle and 180 degrees Fahrenheit during the rinse cycle. The machine was run through a complete cycle 3 times, approximately 5 minutes apart. During each of the complete cycles, the machine wash temperature never rose above 120 degrees Fahrenheit. In an interview with staff #A-16, staff #A-16 initially stated that the wash temperature gauge was broken but then stated that the "Health Department" had been contacted and told the facility that it didn't matter that the wash temperature wasn't reaching manufacturer specifications as long as the rinse temperature was reaching manufacturer specifications.

* In the food serving line, dust, what appeared to be rust and a thick, brown substance were visible on a shelf beneath the hot serving line. The lids to the hot serving dishes were being stored on the shelf.

* On the floor behind the serving line, water was visible around a floor tile and the tile was bulging. When the surveyor stepped on the tile, water spurted out from around the edges of the flooring. Surrounding flooring behind the serving line was loose or missing completely. In an interview with staff #A-18 during the tour, staff #A-18 stated that he was aware of the problem and it was caused by a floor drain issue.

The FDA Food Code 2017: Annex 3 - Public Health Reasons / Administrative Guidelines - Chapter 4, Equipment, Utensils, and Linens stated in part,
"4-204.115 Warewashing Machines, Temperature Measuring Devices.
The requirement for the presence of a temperature measuring device in each tank of the warewashing machine is based on the importance of temperature in the sanitization step. In hot water machines, it is critical that minimum temperatures be met at the various cycles so that the cumulative effect of successively rising temperatures causes the surface of the item being washed to reach the required temperature for sanitization. When chemical sanitizers are used, specific minimum temperatures must be met because the effectiveness of chemical sanitizers is directly affected by the temperature of the solution ...
4-501.110 Mechanical Warewashing Equipment, Wash Solution Temperature.
The wash solution temperature in mechanical warewashing equipment is critical to proper operation. The chemicals used may not adequately perform their function if the temperature is too low. Therefore, the manufacturer's instructions must be followed. The temperatures vary according to the specific equipment being used."

A review of the facility dishwasher temperature log was conducted. The reviewed encompassed the dates of 3-4-18 through 4-11-18. The dishwasher log stated "Wash temp[erature] must be ?[greater than] 160 degrees F.[Fahrenheit] and rinse temp[erature] must be >[greater than] 180 degrees F.[Fahrenheit]." The dishwasher wash temperatures ranged from 160 degrees to 165 throughout the time period reviewed.

A copy of the monthly maintenance inspection & preventive maintenance of dietary equipment was provided to the surveyors. A review of the "procedures" for the commercial dishwasher revealed the following:
"Using temperature sensitive tape, run a cycle and check for at least 180 degrees in the rinse cycle."
The procedures contained no instructions for checking temperature requirements of the wash cycle.

A diagram on page 17 of the operation manual for the facility's MD-44 dishwasher indicated that the machine should operate its wash cycle with water a minimum of 160 degrees Fahrenheit. The same diagram indicated that the machine should operate its rinse cycle with water a minimum of 180 degrees Fahrenheit.

The "Product Specification Document" for the "Oasis 146 Multi-Quat Sanitizer" found at https://cdndadepaper.blob.core.windows.net/paper-images/c89edc00-d4b7-4fae-abc4-b872e826abe6.pdf stated in part,
DIRECTIONS FOR USE:
* Oasis 146 Multi-Quat Sanitizer can be used to sanitize hard, non-porous food contact surfaces such as tables, counters, and food processing equipment.
Oasis 146 Multi-Quat Sanitizer is an effective sanitizer against Escherichia coli and Staphylococcus aureus on food contact surfaces when used at 0.25 oz-0.67 oz. per 1 gallon of 400 ppm hard water (150 ppm to 400 ppm active quat). Oasis 146 Multi-Quat Sanitizer is an effective sanitizer against Escherichia coli, Staphylococcus aureus, Campylobacter jejuni, Escherichia coli O157:H7, Klebsiella pneumoniae, Listeria monocytogenes, Salmonella choleraesuis, Shigella sonnei, Yersinia enterocolitica and Enterobacter sakazakii on food contact surfaces when used at 0.32 oz.-0.67 oz. per 1 gallon of 500 ppm hard water (200 ppm to 400 ppm active quat).
Sanitizing Equipment - (Food Processing Plants or Restaurants): For sanitizing precleaned food processing equipment or utensils in federally inspected meat and poultry processing plants or restaurants. Prior to application, remove gross food particles and soil by a pre- flush, pre-scrape or when necessary, a pre-soak. Then thoroughly wash or flush objects with a good detergent or compatible cleaner followed by a potable water rinse before application of the sanitizing solution. Apply a use-solution of 1 oz. to 2.67 oz. of Oasis 146 Multi-Quat Sanitizer per 4 gallons of 400 ppm hard water (150-400 ppm active quat) or 1.25 oz. to 2.67 oz. Oasis 146 Multi-Quat Sanitizer per 4 gallons of 500 ppm hard water (200-400 ppm active quat). Expose all surfaces to the sanitizing solution for a period of not less than 1 minute. Allow equipment to drain thoroughly and air dry ...
Usage Notes: ...
o When testing dilution strength using quat test strips, always follow temperature guidelines printed on the test strip dispenser - i.e. solution temp between 65 and 75 degrees."
The product information for QAC test strips found at https://preclaboratories.com/product/quick-response-qac-test-strip/ stated in part,
* Quick Response QAC Test Strip
The Quick Response QAC Test strip (Quaternary Ammonium Compounds) is calibrated at 0, 100, 200, and 400ppm, and give a response in just one second. This test strip can determine levels of up to 0-400ppm for hyamine- and steramine-type chlorinated amine disinfectants to confirm their cleaning power is at full strength.
Instructions:
1.Dip the test strip into the solution to be tested for 1-2 seconds.
2.Compare the test strip to the color chart within 10 seconds.
NOTE: These strips are guaranteed to accurately test: OASIS 146, Hyamine 35, Bardac 2250, Sysco (tablets)."

A document titled "Dietary Maintenance Log", dated 3-26-18 (and authenticated with the signature of staff A-15) stated:
"The following list consists of the items in the kitchen and dining room that are currently in disrepair and need attention from the maintenance department.
...
* Ceiling leak by sinks in dishwasher area (light looks like it may fall from ceiling) pain chips falling from ceiling in food prep area.

* Kitchen and serving line drains need to be serviced (drain strainers ordered Feb-2018)"

Facility policy 1600.75 titled "Inservice Training on Infection Control for Dietary Staff" states, in part:
"Policy: Dietary Service Staff will attend and participate in Infection Control In-services specific for Dietary Service Staff.
Procedure:
Dietary Staff must attend the following in-services, but not limited to:
...
5. Explanations of the causes of food contamination
6. Means of prevention of food contamination including the relationship of temperature to bacterial growth
7. Proper cleaning and sanitizing of equipment
8. Training in use of dish washing(sic) machines and dish washing(sic) compounds"

Facility policy 1900.1 titled "Food Services Department - Purpose and Responsibility" states, in part:
"Procedure:
...
2. Food Services Staff are responsible for food preparation:
2.1 Staff shall prepare food under strict sanitary conditions and in accordance with local and state regulations.
...
7. Director of food Services is responsible for:
...
7.3 Ensuring that the Food Services Staff are following hospital and department policies and procedures."

Facility policy 1900.12 titled "Food Services Interface with Maintenance" states, in part:
"Policy: Food Service Department interfaces closely with the Maintenance Department.
Procedure:
1. The Maintenance Department will provide an ongoing Preventive Maintenance Programs(sic) for Food Services Department's equipment and Physical plant."

Facility policy 1900.40 titled "Food Services Infection Control" states, in part:
"Policy: The Food Services Department will prevent contamination of foods served to patients and others which may result in food-borne illnesses.
Procedure:
...
5. Food Service Staff shall store food appropriately. Foods must be handled properly immediately after being received by:
...
5.4. Refrigerating leftover foods immediately after labeling and dating.
...
6. Food Service Staff shall store dry foods appropriately:
...
6.2. Store dry foods according to the following:
6.2.1. Store promptly in a clean, dry, ventilated and lighted storeroom.
...
6.6.2. Rotate all foods and supplies to keep fresh stock on hand.
...7. Food Services Staff responsible for cleaning storerooms:
7.1. Perform standard damp mopping of floors at least one time each day.
...
9. Food Services Staff must follow appropriate dishwashing procedures. The following procedures are considered a minimum:
...
9.2. Washing:
...
9.2.2. Water temperature should be as hot as hands can tolerate, or if by machine, at 160-165F[Fahrenheit] on high-temperature dish-machine ...
9.3. Sanitizing Rinse:
9.3.1. This is the final rinse of clean utensils and should be 15 seconds at 180F[Fahrenheit] temperature for high-temperature dish-machine ...
...
11. Food Service Staff maintain kitchen equipment:
...
11.4. Electrical Equipment, e.g., toasters, choppers, grinders, mixers, can openers and peelers must be cleaned after each use.
...
12. Food Service Staff are responsible to keep the kitchen clean:
12.2. Scrub floors with germicidal detergent once daily."

Facility policy 1600.76 titled "Food Products/Storage" states, in part:
"Policy: Food products shall be stored in a safe and sanitary manner and recommended temperature in order to ensure integrity of food.
Procedure:
The food Services Manager and Food Services Staff will ensure:
...
9. Food service area is kept clean and free from rodents, roaches and insects. Floors swept and mopped as needed. Routine cleaning per job descriptions and per cleaning schedule.
...
14. Foods must always be properly dated, labeled, and wrapped.
15. Rotate stock. (First-in, First-out.)"

Facility policy 1600.77 titled "Food Preparation and Service" states, in part:
"Policy: Foods shall be prepared and serviced in such a manner as to prevent food-borne illness and contamination.
Procedure:
1. The Director of Food Services is responsible for monitoring and supervision of food preparation and service including:
...
1.6. Cleaning:
...
1.6.4. All equipment is cleaned and sanitized according to procedure.
...
1.7. Storing:
...
1.7.2. Food storage areas are kept clean per Cleaning Schedule."

Facility policy 1900.43 titled "Prevention of Cross-Contamination in Dishwashing Procedures" states, in part:
"Policy: Food Services Department prevents cross-contamination in dishwashing procedures.
Procedure:
Food Services Staff will:
...
6. After the rinse cycle is completed, open the dish machine, pull out racks. Air dry wares by letting racks set.
...
9. Retrieve dishes and wares and stores in designated areas. Do not wipe dishes to dry - air dry."

Facility policy 1900.50 titled "Care of Storeroom" states, in part:
"Policy: A regular cleaning schedule of the storeroom is carried out for cleanliness and sanitation.
Procedure:
1. Food Services Staff will:
...
1.6. Mark or stamp date of delivery on new stock,
1.7. Place new stock in back of previously delivered items of the same food so that older stock will be issued first."

Facility policy 1900.52 titled "Food and Supply Storage" states, in part:
"Policy: Appropriate storage space for food and supplies is provided.
Procedure:
1. Food Service Staff order food and supplies from vendors approved by local and state health departments.
...
3. Food Service Staff follow these guidelines for processing deliveries:
...
3.2. Date all packages received
...
3.4. Place new stock behind older stock.
...
4. Food Service Staff utilize storage which will include:
...
4.4. Clean and orderly area
...
8. Food Service Staff will date all foods and rotate by the First in First out rule."

Facility policy 1900.54 titled "Leftovers" states, in part:
"Policy: All leftovers must be labeled, dated and stored in clean, covered containers."

Facility policy 1900.57 titled "Dish-Machine Log/Temperature Breakage Form" states, in part:
"Policy: To ensure appropriate sanitation of dishes and wares, the Food Services Department will monitor wash and rinse temperatures of dish-machine on a daily basis."

Facility policy 1900.63 titled "Prevention of Cross-Contamination in the Dishroom" states, as follows:
"Procedure:
...
2. The Food Services Staff removes the rack from the dishmachine(sic) when the dishes have completed the dishwashing and rinse cycle. Allows them to air dry."

Facility policy 1900.66 titled "Safety Checklist for the Food Service Department" states, in part:
"Procedure:
1. The Food Service Director or designee will complete the Safety Checklist at least once each month."

Facility policy 1900.69 titled "Cleaning Procedures" states, in part:
"Policy: The proper technique will be used in the cleaning of all kitchen equipment, floor surfaces, storage bins and sinks.
Procedure:
1. Food Services Staff utilize appropriate dishwashing techniques:
...
1.2. food Services Staff Sanitize the dishes effectively, using a dishwashing machine, the following guidelines will be followed:
...
1.2.4. Check the dish machine for proper operation before and during the dishwashing operation. Check points include:
1.2.4.1. The was temperature should be between 140-160 degrees F[Fahrenheit]. Pressure for the wash water should read 15-25 psi[pounds per square inch].
...
1.2.4.3. The rinse temperature should be at least 180 degrees F[fahrenheit]. Pressure of the rinse water should be 10 psi.
...
1.2.6. Dishes are to be allowed to air dry before stacking and storing.
...
4. Food Service Staff are responsible for cleaning the can opener as follows:
4.1. The can opener should be cleaned following each meal preparation, as well as after the opening of any spoiled canned foods.
4.2. Remove the blade and shaft from the main body of the can opener, wash in hot, soapy water, rinse and sanitize.
...
12. Food Service Staff will keep the dry storage area clean. This will include the following:
12.1. keep all food items off the floor at all times.
12.2. Sweep and mop floors on a daily basis.
...
21. Food Service Staff clean meat slicer by the following process:
21.1. Disassemble slicer per manufacturer's directions.
21.2. Scrub with a brush to remove debris.
21.3. Soak in a sanitizing solution and let air dry.
21.4. Reassemble and clean the outside.
21.5. Cleaning should b(sic) done each time after use.

22. Food Service Staff clean the mixing machine. They will:
22.1. Wash machine immediately after using to prevent food particles from drying on the surface.
22.2. Wash the stand on a daily basis.
22.3. Clean the machine and stand with detergent and water - if stainless steel, polish with stainless steel polish."

Facility policy 1900.75 titled "Operating, Cleaning and Maintenance of Equipment" states, in part:
"Policy: Food Service Staff will work closely with the maintenance department to ensure efficiency, safety, and maximum use of equipment.
Procedure:
...
3. The food service staff and maintenance staff follow these procedures for equipment as follows:
...
3.5 Mixer
...
3.5.2. Cleaning:
3.5.2.1. Check control switch to be sure mixer is turned off.
3.5.2.2. Remove bowl and whip from the base of the mixer.
3.5.2.3. Remove build up from corners and joints of the mixer with a soft bristle brush.
3.5.2.4. Wipe exterior with a damp cloth and use hot soapy water to remove food deposits or grease.
...
3.7. Slicer
...
3.7.2. Cleaning
3.7.2.1. Clean slicer after each use.
3.7.2.2. Take special care when cleaning slicer after raw meats have been cut since bacteria from raw meat could be transferred to cooked meat if the slicer is not properly cleaned.
...
3.7.2.9. Carefully wash front and rear of blade with cloth dipped in soap solution. Always stand facing the slicer as you would when you are actually slicing.

Facility policy 1900.76 titled "Preventative Maintenance Program" states, in part:
"Policy: Maintenance department will systematically check and maintain equipment in the Food Service department in order to avoid breakdowns.
Procedure:
1. Maintenance staff will complete an inspection of equipment each month.
2. Maintenance will document the inspection including:
2.1. Date of inspection.
2.2. Equipment that is not functioning properly.
2.3. Actions taken to remedy the malfunction.
3. Maintenance staff will review the inspection upon completion with the administrator and the food service staff."

Facility policy 1900.77 titled "Preventative Maintenance" states, in part:
"Policy: Items are inspected for safety and proper operation on [a] regular basis.
Procedure:
1. Maintenance staff test, service, log all non-clinical equipment.
2. Maintenance staff replaces malfunctioning parts as soon as possible after their discovery.
...
4. Food Service Staff will inspect for safety and proper operation of the following items:
...
4.3. Check dishwasher and booster heater to make sure they are running properly and maintaining the proper wash and rinse temperatures. (daily)"

The above was confirmed in an interview with the CEO, Corporate Vice-President of Clinical Services, Corporate Director of Quality Measures and Corporate Director of Clinical Services on the evening of 4-12-18.

Based on observation, staff interviews and documentation review, the facility failed to ensure that the physical environment, including the hospital grounds, buildings, furniture and equipment, were maintained in a manner that ensured the safety of patients, visitors and staff as:

a. objects hazardous to patients and potentially to staff were not secured or removed as necessary (cross refer A701);
b. buildings, including patient rooms and examination rooms were maintained in a clean and sanitary manner (cross refer A701);
c. patient medical equipment was stored and maintained in a clean and sanitary setting (cross refer A701);
d. facility furniture was in disrepair and provided additional safety hazards to patients and visitors (cross refer A701); and
e. proper temperature controls were not implement in all areas of patient food and medical supply storage (cross refer A726).

These failed practices resulted in potential threats to patient safety. The cumulative effect of these systemic deficient practices resulted in noncompliance with the Condition of Participation for Physical Environment.

Based on observation, staff interviews and documentation review, the facility failed to ensure that the hospital physical environment, including the grounds, buildings, furniture and equipment, were maintained in a manner that ensured the safety of patients, visitors and staff as:

a. objects hazardous to patients and potentially to staff were not secured or removed as necessary;
b. buildings, including patient rooms and examination rooms were maintained in a clean and sanitary manner, and in good repair;
c. patient medical equipment was stored and maintained in a clean and sanitary setting; and
d. the hospital kitchen included physical issues that made the kitchen unclean and unsanitary.

Findings were:

Facility policy #1600.82 entitled "Environment of Care," last revised 3/11, included the following:
"POLICY: The Environment of Care Services & Housekeeping provides a hygienically clean environment by systematic inspection and preventive maintenance of all equipment, routines for emergency repairs and by proper care for the entire physical structure ...
PURPOSE:
A. To promote an environment for patients, staff and visitors that is free from safety hazards and that all facility areas are in compliance with local and state regulations ..."

Facility policy #1000.53 entitled "Outdoor Recreational Activities," last reviewed 10/15, included the following:
"POLICY: Cedar Crest Staff facilitate the therapeutic use of outdoor recreational activities and safety regarding hospital & RTC (residential treatment center) grounds ...
PROCEDURE: ...
2.5 AT (activity therapy) Staff and all Staff shall monitor hospital & RTC environment of care (EC) grounds for safety or treatment risks ..."

Facility policy #SM-001 entitled "Administrative Policy on Safety Program," original date of issue 1/17, included the following:
"The Hospital shall establish a hospital-wide program that is designed to:
a. Reduce to the extent possible, hazards to patient, visitors and Hospital staff members ...
f. Provide safe health care practices and facilities for both patients and visitors ...
Housekeeping
Safety begins with good housekeeping ...It is everyone's responsibility to help keep the work place clean and safe.
Plant Operations
1. Plant Operations service's first priority is to maintain the Hospital as it relates to the safety for patients and staff ..."

Facility policy #1600.57 entitled "Floor Scrubbing," last revised 3/11, included the following:
"Cedar Crest Hospital provides cleanliness of floors in order to provide a clean and safe environment for patients, staff and others ..."

Facility policy #1600.54 entitled "Cleaning Patient Rooms," last revised 3/11, included the following:
"Patient rooms are cleaned to prevent spread of infection and protection of patients, staff and others ...
5. Clean patient bathroom ..."

Facility policy #1800.2 entitled "Patient Rights to Care and Treatment," last revised 4/16, included the following:
"PROCEDURE: ...
5. Staff will provide care in consideration of psychosocial, spiritual, and cultural variables as well as the patient's response to and identified needs relating to those issues:
5.2 Treatment team implement treatment approaches in response to identified problems/behaviors which led to admission to any level of care.
6. Admission staff advises parents of minors of their rights and responsibilities at admission and throughout the continuum of care.
6.1 Parents have the right to be assured that their dependent minor is provided
6.1.1 A safe and comfortable environment ..."

Facility policy #1000.98 entitled "Sexually Acting Out Precautions (SAOP)," last revised 10/17, included the following:
"3. Room assignments are made with regard to client's age and degree of vulnerability to sexually acting out victimization or perpetrating characteristics ..."


During a tour of the child and adolescent unit on 04/09/18 the following observations were made:

In the patient seclusion area:
o A 2 X 2-inch indention was observed in the wall behind the door, it appeared to be a result of the door handle hitting the wall. This area cannot be cleaned effectively. A metal electric switch plate was observed separating from the wall, which could create and an opportunity for the plate to be removed, creating a safety hazard. This plate could be pried off and used for self-harm or as a weapon.

In the patient rooms:
o In Room 402 a 2 X 2-inch indention was observed in the wall behind the door, it appeared to be created from the door hitting the wall. This area cannot be cleaned effectively.
o In Room 403 mold and missing wallpaper was observed on the wall surrounding the shower. The presence of mold present is evidence of water damage with the opportunity for bacterial growth.
o Outside Room 408 the wallpaper around the door frame outside the room was observed peeling and separating from the wall, preventing this surface from being cleaned effectively.
o In Room 417 small holes were observed in the wall.
o In Room 450 (linen room) the 2 laundry/linen carts were observed uncovered, presenting a risk of contamination of the linen.
o An 8-year-old girl was housed in room 419 - a room with a large penis painted on each of two walls of the room. In addition, the room had no curtains and the window of the room looked out directly into the window of the activity room of the adult acute unit. The 8-year-old female patient was on sexually acting out precautions. A disabled motion detector high on the wall in the room was missing a cover, leaving wires and hardware exposed. A nightstand was placed directly beneath the motion detector, which placed the detector potentially within patient reach, and thus posing a threat to patient safety.

In the latency hallway:
o Chips and gouges of varying sizes in the wall plaster throughout the unit, but notably in the latency hallway [exhibit and hallway by the old nurses' station, including a crack in the wall approximately a foot long [exhibit A].
o Double doors which closed off the area near the old nurses' station from the latency hallway had a metal strip protruding off the back of the door near the top of it.
o Counter laminate missing on the corner of the latency nurses' station revealing the permeable surface beneath which appeared to be oriented strand board.
o A crack in the ceiling tile [exhibit B] which could provide an entry point for pest and debris.
o A closet with drywall missing and a dirty curtain laying in front of it with dirt build-up on the floor [exhibit O&P]

In the latency activity/play room:
o Several chips in the laminate and walls of the unused nurse's station by the latency activity room [exhibits M & N]
o An approximate 4'x 4' play table with loose and missing laminate. The loose laminate could be pulled out and snapped back toward the table posing a safety risk.

In the adolescent girls' activity room:
o There were three chairs with tears in the plastic cushions
o A dry-erase easel with only two legs that could not stand on its own

In the adolescent males' activity room:
o 3 chairs were observed with tears present. One chair tear was approximately 1.5 feet in length across the back of a chair. One chair had an 8 inch tear down the back. Two chairs had foam exposed. Theses tears prevent effectively cleaning of these surfaces.

On the patient patios:
o A table with a piece of plastic approximately 3.5 inches hanging off [exhibit C & D] on the latency patio
o Several sharp plant stumps a patient could injure themselves on [exhibits E, F, G, H] on the latency patio
o A wooden fence with several areas where it meets the ground a child could elope from [exhibits I, J, K, L] on the latency patio (see facility Incident Report information below)
o A table with bottom plastic half-way peeled off on the adolescent girls' patio [exhibit Q]
o The adolescent girls' patio had a garden hose strung across it from a faucet on the unit wall over and beyond the fence. The hose could have been used to go over the fence or in a variety of other ways to hurt others or self-harm.
o Obscenities were painted on the walls of the latency patio and the adolescent girls' patio. Some of the writing was faint and it was unclear how long it had been there.

In the patient examination room:
o In a room off the examination room of the unit, patient supplies were found under the sink, including otoscope ear covers and other patient examination supplies. The floor of the room was dirty and an old bottle of bleach was lying upended on the floor next to a cricket leg. The light fixture contained what appeared to be approximately 30 carcasses of small bugs. The room contained a patient EKG machine. An old filing cabinet with large patches of rust on the exterior housed additional patient supplies.


Incident report dated 3/30/18 at 9:50 am stated in part, "Pt shared she broke off a piece of a plastic table outside, went into the bathroom and scratched herself ...
Actions taken/follow-up info/recommendations as a result of the incident: Inspected arms, called maintenance to remove the table." Signed by the risk manager on 4/2/18.

Incident report dated 3/31/18 at 9:30pm stated in part, "Eloped from unit 4 activity RM [room]."

Incident report dated 4/1/18 at 10:15 am stated in part, "Pt was playing around and climbed the wooden fence. Pt was asked to get down. As pt was coming down her foot slipped and she fell obtaining a small cut to her L [left] lower leg [LLE] and stating her finger hurts right afterwards.
Actions taken/follow-up info/recommendations as result of the incident: scrap [sic] to LLE cleaned with NS [normal saline], patted dry." Signed by the risk manager on 4/2/18.
Nursing progress note dated 4/1/18 at 10:15 am stated in part, "Pt was outside with other kids and staff in the fenced area. Pt stated, 'I'll show you how that boy escaped.' Pt was then seen climbing the wooden fence and was asked to get down ..."


A tour of Cedar Crest Hospital Unit 2 was conducted with Staff #B13 and Staff #B14, a unit LVN and MHT respectively, on the afternoon of 4/11/18 beginning at approximately 1:45 p.m. Tour findings included the following:

In the unit medication room:
o There was dirt and debris on the floor of the room. Staff #B13 stated that housekeeping regularly cleaned the room, but she was unsure how often.

o An old and ill-fitting phone plate cover had open gaps around it which opened to the wall space behind it. This allowed for entry of dust, debris and pests into the patient medication room from the wall space behind.

o Under the sink there were ill-fitting PVC pipes with gaps between adjoining pipes. Old sticky glue had been exposed where the pipes had come apart making thorough cleaning impossible. A stain on the flooring under the pipes revealed either a previous or current issue with leaking. A plastic gray tub was under the sink, identified by Staff #B13 as "maybe there to catch the leaks?" Patient supplies had been stored under the sink including nebulizer masks and hosing. The plastic container holding these supplies had a thick layer of dust on the sides. In addition, an oxygen machine had been stored touching against the ill-fitting pipes. Items stored under sinks are exposed to contamination and mold damage from splashes and/or leaks. Staff #B13 stated the patient items were still in use on the unit.

In patient rooms:
o A shelf in the shower areas of room 207/208 and room 205 included a metal pipe surround on the shelf. Water could not drain from the shelf once filled. Patient #B12, the patient in room 205 stated, "The water just fills up in there every time you take a shower. It can't get out. It gets soapy and disgusting and then the old water and soap just drips out of there when you're taking a shower." He added, "It's only like that in this room and one other room on the unit, but it's gross. They just finally cleaned it out yesterday. The other rooms have some kind of plastic covering that area."

In the patient quiet/seclusion room:
o There was an approximate 3" x 1.5" hole sharply cut through the wall plaster which revealed what appeared to be old foam insulation in the wall space behind it. This allowed for dust, debris and pests to enter the area, but also posed a safety hazard as the insulation could be easily reached and extracted by any patient in the area.

In a patient supply storage closet:
o An air conditioning vent in the tiled ceiling above the supplies had an old discolored water stain around it approximately 8" diameter in size. Ceiling tiles with water stains can harbor mold and may crumble, contaminating items below.

In the patient examination room:
o There was missing Formica-like covering on a corner of the sink surround. An old band-aid had been placed over the area presumably to cover the permeable surface beneath. The band-aid did not cover the entire opening, and was dirty and sticky. This made thorough cleaning of the surface impossible.

o Under the sink were stored boxes of paper patient gowns and paper examination table covers. These boxes were open and the gowns - the box on top - were completely exposed. The other box with table covers was also open, but the cardboard box of gowns sitting on top of the covers blocked them from complete exposure.

o A room directly across the hallway from the patient examination room was a room identified by Staff #B13 as "an old men's bathroom that wasn't mechanically right. We don't use it anymore." The door was closed, but had a layer of dust at the top and bottom that was visible even in the hallway. Inside the room, there was heavy dirt and debris on the floor, including large clumps of dust and dirt. Inside the room were found packages of laundered patient towels and bathroom linens with labels reading, "Route Load March 23 2018." Boxes identified as containing a mix of patient and office supplies were opened and stored on the floor next to an old and filthy toilet which appeared to be no longer in use. In the water inside the toilet were clumps of dirt. An opened box of syringes available for patient use was stored against the wall, as well as a box of scrub pants. On top of these boxes were two plastic bins which are typically used to store medication vials or patient supplies. Inside a plastic container with three drawers were alcohol wipes and other patient supplies. Dirt and debris were found atop storage containers all through the room. Staff #B14 stated, "This is nasty."

Throughout the unit:
o Light fixtures on the unit included what appeared to be numerous dead bug carcasses. In patient room 207/208, there were approximately 25 of these in the bedroom light fixture, and 10 in that of the bathroom. The light fixture in the bedroom of room 205 included approximately 20 of these. The light fixture above the examination table in the patient examination room again included what appeared to be dead bug carcasses in a quantity too numerous to count, but greater than 40 in number.

o The unit contained no soap dispensers. When asked why this was the case, Staff #B13 stated, "They were all removed because of an issue with the spring inside the containers. We were told that you guys [surveyors] had said they had to be removed. We have a big container of soap at the nurses' station and we give soap out to the patients in cups when they need it."


In an interview with Staff #8, Plant Ops Manager, on the morning of 4/12/18 in his office, he stated, "I only know about one patient elopement that happened anytime recently - that was out of admissions maybe a month or so ago. The patient broken through the magnetic doors there ...We do environment of care rounding." He stated he was aware of a number of the items above and added, "There's really been such an emphasis on other priorities, but a lot of those things I know need to be addressed." He added he performed rounds on all the units, the patient patios and the dietary area, but added, "I round in the kitchen, but only to check whether equipment is working or not. That floor issue in the kitchen we knew about, and that will be addressed immediately. Otherwise, I'm checking equipment when I'm in there." He stated that some of the physical environment items needed to be brought before the Quality Assessment/Performance Improvement committee in a more assertive manner.

The above was confirmed in an interview with the CEO, Corporate Vice-President of Clinical Services, Corporate Director of Quality Measures and Corporate Director of Clinical Services on the evening of 4-12-18.

Based on observation, staff interviews and documentation review, the facility failed to ensure proper temperature controls in all areas of patient food and medical supply storage.

Findings were:

Facility policy #SM-001 entitled Safety Management, no revision date, included the following:
"The Hospital shall provide a safe, sanitary environment for patients, employees and visitors as indicated in the following:...
2. The Hospital shall establish a hospital-wide program that is designed to:
a. Reduce to the extent possible, hazards to patients, visitors and Hospital staff members..."

Facility policy #1600.82 entitled Environment of Care, last revised 3/11, included the following:
"2. The Housekeeping/Maintenance Staff ensures that he service area is kept clean, including:
2.1 Maintaining proper equipment daily..."

During a tour of Cedar Crest Hospital Unit 4 on the morning of 4/9/18, a refrigerator in the patient examination room was noted to have a temperature check sheet for the month of April 2018 with daily temperatures noted as ranging from 38 to 41 degrees. The temperature for 4/9/18 had been listed as 40 degrees at 10:00 a.m. When the refrigerator temperature was actually checked, the thermometer read 55 degrees. Staff #12, Nurse Practitioner, stated "We keep lab draws in here usually. Right now there are no medications in the refrigerator." The check sheet included no range for acceptable temperature for the refrigerator.

A tour of Cedar Crest Hospital Unit 2 was conducted with Staff #B13 and Staff #B14, a unit LVN and MHT respectively, on the afternoon of 4/11/18 beginning at approximately 1:45 p.m. In the patient food area on the unit a refrigerator included snack items for patients to eat. A review of the refrigerator temperature checks for April 2018 revealed the temperatures running from 38 to 40 degrees. The temperature listed for 4/11/18 was 40 degrees. When the thermometer in the refrigerator was checked during the tour, it read 44 to 45 degrees as the current temperature. The check sheet included no range of acceptable temperatures.

In an interview with Staff #B13, an LVN, during the tour, she stated, "I think it's supposed to be between 35 and 40 degrees. There used to be a temperature range on the old check sheet. I don't know what happened to it." Staff #B14, a mental health tech, was also unsure of what the refrigerator temperature range should be.

The above was confirmed in an interview with the CEO, Corporate Vice-President of Clinical Services, Corporate Director of Quality Measures and Corporate Director of Clinical Services on the evening of 4-12-18.

Based on a review of documentation, interviews, tour, and observations, the facility failed to provide a sanitary environment to avoid sources and transmission of infections and communicable diseases. The facility also failed to ensure there was an active program for the prevention, control, and investigation of infections and communicable diseases. Infection Control issues included the following:

1. Failing to ensure that the infection control director had adequate training and time available to address infection control issues and surveillance at the facility. Cross refer to A0748.

2. The facility infection control officer or officers failed to implement and maintain a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel.
Examples inlcude:
* Soap dispensers were removed from patient bathrooms in February 2018. This action directly impacts infection control at the facility, due to patients have limited access to hand soap and hand sanitizer (dispensed by staff) impacting the ability to complete hand hygiene consistently. Proper hand hygiene, which includes frequent access to soap and hand sanitizer are essential to reduce germs and potential transmission of infections per CDC guidance.
* The infection control program was not effectively monitoring facility identified goals and indicators which could affect patient and staff health. Issues impacting infection control were not documented or included in the Perfomance Improvement meeting minutes, such as the removal of hand soap dispensers, the outcome of hand hygiene surveillance, patient influenza vaccination rates, and analysis of HAIs at the facility.
* No inpatients were monitored or observed for hand hygiene compliance, per the facility based infection control plan. With no surveillance of inpatient hand hygiene by infection control it is unknown if patients were effectively and properly completing hand hygiene. Hand hygiene surveillance could provide important data about how units are addressing the removal of soap dispensers on the units.
* Hand hygiene is important to reduce the potential transmission of illness including the influenza virus. The child and adolescent unit had 2 influenza positive patients at the start of April 2018, effective hand hygiene including routine access to hand soap and hand sanitizer is essential to minimize the potential spread of influenza. The removal of soap dispensers, with the inconsistent provision of soap and hand sanitizer to patients, could potentially increase the transmission of germs and increase the risk of influenza transmission the unit and throughout the facility. This placed patients and staff at increased risk of illness.
Cross refer to A0749.

Based on a review of documentation and interviews, the facility failed to ensure that the person or persons designated as infection control officer developed and implemented policies governing control of infections and communicable diseases, as evidence by failing to ensure that the infection control director had adequate training and time available to address infection control issues and surveillance at the facility.

According to CMS Interpretive Guidelines: The hospital must designate in writing an individual or group of individuals as its infection control officer or officers. In designating infection control officers hospitals should assure that the individuals so designated are qualified through education, training, experience, or certification (such as that offered by the Certification Board of Infection Control and Epidemiology Inc. (CBIC), or by the specialty boards in adult or pediatric infectious diseases offered for physicians by the American Board of Internal Medicine (for internists) and the American Board of Pediatrics (for pediatricians)). Infection control officers should maintain their qualifications through ongoing education and training, which can be demonstrated by participation in infection control courses, or in local and national meetings organized by recognized professional societies, such as APIC and SHEA."

Findings included:

Facility based Policy #1600.3 entitled, "Infection Control Nurse Job Description" stated in part,
"1. The IC Nurse must be a graduate of an appropriately accredited school of nursing, is licensed by the State of Texas to practice as a Registered Nurse and demonstrates an understanding of the principles of epidemiology, infectious disease in the hospital, and principles of learning.
2. The Infection Control Nurse assumes direct responsibility for infection surveillance which includes:
2.1. Develops and maintains a method of identifying and recording known or suspected infections for inpatients and employees.
2.2. Carries out periodic surveillance inspections to ensure that procedures for the control of infections are being followed correctly.
2.3. Collects and maintains statistical data of value in the identification and control of infections.
2.4. Maintains close liaison with the public health service and local physicians to identify patients with infections that become apparent after discharge from the hospital.
2.5 Is responsible for the ordering and administration of Vaccines and maintains compliance with the Texas Vaccines for Children Program through the Health Department.
2.6 Is responsible for ordering and administering Flu vaccines to patients and staff ...
5. The Infection Control Nurse provides technical support and education for the hospital staff which includes:
5.3 Obtain and maintain current literature as resource information that is relevant to the infection control programs or practice."

Facility based Policy #1600.1 entitled, "Infection Control Program - Written Description" stated in part,
"1. The Infection Control Coordinator and the Committee of the Whole (Medical Executive Committee) will ensure the objectives of the program are met. These include, but are not limited to: ...

5. The IC Coordinator in consultation with the Director of Nursing Services and Medical licensed independent provider (LIP) responsibilities include:
5.4. Determining the number of hours needed in completing Infection Control Activities and assures that the Infection Control Nurse is employed for at least that number of hours ..."

In an interview with staff member #C11 (who was identified by the facility as the current Infection Control Nurse/Infection Control Director) on 04/10/18, they stated that the only infection control training they received was verbally from the prior infection control director. They stated, "He showed me his forms and explained what he was doing." The staff member confirmed they did not have formal infection control training or certification. They stated, "Corporate recently told me I need to get more training in infection control."

Staff member #C11 stated took over as the Infection Control Director around December 2017. While working as the infection control director this staff member was also continuing to working night shifts as a floor nurse. The staff member stated they did not have adequate time to meet all the functions and surveillance as the infection control director. Staff members #C11 and C16 stated that staff member #C28 was assisting staff member #C11 with completing the functions of Infection Control Director, however in interview, staff member #C28 stated they were not completing infection control duties. It appeared that staff member #C11 was not receiving assistance or an adequate amount of time to complete all the tasks required as the Infection Control Director.

The above findings were confirmed in an interview on 04/12/18 with staff members #C16 and C28. These findings indicate that the current facility infection control director did not have adequate training and/or time available to address infection control issues and surveillance at the facility.

The above was also confirmed in an interview with the CEO, Corporate Vice-President of Clinical Services, Corporate Director of Quality Measures and Corporate Director of Clinical Services on the evening of 4-12-18.

Based on a review of documentation, interview, tour, and observations, the facility infection control officer or officers failed to implement and maintain a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel.

Findings Included:

Facility based Policy #1600.1 entitled, "Infection Control Program - Written Description" stated in part,
"1. The Infection Control Coordinator and the Committee of the Whole (Medical Executive Committee) will ensure the objectives of the program are met. These include, but are not limited to:
1.1 Managing as a sentinel event all identified cases of unanticipated death or major permanent loss
of function associated with a healthcare related infection.
1.2 Identifying, evaluating, and making recommendations for the prevention and control of all infectious disease in the hospital whether evident at the time of admission, possibly acquired and evident during hospitalization, or possibly acquired during hospitalization and evident only following discharge from the hospital.
1.3. Defining criteria for identifying major types of infections, either nosocomial or community-acquired, based upon national guidelines such as those provided by the Centers for Disease Control.
1.4. Developing written policies and procedures relating to infection control in all areas and departments of the hospital and to implement a method of monitoring community-acquired, based upon national guidelines such as those provided by the Centers for Disease Control.
1.5. Developing and maintaining a system for reporting and reviewing infections in patients and personnel based on Total House Surveillance.
1.6. Conducting routine surveillance of the inanimate environment and conducting environmental microbiologic sampling only as indicated or when specifically required by a program/service/area ...

5. The IC Coordinator in consultation with the Director of Nursing Services and Medical licensed independent provider (LIP) responsibilities include:
5.1. Establishing and operating practical systems for identifying, reporting, and evaluating infections in patients and personnel (surveillance system) ...
5.4. Determining the number of hours needed in completing Infection Control Activities and assures that the Infection Control Nurse is employed for at least that number of hours ...
6.7. Controlling HAl infections by the following additional functions:
6.7.1 Monitoring and encouraging adherence to the Hand-Washing Program
6.7.2. Ensuring the availability of reliable microbiological services.
6.7.3. Reviewing for adequate isolation policies and procedures ..."

Facility Based Infection Control Plan Goals 2018 stated in part,
"GOALS
1. To Increase compliance with Guidelines for Hand Hygiene throughout the facility among staff, caregivers, patients, family members and visitors. (Please refer to Hand Hygiene Policy/Program #1600.17). Goal for hand hygiene compliance: average of 70% compliance for the year.
2. To minimize the risk for transmission of infection at the patient's point of entry by following screening procedures during initial Psycho-social screening/ assessment, initial Nursing Assessment and subsequent H & P.
3. To minimize the risk for transmission of infection with specific risks identified by IC Tracking & Trending data. Healthcare Associated Infection Rate Goal: <5%
4. To minimize the risk for Flu out-break among staff and patients by offering and promoting Free Flu vaccinations and achieving 70%% compliance vaccination rate for 2018 and incrementally increasing each year until reaching 100% by CY 2020 in accordance with CMS Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program: IMM-2 and TJC Standards.
Incremental yearly goal: 2018 - 80%
2019- 85%
2020-90%...

The Infection Control Coordinator in consultation with the CNO and medical LIP will ensure that the planning, implementation and evaluation of adopted infection prevention and control activities are based on the identified risks of the population served and are reasonable to follow in order to achieve established IC goals. In addition to the main goals identified, other activities of the IC Coordinator in consultation with the CNO and medical LIP may include, but not limited to:..

5. Developing and maintaining a system for reporting and reviewing infections in patients and personnel based on Total House Surveillance."

Facility based Policy #1600.2 entitled, "Agenda for Infection Control Reports" stated in part,
"POLICY: The Infection Control Coordinator shall utilize the following agenda when developing the quarterly tracking and trending IC Reports to be presented to the PI Committee,
Medical Executive Committee and Board of Trustees.
PROCEDURE:
The Infection Control Coordinator will address the following:
1. Follow-up from Previous Recommendations/Actions Taken:
2. Infection Control Report
2.1. Identified patient Infections
2.2. Analysis of Healthcare Acquired Infection (HAl) Rate
2.3. Significant Employee Infections
2.5. Review of Clusters of Infections, Unusual Infections, Epidemics, or Endemic Infections
2.6. IC Surveillance Rounds results
2.7. Reportable Infections
2.8. Discussion of Any New Policy/Procedures
2.9. Report from the IC Committee
2.10 Infection Control Activities related to the Immunization Program & annual FluVaccine.
2.11 Other pertinent IC control activities, initiatives, recommendations, etc."

Review of the Performance Improvement (PI) meeting minutes (where Infection Control tracking and data is presented) for the past six months revealed the following:
* The October 6, 2017 meeting only addressed the following infection control data: HCA and CAI.
* The November 9, 2017 meeting only addressed the following infection control data: HCA and CAI.
* The November 30, 2017 meeting only addressed the following infection control data: HCA and CAI.
* The December 2017 meeting only addressed the following infection control data: HCA, CAI, and employee flu vaccination.
* The February 28, 2018 meeting only addressed the following infection control data: HCA, CAI, and employee flu vaccination.

The documentation of reported HAIs in the meeting minutes only listed the infections with no further analysis.

According to the Infection Control Plan 2018, surveillance of hand hygiene (patient and staff) and flu vaccinations (patient and staff) were goals set for the year to be tracked and monitored. In an interview on 04/09/18, staff member #C11 (Infection Control Director since December 2017) confirmed that hand hygiene surveillance was completed at the facility mainly for staff, however this data had not been presented in the performance improvement meetings. This staff member stated were not tracking any other infection control surveillance measures, only monitoring hand hygiene. Only employee vaccinations were being tracked in the recent Performance Improvement meetings. Patient influenza vaccination should have also been monitored. Patient vaccination data would have been useful to maintain due to the severity of the influenza season for 2017/2018 and at start of April 2018, 2 child patients at the facility were diagnosed with the flu (Patients #C12 and C13). According to the facility "Agenda for Infection Control Reports" other infection control issues are to be addressed quarterly such as: the analysis of Healthcare Acquired Infection (HAl)rates and infection control surveillance rounds results. The HAI which were tracked in the meetings had no analysis of the illnesses. Per staff member #C11 hand hygiene surveillance was being completed for staff but the results were not reported in the meeting minutes.

Other infection control issues, such as the removal of soap dispensers on unit, were not addressed in the PI meeting minutes. According to an interview with staff member #C29 on 04/12/18, the soap dispensers were removed in February 2018. This action directly impacts infection control at the facility, due to patients have limited access to hand soap and hand sanitizer (dispensed by staff) impacting the ability to complete hand hygiene consistently. The removal of the dispensers was only discussed in the Patient Safety and Facility Safety Committee meeting minutes on March 28, 2018 stating, "POD to look into ligature free soap dispensers to be installed first on Unit 2 for military rooms" with a goal date of 04/30/18. The removal of soap dispensers would qualify as "Other pertinent IC control activities, initiatives, recommendations" to be included in infection control reports. Staff member #C11 confirmed the removal of soap dispensers was not reflected quality committee meeting minutes. "I know we talked about it in the last month or so."

The above evidence indicated that the infection control program was not effectively monitoring facility identified goals and indicators which could affect patient and staff health. Many issues impacting infection control were not documented or included in the meeting minutes, such as the removal of hand soap dispensers, the outcome of hand hygiene surveillance, patient influenza vaccination rates, and analysis of HAIs at the facility.

According the CDC "Guideline for Hand Hygiene in Health-Care Settings Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force" found at https://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf stated in part,
"Recommendations
1. Indications for handwashing and hand antisepsis
A. When hands are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or other body fluids, wash hands with either a nonantimicrobial soap and water or an antimicrobial soap and water (IA) (66).
B. If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all other clinical situations described in items 1C-J (IA) (74,93,166,169,283,294,312,398). Alternatively, wash hands with an antimicrobial soap and water in all clinical situations described in items 1C-J (IB) (69-71,74)."

According to the CDC "Clean Hands Count for Safe Healthcare" found at https://www.cdc.gov/features/handhygiene/index.html stated in part,
"Most germs that cause serious infections in healthcare are spread by people's actions. Hand hygiene is a great way to prevent infections. However, studies show that on average, healthcare providers clean their hands less than half of the times they should. This contributes to the spread of healthcare-associated infections that affect 1 in 25 hospital patients on any given day. Every patient is at risk of getting an infection while they are being treated for something else. Even healthcare providers are at risk of getting an infection while they are treating patients. Preventing the spread of germs is especially important in hospitals and other facilities such as dialysis centers and nursing homes."

Per the CDC, "Show Me the Science - When & How to Use Hand Sanitizer" found at https://www.cdc.gov/handwashing/show-me-the-science-hand-sanitizer.html
Stated in part,
"Washing hands with soap and water is the best way to reduce the number of microbes on them in most situations. If soap and water are not available, use an alcohol-based hand sanitizer that contains at least 60% alcohol ...

Many studies have found that sanitizers with an alcohol concentration between 60-95% are more effective at killing germs than those with a lower alcohol concentration or non-alcohol-based hand sanitizers 1,2. Non-alcohol-based hand sanitizers may 1) not work equally well for all classes of germs (for example, Gram-positive vs. Gram-negative bacteria, Cryptosporidium, norovirus); 2) cause germs to develop resistance to the sanitizing agent; 3) merely reduce the growth of germs rather than kill them outright, or 4) be more likely to irritate skin than alcohol-based hand sanitizers 1,2...

Although alcohol-based hand sanitizers can inactivate many types of microbes very effectively when used correctly 1-10, people may not use a large enough volume of the sanitizers or may wipe it off before it has dried 10. Furthermore, soap and water are more effective than hand sanitizers at removing or inactivating certain kinds of germs, like Cryptosporidium, norovirus, and Clostridium difficile 11-15 ...

Many studies show that hand sanitizers work well in clinical settings like hospitals, where hands come into contact with germs but generally are not heavily soiled or greasy 1. Some data also show that hand sanitizers may work well against certain types of germs on slightly soiled hands 2,3. However, hands may become very greasy or soiled in community settings, such as after people handle food, play sports, work in the garden, or go camping or fishing. When hands are heavily soiled or greasy, hand sanitizers may not work well 1,4,5 Handwashing with soap and water is recommended in such circumstances."

Facility based Policy #1600.15 entitled, "Hand Hygiene Program" stated in part,
"POLICY: The purpose of this policy is to outline indications for and methods of hand hygiene throughout Cedar Crest Hospital & RTC. Hand Hygiene measures are the single most important prevention strategy for avoiding Healthcare Acquired Infections (HAl). The failure to perform appropriate hand hygiene is considered the leading cause of HAIs, [sic] It has contributed to the spread of multi-resistant organisms and has been recognized as a substantial contributor to outbreaks. In addition, any personnel involved in food processing or food-service should follow the guidelines established by the Texas Department of State Health Services- TAC 25 - Food Establishment Rules and the FDA's Model Food Code for hand hygiene.

RESPONSIBILITY:
1. Program Compliance:
Efforts to improve appropriate hand hygiene practices should be multifaceted and should include continuing education and feedback to patients and staff on behavior or infection prevention initiatives ...

A. Environment of Care:
* Will post hand-washing procedure signs in every bathroom above every sink. Housekeeping staff will replace missing signs as needed during their daily housekeeping rounds.
* Will ascertain the existence of soap and paper-towels in every bathroom.
* Will supply hand sanitizers to all nursing stations, exam/treatment/therapy rooms ...

D. Surveillance: ...
* The IC Nurse and/or Coordinator will perform random surveillance, staff and patient interview rounds throughout the organization in order to assess continuous compliance with proper hand hygiene program initiatives ..."

In an interview on 04/10/18, staff member #C11, the infection control director, was asked what infection control surveillance they were completing at the facility. The staff member replied, "I've done some handwashing monitoring. Like three in January and three or four in February". The staff member was asked who they were monitoring for hand hygiene and replied that it was mainly staff members, "nurses, therapists, tech, and everyone".

Review of the "Hand Hygiene Observation Tool" used by staff member#C11 revealed the following:
* On December 27, 2017-3 staff members were observed for compliance with hand hygiene.
* On January 18, 2018-4 staff members and 1 partial hospitalization patient were observed for compliance with hand hygiene.
* On January 20, 2018-3 staff members were observed for compliance with hand hygiene.
* On February 14, 2018-3 staff members were observed for compliance with hand hygiene.
* On February 20, 2018-3 staff members were observed for compliance with hand hygiene.

No inpatients were monitored or observed for hand hygiene compliance, per the facility based infection control plan. With no surveillance of inpatient hand hygiene by infection control it is unknown if patients were effectively and properly completing hand hygiene. Hand hygiene surveillance could provide important data about how units were addressing the removal of soap dispensers on the units in December 2017, such as whether patients are routinely being offered/utilizing hand soap or sanitizer provided by staff members.

Staff member #C11 stated they were not tracking any other infection control surveillance measures, only monitoring hand hygiene. This staff member confirmed that they had been reporting infection control information to quality/performance improvement since December 2017 when they became the Infection Control Director.

During a tour of the child and adolescent unit on 04/09/18 it was observed that there were no soap dispensers in the bathrooms. Staff member #C16 stated that the soap dispensers were removed because, "the patients were taking them apart and using the springs to cut themselves." This staff member was asked how the children and adolescents were completing hand hygiene, they replied, "the staff carry hand sanitizer with them and before meals they give them soap to wash their hands."

This staff member was asked where the soap for the unit was stored. They replied in the laundry room. The surveyor accompanied the staff member to the laundry room. Staff member #C16 stated the soap was in a "big pump container and staff will fill up little cups for the patients to use". Initially the staff member could not locate the soap. They were able to find a large gallon jug of soap up in a closed cabinet. The staff member stated the soap jug should have a pump on it for dispensing and be located in the open area of the room, not in a closed cabinet. The staff member stated that there should be another soap container in the nurse's station.

At the nurse's station staff member #C3 stated, "they (MHAs) come and ask us to get it from the laundry room." The staff member then added "we have a gallon in the nursing station". Another staff member #C9 was able to locate the gallon jug of soap under the desk; this jug also did not have a pump dispenser. During observations on 04/09/18, the surveyor observed one MHT offer a latency patient hand sanitizer after using the bathroom. An adolescent male was observed using the restroom that was not offered hand sanitizer or soap afterwards. Observations were made until 11:30 AM, near lunchtime for the unit, it was not observed that the adolescent boys were offered soap or hand sanitizer to complete hand hygiene prior to meals.

Surveyors on Units 2 and 3 also observed that hand hygiene products such as soap and hand sanitizer were not consistently being offered by staff for use by patients to maintain hand hygiene. During a tour of Unit 2 on 04/11/18 it was observed the unit contained no soap dispensers. When asked why this was the case, Staff #B13 stated, "They were all removed because of an issue with the spring inside the containers. We were told that you guys [surveyors] had said they had to be removed. We have a big container of soap at the nurses' station and we give soap out to the patients in cups when they need it." Tours of Units 2, 3, and 4 also revealed that hand-washing procedure signs were not observed in every bathroom above every sink, per the facility based Hand Hygiene policy. This policy also stated that the environment of care will include ascertaining "the existence of soap and paper-towels in every bathroom". The inconsistent patient hand hygiene and access to hand hygiene products placed patients and staff at increased risk of illness.

On 04/09/18 in an interview, staff member #C11 (Infection Control Director) was asked about the removal of the soap dispensers on the units. This staff member confirmed that the soap dispensers were removed on the unit. They stated that hand hygiene was provided by "hand sanitizer and on the units and the staff give patients soufflé cups of soap whenever they ask". The staff member confirmed this was not reflected quality committee meeting minutes. "I know we talked about it in the last month or so."

In an interview on 04/10/18, staff members #C16 and C28 confirmed that soap dispensers were removed on the unit due to ligature risks. The staff members stated that the facility was pricing soap dispensers that do not present ligature risks to use at the facility. The staff members confirmed there was no plan in place to dispense hand soap consistently to patients, particularly for the child and adolescent patients who currently had an influenza B positive patient on the unit. Per interview on the units, the patients request the hand soap from staff members. Based on observation on units this is not offered consistently to patients after using the restroom and/or before meals. Patients should be given access to hand sanitizer and hand soap frequently to increase hand hygiene compliance and reduce the risk of infection transmission. The infection control issue of the removal of hand soap dispensers was not included in the performance improvement meeting which would have been an opportunity to discussing actions to maintain appropriate hand hygiene standards. Proper hand hygiene, which includes frequent access to soap and hand sanitizer are essential to reduce germs and potential transmission of infections per CDC guidance.

CDC guidelines and recommendations for "Prevention Strategies for Seasonal Influenza in Healthcare Settings" found at https://www.cdc.gov/flu/professionals/infectioncontrol/healthcaresettings.htm stated in part,
"The following guidance is current for the 2017-2018 influenza season. Please see Recommendations of the Advisory Committee on Immunization Practices - United States, 2017-18 Season for the latest information regarding recommended influenza vaccines. Please see Antiviral Drugs: Information for Health Care Professionals for the current summary of recommendations for clinical practice regarding the use of influenza antiviral medications ...
5. Adhere to Droplet Precautions
* Droplet precautions should be implemented for patients with suspected or confirmed influenza for 7 days after illness onset or until 24 hours after the resolution of fever and respiratory symptoms, whichever is longer, while a patient is in a healthcare facility. In some cases, facilities may choose to apply droplet precautions for longer periods based on clinical judgment, such as in the case of young children or severely immunocompromised patients, who may shed influenza virus for longer periods of time."

Facility based Policy 1600.39 entitled "Isolation/Precaution Guidelines Defined" stated in part,
"2. Nursing and other staff will follow the following guidelines for more frequently seen diseases (noted in alphabetical order) as listed with the corresponding isolation/precaution category: ...
2.16. Influenza None ..."

Review of the facility based policy "Isolation/Precaution Guidelines Defined" revealed this policy does not reflect the current CDC guidance to implement droplet precautions for suspect or conformed influenza. Facility based policy should reflect current guidance for precautions related to infections and illnesses.

Staff member #C11, Infection Control Director, was asked if influenza was tracked at the facility. The surveyor had observed during a tour of the child and adolescent unit on 04/09/18 that a male adolescent was wearing a face mask and was influenza positive, per staff. This patient was observed in the activity room socializing with other adolescent males. Staff member #11 stated that it was tracked on RTC (residential treatment center which is separate from the inpatient population), "but we don't track it in the other units". The staff member confirmed that one adolescent and one adult patient that were currently influenza positive and added "they came in with it".

Review of medical records revealed 2 influenza B positive patients at the facility. Patient #C12 had a positive influenza B test reported on 04/08/18. Patient #C13 had a positive influenza A and B test reported on 04/06/18. Both of these patients were on the Child and Adolescent Unit where it was observed that hand soap dispensers had been removed for bathrooms. This unit was observed to be inconsistent in offering hand soap and hand sanitizer to patients.

Per the Texas Department of State Health Services information regarding Influenza found at http://dshs.texas.gov/idcu/disease/influenza/ which stated in part,
"Transmission
Human to Human
Influenza viruses are spread from person to person by respiratory droplets generated when an infected person coughs, sneezes, or talks in close proximity to an uninfected person. Sometimes, influenza viruses are spread when a person touches a surface with influenza viruses on it (e.g., a doorknob), and then touches his or her own nose or mouth ...

Treatment & Prevention
* Hand washing and using alcohol-based hand sanitizers ..."

Hand hygiene is important to reduce the potential transmission of illness including the influenza virus. The child and adolescent unit had 2 influenza positive patients at the start of April 2018, effective hand hygiene including routine access to hand soap and hand sanitizer is essential to minimize the potential spread of influenza. The removal of soap dispensers, with inconsistent provision of soap and hand sanitizer to patients, could potentially increase the transmission of germs and increase the risk of influenza transmission the unit and throughout the facility. This placed patients and staff at increased risk of illness.

During a tour of the facility the following infection control issues related to maintaining a sanitary environment were observed.

A tour of Unit 4 was conducted with Staff #C16 on the afternoon of 4/09/18, tour findings included the following:
* In Room 402 a 2 X 2-inch indention was observed in the wall behind the door, it appeared to be created from the door hitting the wall. This area cannot be cleaned effectively.
* In Room 403 mold and missing wallpaper were observed on the wall surrounding the shower. The presence of mold present is evidence of water damage with the opportunity for bacterial growth.
* Outside Room 408 the wallpaper around the door frame outside the room was observed peeling and separating from the wall, preventing this surface from being cleaned effectively.
* In Room 450 (linen room) the 2 laundry/linen carts were observed uncovered, presenting a risk of contamination of the linen.
* In the hallway used by the adolescent and latency females, a broken ceiling tile was observed, which could provide an entry point for pest and debris.
* In the activity room for the adolescent male, 3 chairs were observed with tears present. One chair tear was approximately 1.5 feet in length across the back of a chair. One chair had an 8 inch tear down the back. Two chairs had foam exposed. These tears prevented effectively cleaning of these surfaces.

The above findings were confirmed in an interview with staff member #C16 on 04/09/18.

A tour of Unit 2 was conducted with Staff #B13 and Staff #B14, on the afternoon of 4/11/18, tour findings included the following:

In the unit medication room:
* There was dirt and debris on the floor of the room. Staff #B13 stated that housekeeping regularly cleaned the room, but she was unsure how often.
* An old and ill-fitting phone plate cover had open gaps around it which opened to the wall space behind it. This allowed for entry of dust, debris and pests into the patient medication room from the wall space behind.
* Under the sink there were ill-fitting PVC pipes with a gap between two adjoining pipes. Old sticky glue had been exposed where the pipes had come apart making thorough cleaning impossible. A stain on the flooring under the pipes revealed either a previous or current issue with leaking. A plastic gray tub was under the sink, identified by Staff #B13 as "maybe there to catch the leaks?" Patient supplies had been stored under the sink including nebulizer masks and hosing. The plastic container holding these supplies had a thick layer of dust on the sides. In addition, an oxygen machine had been stored touching against the ill-fitting pipes. Items stored under sinks are exposed to contamination and mold damage from splashes and/or leaks. Staff #B13 stated the patient items were still in use on the unit.

In the patient food area:
* A refrigerator included snack items for patients to eat. A review of the refrigerator temperature checks for April 2018 revealed the temperatures running from 38 to 40 degrees. The temperature on 4/11/18 was noted as 40 degrees on the check sheet. When the thermometer in the refrigerator was checked during the tour, it read 45 degrees. The check sheet included no range of acceptable temperatures. Staff #B13 stated, "I think it's supposed to be between 35 and 40 degrees. There used to be a temperature range on the old check sheet. I don't know what happened to it." Staff #B14 was also unsure of what the refrigerator temperature range should be.

In patient rooms:
* A shelf in the shower areas of room 207/208 and room 205 included a metal pipe surrounding the shelf, making it impossible for water to drain from the enclosed shelf. Patient #B12, the patient in room 205 stated, "The water just fills up in there. It can't get out, so it stays there and gets soapy and disgusting. Then that old water and soap just drips out of there over the top of the rim each time you're taking a shower." He added, "It's only like that in this room and one other room on the unit, but it's gross. They just finally cleaned it out yesterday, but it had been full the whole time I've been here -- weeks. The other rooms have some kind of plastic covering that area."

In the patient quiet/seclusion room:
* There was an approximate 3" x 1.5" hole sharply cut through the wall plaster which revealed what appeared to be old foam insulation in the wall space behind it. This allowed for dust, debris and pests to enter the area, but also posed a safety hazard as the insulation could be easily reached and extracted by any patient in the seclusion area.
In a patient supply storage closet:
* An air conditioning vent in the tiled ceiling above the patient supplies had an old discolored water stain around it approximately 8" diameter in size. Ceiling tiles with water stains can harbor mold and may crumble, contaminating items below.
In the patient examination room:
* There was missing Formica-like covering on a corner of the sink surround. An old band-aid had been placed over the area presumably to cover the permeable surface beneath. The band-aid did not cover the entire opening, and was dirty and sticky. This made thorough cleaning of the surface impossible.
* Under the sink were stored boxes of paper patient gowns and paper examination table covers. These boxes were open and the gowns - the box on top - were completely exposed. The other box with table covers was also open, but the cardboard box of gowns sitting on top of the covers blocked them from complete exposure.

A room directly across the hallway from the patient examination room was a room identified by Staff #B13 as "an old men's bathroom that wasn't mechanically right. We don't use it anymore." The door was closed, but had a layer of dust at the top and bottom that was visible even in the hallway. Inside the room, there was heavy dirt and debris on the floor, including large clumps of dust and dirt. Packages of laundered patient towels and bathroom linens with labels reading, "Route Load March 23 2018" were sitting on top of a pile of plastic containers. Cardboard boxes identified as containing a mix of patient and office supplies were opened and stored on the floor next to an old and filthy toilet which appeared to be no longer in use. In the water inside the stained toilet were clumps of dirt. An opened box of syringes available for patient use was stored against the wall, as well as a box of scrub pants. On top of these boxes were two plastic bins which are typically used to store medication vials or patient supplies. Inside a plastic container with three drawers were alcohol wipes and other patient supplies that looked new. Dirt and debris were found atop storage containers all through the room. Staff #B14 stated, "This is nasty."

Throughout the unit:
* Light fixtures on the unit included what appeared to be numerous dead bug carcasses. In patient room 207/208, there were approximately 25 of these in the bedroom light fixture, and 10 in the fixture of the bathroom. The light fixture in the bedroom of room 205 included approximately 20 of these. The light fixture above the examination table in the patient examination room again included what appeared to b

Based on a review of facility documentation and staff interview, the facility failed to have an agreement with an organ procurement organization (OPO) for organ donation of individuals whose death was imminent or who died in the hospital. In addition, the facility policy relating to such an agreement was incongruent with regulatory requirements.

Findings were:

Facility policy #900.38 entitled "Potential Organ/Tissue Donors," last reviewed 2/18, included the following:
"POLICY: Cedar Crest Hospital is a specialty psychiatric hospital and does not accept patients who are medically unstable and at risk if [sic] imminent death. Therefore, it is our policy that patients who are medically unstable and in need of acute medical care will be transported to the Emergency Room as per transfer agreements ...
PROCEDURE:
1. The RN will preserve the body of any patient that expires at the facility according to the directions of the medical-surgical hospital that this facility has a contract with for medical services, including harvesting of organ donations.
1.1 The body will be transferred A.S.A.P ..."

In an interview with Staff #2, Director of Risk Management, on the morning of 4/11/18, she stated the facility did not have an agreement with an organ procurement provider, and that the above policy was the only facility policy relating to this matter.

The above was confirmed in an interview with the CEO, Corporate Vice-President of Clinical Services, Corporate Director of Quality Measures and Corporate Director of Clinical Services on the evening of 4-12-18.

The hospital failed to meet the special medical record requirements and special staffing requirements applying to psychiatric hospitals.

42 CFR 482.61 Special Medical Record Requirements for Psychiatric Hospitals
42 CFR 482.62 Special Staffing Requirements for Psychiatric Hospitals

The facility was not compliant with the special medical records requirement for psychiatric hospitals, as the medical records did not reflect the degree and intensity of the treatment provided to the patients.

* The treatment plans found in the clinical records of 5 of 6 patients were not individualized (cross refer to B0118).

* The treatment plans found in the clinical record of 6 of 6 patients did not identify each individual on the treatment team primary responsible for ensuring compliance with particular aspects of the patient's individualized treatment program (cross refer to B0123).

* The clinical records of 5 of 5 patients contained no documentation of discharge arrangements to include specific appointments with appropriate services concerning follow-up or after care. The same discharge plans contained no description of the involvement of family with the patient after discharge (cross refer to B0134).

Based on a review of facility documentation and staff interview, the facility failed to ensure each patient's treatment plan included appropriate individualized problems related to the patient's reason for admission and diagnoses, as well as assessed needs for 5 of 6 patients [Patients #B2-B5 and #B10). This deficient practice had the potential to impact the appropriateness of treatment supplied to all patients at the facility.

Findings were:

Facility policy #1800.1 entitled "Patient Bill of Rights and Responsibilities," last revised 11/16, included the following:
"PROCEDURE: ...
4. Treatment team will plan each patient's care based on individual needs, strengths, and assets.
4.1 Care will be reviewed periodically and appropriately updated and revised ..."

Facility policy #1000.77 entitled "Treatment Planning," last revised 12/16, included the following:
"POLICY: An individualized interdisciplinary Treatment Plan will be developed for each patient admitted to Cedar Crest. The Treatment Plan will be initiated, reviewed and updated by the interdisciplinary Treatment Team with patient and parent/guardian/family member participation (as appropriate) on a regular basis during the course of treatment ...

PROCEDURE: ...
2. The treatment planning process begins at admission with the initial treatment plan being completed upon admission with strategies for the care and treatment of patients during the evaluation process. It is located in the patient's medical chart within the Integrated Assessment ..."

Patient #B5 was a 10-year-old female admitted to Cedar Crest Hospital on 3/9/18. A Psychiatric Evaluation on 3/10/18 at 4:24 p.m. included the following:
"[Patient #B5] is a 10 yo female who presented from [hospital name] ED (emergency department) for SI (suicidal ideation) ...While [her mother] was driving, [Patient #B5] threw her shoe at her. She then tried to jump out of the vehicle and then attempted to strangle herself with a seatbelt...She has initial insomnia. Shortly after arrival she vomited x1 and was having an upset stomach ..."

A review of her treatment plan included only the problem of anger/aggression. No active medical problems were included on the plan's problem list. The plan was signed only by the patient with her printed first name (no date / no time). Another page of the treatment plan, dated 3/9/18, included the problem "Headache." The RN adding the problem had signed the problem form. An Activity/Recreational Therapy section on an additional page of the treatment plan was added on 3/14/18 at 1:46 p.m. and just included the information that the patient was attending groups. This was again signed by an activities/recreational therapist.

Large sections of this patient's treatment plan were completely blank, including discharge planning issues, family/legal representative support/involvement, and psychiatric problem updates/comments. The patient was discharged on 3/20/18. No additional treatment plans were located within the patient record, though the patient was on line-of-sight precautions for suicidality and as a ligature risk for her entire inpatient stay.

Patient #B10 was a 14-year-old female admitted on 1/30/18. A review of the Psychiatric Evaluation on 1/31/8 at 9:15 a.m. revealed the following:
"[Patient #B10], 14 yrs old WF (white female) was admitted to acute care unit for SI (suicidal ideation), self harming behaviors and risky behaviors ..." A PreAdmission Evaluation / Management form included the following:
"Physician Note
Per staff: Pt presented to [acute care hospital] ED as a 14 y/o female c/o (complaining of) SI (suicidal ideation) and attempt to cut wrists per ED record. Pt endorsed depressed mood per ED record with exacerbating factor being family problems ..."

A review of an Interdisciplinary Treatment Plan on 1/31/18 revealed the problem identified for treatment as "Manic Mood Without Psychosis." Another problem on 3/11/18 identified "Depressed Mood Without Psychosis." No additional problems were noted as having been included in the patient's treatment plan.

Patient #B4 was admitted on 3/12/18 to Cedar Crest Hospital. A review of the Psychiatric Evaluation on 3/13/18 at 1:50 p.m. revealed the following:
"History of Present Illness:
"States she had a lot of "stuff piling up ..." Admits to being sad & mad yesterday and tried to hang self & cut leg multiple times with a "spring from a pen ..." Tried hanging self with sheet ...Admits to wanting to die ..." Admitting diagnoses included: Bipolar I D/O (Disorder) ...ADHD (Attention Deficit & Hyperactivity Disorder), ODD (Oppositional Defiant Disorder) ..."

A review of the Interdisciplinary Treatment Plan for Patient #B4 included only one problem to address while at the facility which was "anger/aggression." An Interdisciplinary Treatment Plan Update on 3/19/18 at 8:45 a.m. included risks documented by the physician. The risk of Suicidal Ideation had "Plan" checked, "Self-Harm Risk" section had "Yes" checked, and "Other Risks" included "Yes" checked with the word "Aggression" written in.

A final Interdisciplinary Treatment Plan Update on the 3/20/18, the date of the patient's discharge, included the section "Medical and Psychiatric Problems: Updates, Risk, Comments." The handwritten entry in this section read as follows: "Patient punched staff, threw a carton of milk to the doctor, requires constant redirection." Again checked was "Suicidal Ideations ...Plan," "Self-Harm Risk..Yes," "Homicidal Ideations ...Plan," and "Other Risks ...Yes" with handwritten "Aggressive."

The only Interdisciplinary Treatment Plan signed by the patient was on 3/15/18. The area for participation of a legal representative included only the checked box, "Legal representative is unable to review in person ..." The final plan update on Patient B4's date of discharge included only the checked box "Refused to participate" for patient participation with the handwritten note below, "Per MD pt is in seclusion room."

A nursing note on 3/19/18 at 6:45 p.m. read as follows: "Pt. agitated and angry at staff after she attempted to hang self and is being closely monitored at the nurse's station ...Continue 1:1 observation status, placed on ligature precautions ..."

Patient #B2 was a 7-year-old female admitted to the hospital on 2/28/18 and was still at there on the date of survey. Her Interdisciplinary Treatment Plan identified only one problem - "Anger." Multiple updates to her treatment plan included her printed name as having participated in her treatment planning, with no documentation of a legal representative having been notified of the treatment planning meetings. An Interdisciplinary Treatment Plan Update on 3/21/81 at 11:50 a.m. included the following update to Patient #B2's "Anger" problem in the "Psychiatric Problems - Updates/Comments" section entry: "Pt and therapist discussed pt SAOP (sexually acting out precautions) behavior and precuassions [sic] that are in place. Pt will no longer have a roommate and will be required to stay an arms length from peers. Pt was guarded, but agreed to "keep hands to yourself, no touching peers."" One documented attempt of notification of a legal representative for Patient #B2 was made for a meeting on 3/19/18 at 4:05 p.m. The attempted contact of this individual was made on 3/19/18 at 4:11 p.m.

Patient #B3 was admitted to the facility on 3/12/18. A Psychiatric Evaluation on 3/13/18 at 12:59 p.m. included the following: "History of Present Illness: Did try to OD 6 days ago b/c (because) of possibility of going to Juv. States he tried to kill self. Took unspecified amounts of his own "antidepressants" - 500 mg each ...Admitting Diagnosis: MDD (Major Depressive Disorder) severe without psychotic features, Borderline Personality Trait, Victim of Physical Abuse ..." An admitting report to the hospital from another facility on 3/12/18 at 5:33 p.m. included "Intentional OD on atarax, Celexa & Depakote (all 3 bottles were empty). Hospitalized on the 3/6/18 intubated & extubated 3/9/18 ..."

A review of his Interdisciplinary Treatment Plan Master Sheet on 3/15/18 at 11:00 a.m. included only one problem: "Impulsivity." The patient's grandmother was contacted on 3/13/18 at 12:00 p.m. and provided "Date and time of meeting: 3/16/18 TBD (to be determined) ..."

These findings were discussed in an interview with Staff #9, the Director of Clinical Services on the morning of 4/11/18 in her office. She stated, "I've tried to talk to the staff about this. We've been done a lot of training. I guess we're still not there yet."

Based on a review of facility documentation and staff interviews, the facility failed to ensure each patient's written treatment plan identified each individual on the treatment team who was primarily responsible for ensuring compliance with particular aspects of the patient's individualized treatment program for 6 of 6 patients [Patient #B5]. In addition, family or legal representatives were not involved in the treatment planning of 6 of 6 patients [Patients #B1-B5 and #B10], thus there was no documented evidence of their being aware of the staff responsible for various aspects of treatment.

Findings were:

Facility policy #1800.1 entitled "Patient Bill of Rights and Responsibilities," last revised 11/16, included the following:
"PROCEDURE: ...
4. Treatment team will plan each patient's care based on individual needs, strengths, and assets ...
4.2 Each patient will participate in the development of his/her treatment to the greatest extent possible.
4.3 Each patient will review and sign the plan, as appropriate.
4.4 Patients and families, guardians, and other resources will be included in the patient care planning as appropriate ...
8. The patient or the patient's legal guardian and the patient's family shall be fully informed about the following: ...
8.10 The plan for discharge and after care ...

Facility policy #1000.77 entitled "Treatment Planning," last revised 12/16, included the following:
"POLICY: An individualized interdisciplinary Treatment Plan will be developed for each patient admitted to Cedar Crest. The Treatment Plan will be initiated, reviewed and updated by the interdisciplinary Treatment Team with patient and parent/guardian/family member participation (as appropriate) on a regular basis during the course of treatment.

DEFINITIONS:
Master Treatment Plan (MTP) - Is interdisciplinary in nature ...
PROCEDURE: ...
8. The involvement of the family/guardian throughout the course of the patient's treatment begins at admission, continues throughout treatment and discharge. Patients and parents/guardians/family members are strongly encouraged to participate in treatment team meetings, as patient and parent/guardian/family member input into treatment objectives and goals are valuable in planning the patient's course of treatment and aftercare. The clinical services staff member will ensure that the patient/parents/guardians/family members are informed about the schedule for treatment team meetings. Parent/guardian/family members may participate in the MTP or TPR (Treatment Plan Review) meeting via conference call if unable to attend in person ..."

Patient #B5 was a 10-year-old female admitted to Cedar Crest Hospital on 3/9/18. A Psychiatric Evaluation on 3/10/18 at 4:24 p.m. included the following:
"[Patient #B5] is a 10 yo female who presented from [hospital name] ED (emergency department) for SI (suicidal ideation) ...While [her mother] was driving, [Patient #B5] threw her shoe at her. She then tried to jump out of the vehicle and then attempted to strangle herself with a seatbelt...She has initial insomnia. Shortly after arrival she vomited x1 and was having an upset stomach ..."

The Interdisciplinary Treatment Plan for Patient #B5 was signed only by the patient with her printed first name (no date / no time). The section for participation of the patient's legal representative was completely blank, including no justification for why there was no participation of this individual. The only member of the treatment team who signed this plan was an activity therapist who signed the plan on 3/10/18 at 4:37 p.m.

Another page of the treatment plan, dated 3/9/18, included the problem "Headache." The RN adding the problem had signed the problem form. An Activity/Recreational Therapy section on an additional page of the treatment plan was added on 3/14/18 at 1:46 p.m. and just included the information that the patient was attending groups. This was again signed by an activities/recreational therapist.

Large sections of this patient's treatment plan were completely blank, including discharge planning issues, family/legal representative support/involvement, and psychiatric problem updates/comments.

A Treatment Team Notifications page included documentation of an attempt to contact Patient #B5's mother. The first attempt was made on 3/12/18 at 12:30 p.m. The note included the date and time of the treatment team meeting as 3/12/18 at 1:00 p.m. A second entry documented an attempt to contact the father of Patient #B5 on 3/12/18 at 4:00 p.m. to include him in the treatment team meeting held three hours earlier. There was no documentation included of whether either individual wished to participate or declined to participate.

The patient was discharged on 3/20/18. No additional treatment plans were located within the patient record, though the patient was on line-of-sight precautions for suicidality and as a ligature risk for her entire inpatient stay.

Patient #B4 was admitted on 3/12/18 to Cedar Crest Hospital. A review of the Psychiatric Evaluation on 3/13/18 at 1:50 p.m. revealed the following:
"History of Present Illness:
"States she had a lot of "stuff piling up ..." Admits to being sad & mad yesterday and tried to hang self & cut leg multiple times with a "spring from a pen ..." Tried hanging self with sheet ...Admits to wanting to die ..." Admitting diagnoses included: Bipolar I D/O (Disorder) ...ADHD (Attention Deficit & Hyperactivity Disorder), ODD (Oppositional Defiant Disorder) ..."

The only Interdisciplinary Treatment Plan signed by the patient was on 3/15/18. The area for participation of a legal representative included only the checked box, "Legal representative is unable to review in person ..." The final plan update on Patient B4's date of discharge included only the checked box "Refused to participate" for patient participation with the handwritten note below, "Per MD pt is in seclusion room."

A nursing note on 3/19/18 at 6:45 p.m. read as follows: "Pt. agitated and angry at staff after she attempted to hang self and is being closely monitored at the nurse's station ...Continue 1:1 observation status, placed on ligature precautions ..."

Patient #B10 was a 14-year-old female admitted on 1/30/18. A review of the Psychiatric Evaluation on 1/31/8 at 9:15 a.m. revealed the following:
"[Patient #B10], 14 yrs old WF (white female) was admitted to acute care unit for SI (suicidal ideation), self harming behaviors and risky behaviors ..." A PreAdmission Evaluation / Management form included the following:
"Physician Note
Per staff: Pt presented to [acute care hospital] ED as a 14 y/o female c/o (complaining of) SI (suicidal ideation) and attempt to cut wrists per ED record. Pt endorsed depressed mood per ED record with exacerbating factor being family problems ..."

Updates to the Interdisciplinary Treatment Plan for Patient #B10 included only the printed name of Patient #B10. The section for participation of the patient's legal representative including only the checked "Unable to participate (reason) working."

Patient #B2 was a 7-year-old female admitted to the hospital on 2/28/18 and was still at there on the date of survey. Her Interdisciplinary Treatment Plan identified only one problem - "Anger." Multiple updates to her treatment plan included her printed name as having participated in her treatment planning, with no documentation of a legal representative having been notified of the treatment planning meetings. An Interdisciplinary Treatment Plan Update on 3/21/81 at 11:50 a.m. included the following update to Patient #B2's "Anger" problem in the "Psychiatric Problems - Updates/Comments" section entry: "Pt and therapist discussed pt SAOP (sexually acting out precautions) behavior and precuassions [sic] that are in place. Pt will no longer have a roommate and will be required to stay an arms length from peers. Pt was guarded, but agreed to "keep hands to yourself, no touching peers."" One documented attempt of notification of a legal representative for Patient #B2 was made for a meeting on 3/19/18 at 4:05 p.m. The attempted contact of this individual was made on 3/19/18 at 4:11 p.m.

Patient #B3 was admitted to the facility on 3/12/18. A Psychiatric Evaluation on 3/13/18 at 12:59 p.m. included the following: "History of Present Illness: Did try to OD 6 days ago b/c (because) of possibility of going to Juv. States he tried to kill self. Took unspecified amounts of his own "antidepressants" - 500 mg each ...Admitting Diagnosis: MDD (Major Depressive Disorder) severe without psychotic features, Borderline Personality Trait, Victim of Physical Abuse ..." An admitting report to the hospital from another facility on 3/12/18 at 5:33 p.m. included "Intentional OD on atarax, Celexa & Depakote (all 3 bottles were empty). Hospitalized on the 3/6/18 intubated & extubated 3/9/18 ..."

A review of his Interdisciplinary Treatment Plan Master Sheet on 3/15/18 at 11:00 a.m. included only one problem: "Impulsivity." The patient's grandmother was contacted on 3/13/18 at 12:00 p.m. and provided "Date and time of meeting: 3/16/18 TBD (to be determined) ..."
Was given a problem of "Impulsivity" after having been admitted for suicide attempt

Patient #B1 was a 13-year-old female admitted to the facility on 3/28/18. An Interdisciplinary Treatment Plan Master Sheet on 3/30/18 at 10:45 a.m. included the signature of the 13-year-old patient as having participated in her treatment plan. The patient's legal representative, her mother, was noted as "Unable to participate (reason) working," on 3/30/18 at 2:30 p.m. There was no documented evidence in the patient's record that Patient #B1's mother had been notified of the meeting. A page attached to the Interdisciplinary Treatment Plan was entitled Treatment Team Notifications, and included a space to contact the patient's parent or legally authorized representative (LAR). Check boxes and information lines for "The patient, LAR, and/or consented person was notified of the date, time and location of this treatment plan meeting and the date, time, location of each periodic review meeting to support ongoing participation," were all completely blank down the page.

These findings were discussed in an interview with Staff #9, the Director of Clinical Services on the morning of 4/11/18 in her office. She stated, "I've tried to talk to the staff about this. We've been done a lot of training. I guess we're still not there yet."

Based on observation, staff interview and documentation review, the facility failed to ensure the record of each patient who had been discharged had arranged, specific appointments with appropriate services concerning follow-up or after care for 5 of 5 patients [Patients #B1, #B3-B5 and #B10] whose discharge planning documentation was reviewed. In addition, discharge plans included no description of the involvement of family with the patient after discharge for each of these patients.

Findings were:

Facility policy #1000.86 entitled "Discharge Planning," last reviewed 6/17, included the following:
"POLICY: Discharge planning, or transition planning includes the process of determining the appropriate post-hospital destination for a patient, identifying what the patient requires for a smooth and safe transition from the hospital to his/her discharge destination, and beginning the process of meeting the patient's identified post-discharge needs. The Discharge planning activities are initiated at the point of initial assessment and continued throughout the patient's episode of care. The primary responsibility for development of the discharge plan rests with the attending physician and Interdisciplinary Treatment Team ...
PROCEDURE:
3 ...Recommended disposition are discussed with the patient and parent/guardian/designated other and documented in the Treatment Plan Reviews (TPR), Progress Notes, or other appropriate documentation means in the medical chart ..."

Facility policy #1800.1 entitled "Patient Bill of Rights and Responsibilities," last revised 11/16, included the following:
"PROCEDURE: ...
8. The patient or the patient's legal guardian and the patient's family shall be fully informed about the following: ...
8.10 The plan for discharge and after care ...

Facility policy #1000.77 entitled "Treatment Planning," last revised 12/16, included the following:
"POLICY: An individualized interdisciplinary Treatment Plan will be developed for each patient admitted to Cedar Crest. The Treatment Plan will be initiated, reviewed and updated by the interdisciplinary Treatment Team with patient and parent/guardian/family member participation (as appropriate) on a regular basis during the course of treatment.

PROCEDURE: ...
8. The involvement of the family/guardian throughout the course of the patient's treatment begins at admission, continues throughout treatment and discharge. Patients and parents/guardians/family members are strongly encouraged to participate in treatment team meetings, as patient and parent/guardian/family member input into treatment objectives and goals are valuable in planning the patient's course of treatment and aftercare ..."

Facility policy #1000.87 entitled "Discharge of Patients (Routine, AMAs, 15-30 day request for Transfer)," last revised 11/16, included the following:
PROCEDURE:
1 ...All patients are to be assessed by a physician on the day of discharge ...
2.4 Case Management Staff is responsible for disposition and aftercare activities by planning and arranging services necessary to support the patient's participation in the continuum of treatment process and in the aftercare plan. The case manager is primarily responsible for completing the follow-up appointment section of the discharge instructions on the discharge form ..."

Examples of discharge planning related issues found in patient records included:

Patient #B4 was admitted on 3/12/18 to Cedar Crest Hospital. A Physician/APRN/PA Discharge Note on 3/20/18 at 1:35 p.m. included no Discharge Suicide Risk Assessment Score despite a box being provided for the score. A physician's Comments/Interventions included the following: "Pt is very manipulative, attention seeking, not participating any groups, [illegible] hitting staffs and destroying property, needs to be discharged ..." A review of the Psychiatric Evaluation on 3/13/18 at 1:50 p.m. revealed the following:
"History of Present Illness:
"States she had a lot of "stuff piling up ..." Admits to being sad & mad yesterday and tried to hang self & cut leg multiple times with a "spring from a pen ..." Tried hanging self with sheet ...Admits to wanting to die ..." Admitting diagnoses included: Bipolar I D/O (Disorder) ...ADHD (Attention Deficit & Hyperactivity Disorder), ODD (Oppositional Defiant Disorder) ..."

A Nursing Note on 3/19/18 at 6:45 p.m., the day prior to the discharge of Patient #B4, read as follows:
"Pt. agitated and angry at staff after she attempted to hang self and is being closely monitored at the nurse's station ...Zyprexa 10 mg for severe agitation ordered and administered. Continue 1:1 observation status ...

There was no documented evidence that a parent or legal guardian of 14-year-old Patient #B4 were involved in her discharge planning. The chart included no physician order for discharge.

A review of her Discharge Care Plan revealed contact information only was provided for aftercare, despite the section title of "Scheduled Aftercare Appointments," and despite empty, blank spaces for the date and time of the follow-up appointments for this psychiatric patient. When the facility for follow-up/aftercare was contacted by telephone on 4/12/18 by this surveyor, a spokesperson for the facility stated they were no longer taking patients, but if they had been, appointments could be scheduled.

Patient #B5 was a 10-year-old female admitted on 3/9/18. A review of her Discharge Care Plan completed on 3/20/18 included a section entitled "Scheduled Aftercare Appointments." Contact information only was provided for aftercare, despite empty, blank spaces for the date and time of the follow-up appointments for this psychiatric patient.

There was no documented evidence that a parent or legal guardian of 14-year-old Patient #B5 were involved in her discharge planning, except to receive a copy of the plan. There was no description of the involvement of family and significant others with the patient after discharge. The chart included no physician order for discharge.

Patient #B10 was a 14-year-old female admitted on 1/30/18. Her Discharge Care Plan was completed on 4/6/18 included a section "Scheduled Aftercare Appointments." Contact information only was provided for aftercare, despite empty, blank spaces for the date and time of the follow-up appointments for this psychiatric patient.

A Physician/APRN/PA Discharge Note form in the record was completely blank. The form included no Discharge Suicide Risk Assessment Score despite a box being provided for the score. A review of the Psychiatric Evaluation on 1/31/8 at 9:15 a.m. revealed the following:
"[Patient #B10], 14 yrs old WF (white female) was admitted to acute care unit for SI (suicidal ideation), self harming behaviors and risky behaviors ..." A PreAdmission Evaluation / Management form included the following:
"Physician Note
Per staff: Pt presented to [acute care hospital] ED as a 14 y/o female c/o (complaining of) SI (suicidal ideation) and attempt to cut wrists per ED record. Pt endorsed depressed mood per ED record with exacerbating factor being family problems ..."
There was no documented evidence that a parent or legal guardian of 14-year-old Patient #B104 were involved in her discharge planning, except to receive a copy of the plan. There was no description of the involvement of family and significant others with the patient after discharge. The chart included no physician order for discharge.

In an interview with Staff #9, the Director of Clinical Services, on the morning of 4/11/18 in her office, she stated, "We've just recently hired someone to do discharge planning. We're really good about faxing the continuum of care on to the provider, but most of those places just won't allow us to schedule appointments. They require the person to actually show up ..."

The facility was not compliant with having adequate numbers of qualified professional and supportive staff to evaluate patients, formulate written, individualized comprehensive treatment plans, provide active treatment measures and engage in discharge planning.

* The facility failed to provide adequate numbers of registered nurses, licensed vocational nurses and mental health workers to provide nursing care necessary under each patient's active treatment program and to maintain progress notes on each patient, resulting in injuries to patients, injuries to staff and the need for emergency medication administration (cross refer to B0146).

*The director of nursing services failed to direct, monitor and evaluate the nursing care furnished, resulting in missing or blank initial nursing treatment plans of 6 of 10 clinical records (cross refer to B0148).

*The facility failed to provide the number of qualified therapists, support personnel and consultants must be adequate to provide comprehensive therapeutic activities consistent with each patient's active treatment program, resulting in the failure to meet the activity needs of 1 of 1 patient observed (cross refer to B0158).

Based on interviews, a review of clinical records and tours of the units, the facility failed to provide an adequate number of registered nurses, licensed practical nurses and mental health workers to provide nursing care necessary under each patient's active treatment program and to maintain progress notes on each patient.

Findings were:

Staffing

Staffing variance sheets for Units II & III were reviewed for the time period of 3-27-18 through 4-10-18 and the time period of 3-11-18 through 4-10-18 for Unit IV. Differences between the actual staffing and the appropriate staffing (per the staffing grid verified as current by staff #A-20) were noted. Staff positions noted with [brackets] represent staff positions that should have been scheduled (per the staffing grid) but were not.

Unit 2:
3/27/18:
*7a-7p: 18 patients with two discharges - one RN, one LVN, one MHA [1 MHA]
*7p-7a: 18 patients with two admissions - one RN, one MHA [1 LVN, 1 MHA]
3/28/18:
*7a-7p: 18 patients with two discharges - one RN, one MHA [1 LVN, 1 MHA]
*7p-7a: 18 patients with two admissions - one RN, one MHA [1 LVN, 1 MHA]
3/29/18:
*7a-7p: 18 patients - one RN, one LVN, one MHA [1 MHA]
*7p-7a: 17 patients, one discharge- one RN, one MHA [1 MHA]
3/30/18:
*7a-7p: 17 patients with two discharges - one RN, one LVN, one MHA [1 MHA]
*7p-7a: 17 patients - one RN, one MHA [1 MHA]
3/31/18:
*7a-7p: 15 patients, one discharge - one RN, one LVN, one MHA
*7p-7a: 15 patients, one admission - one RN, one MHA [1 LVN]
4/1/18:
*7a-7p: 16 patients - one RN, one LVN, one MHA [1 MHA]
*7p-7a: 16 patients - one RN, one MHA [1 LVN]
4/2/18:
*7a-7p: 16 patients, two discharges - one RN, one LVN, one MHA [1 MHA]
*7p-7a: 18 patients, four admissions - one RN, one MHA [1 LVN, 1 MHA]
4/3/18:
*7a-7p: 18 patients with four discharges - one RN, one LVN, one MHA [1 MHA]
*7p-7a: 17 patients with three admissions - one RN, one MHA [1 LVN]
4/4/18:
*7a-7p: 17 patients with one discharge and one admissions - one RN, one LVN, one MHA [1 MHA]
*7p-7a: 17 patients with three admissions - one RN, one MHA [1 LVN, 1 MHA]
4/5/18:
*7a-7p: 17 patients with one discharge and two admissions - one RN, one LVN [2 MHAs]
*7p-7a: 17 patients with one admissions - one RN, one MHA [1 LVN, 1 MHA]
4/6/18:
*7a-7p: 19 patients with two discharges - one RN, one MHA [1 LVN, 1 MHA]
*7p-7a: 18 patients with one admission - one RN, one MHA [1 LVN, 1 MHA]
4/7/18:
*7a-7p: 18 patients - one RN, one MHA [1 LVN, 1 MHA]
*7p-7a: 18 patients - one RN, one MHA [1 LVN, 1 MHA]
4/8/18:
*7a-7p: 18 patients - one RN, one MHA [1 LVN, 1 MHA]
*7p-7a: 18 patients - one RN, one MHA [1 LVN, 1 MHA]
4/9/18:
*7a-7p: 18 patients with two discharges, two admissions - one RN, one LVN, one MHA [1 MHA]
*7p-7a: 19 patients with one admission - one RN, one MHA [1 LVN, 1 MHA]
4/10/18:
*7a-7p: 19 patients with two discharges, two admissions - one RN, one LVN, one MHA [1 MHA]
*7p-7a: 19 patients with one admission - ONE RN ONLY [1 LVN, 2 MHAs]

***Of the shifts reviewed for Unit II, 29 of 30 shifts were inadequately staffed per the facility's staffing grid. Patient admissions occurred during 15 of the 30 shifts and patient discharges occurred during 12 of the 30 shifts.***

Unit 3: ("LOS" = Line of Sight precautions, requiring the patient to be within a staff member's line of sight at all times)
(1:1 = requires the patient to have a dedicated staff member that remains within arm's length of the patient)
3/27/18:
*7a-7p: 22 patients; 2 LOS [line of sight]; 1 patient on 1:1; 5 discharges - 1 admission; 1 RN, 1 LVN, 3 MHAs [2 MHAs]
*7p-7a: census: 18 patients; 2 LOS; 1 patient on 1:1; 2 admissions; 1 RN, 1 LVN, 3 MHAs [1 MHA]
3/28/18:
*7a-7p: 21 patients; 1 LOS; 2 discharges - 2 admissions; 1 RN, 1 LVN, 2 MHAs [1 MHA]
*7p-7a: census: 21 patients; 1 LOS; 1 admission; 1 RN, 1 LVN, 4 MHAs until 11pm then down to three until 7a
3/29/18:
*7a-7p: 22 patients; 1 LOS; 4 discharges; 1 RN, 1 LVN, 2 MHAs [1 MHA]
*7p-7a: 18 patients; 1 LOS; 1 discharge; 1 RN, 1 LVN; 1 MHA [1 MHA]
3/30/18:
*7a-7p: 18 patients; 1 LOS; 4 discharges, 1 admission; 1 RN, 1 LVN, 2 MHAs
*7p-7a: 19 patients; 1 LOS; 1 RN, 1 LVN, 2 MHAs
3/31/18:
*7a-7p: 19 patients; 1 LOS; 4 discharges of indeterminate time; 1 RN, 1 LVN, 1 MHA [1 MHA]
*7p-7a: 15 patients; 1 LOS; discharges (see above); 1 RN, 1 LVN, 2 MHAs
4/1/18:
*7a-7p: 15 patients; 1 admission; 1 RN, 1 LVN, 1 MHA [1 MHA]
*7p-7a: 16 patients; 1 RN, 1 LVN, 1 MHA (pulled to another unit from 1930-2300), 1 MHA (listed as 1930 - 2300) unsure if any MHAs were on the unit from 11p-7a [1-2 MHAs]
4/2/18:
*7a-7p: 16 patients; 5 discharges, 4 admissions; 1 RN, 1 LVN; 1 MHA [1 MHA]
*7p-7a: 16 patients; 1 RN, 1 LVN (says " Unit 4"; no time written); 2 MHAs [1 LVN]
4/3/18:
*7a-7p: 15 patients; 2 discharges - 2 admissions; 1 RN, 1 LVN, 1 MHA [1 MHA]
*7p-7a: 15 patients; 1 RN, 1 LVN, 1 MHT
4/4/18:
*7a-7p: 15 patients; 2 discharges; 1 RN, 1 LVN; 1 MHA [1 MHA]
*7p-7a: 13 patients; 2 discharges, 1 admission; 1 RN, 1 LVN , 2 MHTs
4/5/18:
*7a-7p: 14 patients; 1 RN, 1 LVN, 2 MHA
*7p-7a: 14 patients; 1 admission; 1 RN, 1 LVN, 2 MHAs (one listed as "RTC [residential treatment center] 19-2300")
4/6/18:
*7a-7p: 15 patients; 5 discharges; 1 RN, 3 MHAs
*7p-7a: 10 patients; 3 admissions (unknown time); 1 RN, 2 MHAs
4/7/18:
*7a-7p: 13 patients; 1 discharge, 3 admissions; 1 RN, 1 LVN, 2 MHAs
*7p-7a: 15 patients; 1 RN, 2 MHAs [1 LVN]
4/8/18:
*7a-7p: 16 patients; 1 discharge, 6 admissions; 1 RN, 1 LVN, 2 MHAs [1 MHA]
*7p-7a: 21 patients; 3 admissions; 1 RN, 1 LVN, 2 MHAs [1 MHA]
4/9/18: missing
4/10/18:
*7a-7p: 25 patients; 5 discharges; 1 RN, 1 LVN,2 MHTs [1 MHA]
*7p-7a: 20 patients; 1 admission; 1 RN, 1 LVN, 2 MHTs

***Of the shifts reviewed for Unit III, 16 of 26 shifts were inadequately staffed per the facility's staffing grid. Patient admissions occurred during 15 of the 26 shifts and patient discharges occurred during 14 of the 26 shifts.***


Unit IV (staffing/assignment sheets from 3-11-18 through 4-10-18 were reviewed)
3/11:
*7a-2:45p: 32 patients with four on LOS observation; 1 admission; one RN (two RNs from 2:45-7p), one LVN, four MHAs
*2:45p-11:35p: 31 patients with four on LOS observation; 2 admissions - one RN (two until 7p), one LVN, three MHAs
-two incidents of physical aggression by patients; one at 3:45p and one at 8:55p
-one incident of sexual misconduct at 7:30p
*10:45p-7:15a: 32 patients with four on LOS observation; one RN, one LVN, three MHAs
3/12:
*7-3:15p: 35 patients; 11 discharges, 2 admissions;one RN (2nd RN arrived @ 9am), one LVN; three MHAs (4th MHA arrived at 10 am)
-one incident of patients attacking each other at 12:20p
*2:45p-11:15p: 32 patients with five on LOS observation; only 3 MHAs [1 MHA]
*27 patients with six on LOS observation from 7p-7a; 1 discharge, 2 admissions - one RN, one LVN and 2 MHAs from 10:45p-7:15a
3/13:
*7a-7p: 30 patients with four on LOS observation and one on 1:1 observation, 2 admissions 2 discharges; two RNs, 1 LVN, four MHAs [1 MHA]
*10:45p-7:15a: 31 patients with four on LOS observation and one on 1:1 observation; 4 admissions; one RN, one LVN, 2 MHAs [2 MHAs]
3/14:
*7a-7p: 32 patients with three on LOS observation and one on 1:1 observation; 4 discharges, 1 admission - one RN, one LVN, five MHAs
*7p-7a: 29 patients; 3 discharges - one RN, one LVN, five MHAs until 11:15p then three until 7:15a
3/15:
*7a-7p: 27 patients with 7 on LOS observation and one on 1:1 observation; 4 discharges, 2 admissions/ one RN and one LVN; five MHAs (only 3 MHAs from 11:00 pm to 7:00 am)
-one incident of patient self-inflicted injury
*2:45p-11:15p: 25 patients with five on LOS observation and one on 1:1 observation/ 2 admissions - one RN and one LVN, started the shift with two MHAs, one arrived at 3:30 pm, one arrived at 4:30 pm and one arrived at 6:30 pm
3/16/18 (staffing/assignment sheet missing)
-one incident of patient self-inflicted injury at 8:30p
-one incident at 8:45p where patient acted out, staff abandoned 1:1 and physically abused patient
3/17/18:
*7a-7p: 29 patients with six on LOS observation and one on 1:1 observation; 2 discharges, 2 admissions; one RN, one LVN, three MHAs [2 MHAs]
-one incident at 8:40a that stated in part, "Patient running up and down halls cussing, hitting, and kicking staff ..."
*2:45p-11:15p: 29 patients with seven on LOS observation and one on 1:1 observation; 1 admission - one RN, one LVN and four MHAs
3/18: (staffing/assignment sheet missing)
-one incident at 5:45p where patient punched another patient which required transfer to ER
3/19: (staffing/assignment sheet missing)
-one incident at 1:25p where patient attacked another patient
-one incident at 6:14p of patient suicide attempt
-one incident at unknown time where patient drew on peer's buttock
3/20/18:
*7a-7p: 28 patients with six on LOS observation and one on 1:1 observation; 9 discharges, 1 admission - one RN, one LVN and five MHAs
-one incident at 9:20a where patient attacked staff and had to be restrained/secluded
*2:45-11:15p: 20 patients with four on LOS observation and one on 1:1 observation; 3 admissions; one RN, one LVN, three MHAs
*10:45p-7:15a: 23 patients with four on LOS observation and one on 1:1 observation; 3 admissions; one RN, one LVN, three MHAs
3/21/18:
*7a-3:15p: 26 patients with four on LOS observation; 2 discharges, 1 admission - one RN, one LVN, four MHAs
*2:45p-11:15p: 29 patients with four on LOS observation; 1 discharge, 4 admissions - one RN, one LVN, five MHAs
*10:45p-7:15a: 28 patients with four on LOS observation; 1 admission; one RN, one LVN, three MHAs
3/22/18:
*7:15a-3:15p: 29 patients with two on LOS observation; 2 admissions - two RNs, one LVN, three MHAs [1 MHA]
*2:45p-7:15a: 31 patients with two on LOS observation; 2 RNs (only 1 RN after 7:00 pm with two admissions; 1 at 2:45am and 1 at 5am), one LVN, four MHAs
3/23/18:
*7:15a-3:15p: 33 patients with four on LOS observation; 4 discharges, 2 admissions; one RN, one LVN, four MHAs
*2:45-11:15p: 30 patients with four on LOS observation; 1 discharge, 1 admission; one RN, one LVN, four MHAs (five for the hours of 3p-8:45p)
*11:15p-7:15a: 30 patients with four on LOS observation; 2 admissions; one RN, one LVN, three MHAs
3/24/18:
*7a-3:15p: 31 patients with four on LOS observation; 1 admission, 2 discharges; one RN, one LVN, four MHAs
-one incident at 8:05a where patient attacked another patient
*2:45p-11:15p: 30 patients with four on LOS observation; 2 admissions, 1 discharge; one RN, one LVN, five MHAs
-one incident at 2:55p of patient self-inflicted injury
*11:15p-7:30a: 31 patients with four on LOS observation; 1 admission; one RN, one LVN, three MHAs
3/25/18:
*7a to 3pm: 32 patients with four on LOS observation; 1 admission; one RN, one LVN, four MHAs
*2:45p-11:15p: 33 patients with four on LOS observation; one RN, one LVN, four MHAs
-one incident at 6:45p where patient attacked another patient
*10:45p-7:15a: 33 patients with four on LOS observation; one RN, one LVN, three MHAs (decreasing to two at 1:00 am) [1 MHA]
3/26/18: (staffing/assignment sheet and census missing)
3/27/18: (staffing/assignment sheet missing)
-one incident at 6:00p where patient attacked another patient
3/28/18:
*7a-7p: 32 patients with four on LOS observation; 10 discharges, 4 admissions; one RN, one LVN, three MHAs from 7a-3:15p and five MHAs from 2:45p-11:15p
*7p-7a: 27 patients with four on LOS observation; 4 admissions; one RN, three MHAs
3/29/18: (staffing/assignment sheet and census missing)
-one incident at 9:15p of patient self-inflicted injury that resulted in physical restraint
3/30/18:
*7a-7p: 32 patients with eight on LOS observation; 6 discharges; two RNs (only one RN after 11:30 am, during which time 6 patients were discharged), one LVN, five MHAs from 7a-11:15p
-one incident at 9:50a where pt injured self with piece of broken table
*7p-7a: 26 patients with six on LOS observation; 1 discharge, 2 admissions; one RN, one LVN, four MHAs from 11:15p-7:15a
3/31/18:
*7a-7p: 27 patients with eight on LOS observation; 2 admissions; 1 RN, one LVN, four MHAs from 7a-3:15p (five from 10a-3:15p) and four MHAs from 2:45p-11:15p
-one incident at 11:40a where patient attacked another patient
*7p-7a: 29 patients with ten on LOS observation; 2 admissions; one RN, one LVN, four MHAs
-one incident at 8:13p where patient attacked staff and had to be restrained
-one incident charted at 9:50p that stated in part, "This nurse returned to unit from admissions where she was admitting another pt [patient]. Upon arrival to unit I was informed patient was missing ..." Patient that eloped had an observation status of "LOS".
4/1/18:
*7a-7p: 31 patients with ten on LOS observation; two RNs, one LVN, four MHAs (until 11:15p)
-one incident at 10:15a where patient fell from climbing fence
-one incident at 5:45p where patient struck staff and had to be restrained
*7p-7a: 31 patients with ten on LOS observation; 4 admissions; one RN, one LVN, three MHAs from 10:45p-7:15a
4/2/18:
*7a-7p: 35 patients with 11 on LOS observation, 1 admission, 5 discharges; one RN, one LVN, four MHAs (five from 12:45p-3:15p) and four from 2:45-11:15p
*7p-7a: 31 patients with nine on LOS observation; 2 admissions; 1 discharge - one RN, one LVN, three MHAs from 11:15p-7:15a
4/3/18:
*7a-7p: 31 patients with nine on LOS observation; 2 admissions, 6 discharges; one RN, one LVN, six MHAs until 3:15
*7p-7a: 27 patients with nine on LOS observation; 6 admissions; one RN, one LVN, four MHAs until 11:15p then three MHAs until 7:15a
4/4/18:
*7a-7p: 33 patients with seven on LOS observation, 2 admissions, 6 discharges; two RNs, one LVN, five MHAs until 3:15p, four MHAs from 2:45p-11:15p
-one incident at 10:38a where patient attacked another patient
-one incident at 3:45p where patient attacked another patient
*7p-7a: 29 patients with six on LOS observation; 1 admission; one RN, one LVN, four MHAs from 10:45p-7:15a
-one incident at 8:10p where patient attacked another patient
4/5/18:
*7a-7p: 30 patients with five on LOS observation; 3 discharges, 2 admissions; one RN, one LVN, four MHAs until 11:15p
-one incident at 11:45a where patient attacked another patient
*7p-7a: 29 patients with four on LOS observation; 1 admission; one RN, one LVN, three MHAs from 10:45p-7:15a
-one incident at 7:00p where patient made a suicide attempt
-one incident at 8:30p of patient self-inflicted injury
4/6/18 (staffing/assignment sheet missing)
4/7/18:
*7a-7p: 24 patients with two on LOS observation; 3 admissions, 2 discharges; one RN, one LVN, four MHAs (five MHAs from 3:30p-7:30p)
*7p-7a: 25 patients with three on LOS observation; one RN, one LVN, two MHA from 10:45p-7:15a
4/8/18:
*7a-7p: 25 patients with three on LOS observation; one RN, one LVN, three MHA
*7p-7a: 25 patients with three on LOS observation; one RN, one LVN, four MHAs from 2:45p-11:15p then three MHAs from 10:45p-7:15a
4/9/18:
*7a-7p: 25 patients with four on LOS observation; 2 discharges, 10 discharges; two RNs, one LVN, four MHAs until 3:15p and three MHAs until 11:15p
*7p-7a: 17 patients with three on LOS observation; 6 admissions; one RN, one LVN, four MHAs
4/10/18:
*7a-7p: 24 patients with three on LOS observation; 2 admissions, 4 discharges; one RN, one LVN, three MHAs until 11:15p
*7p-7a: 22 patients with two on LOS observation; 1 admission; two RNs, one LVN, two MHAs from 10:45p-7:15a

***Of the days reviewed for Unit IV, 4 of 24 days were inadequately staffed per the facility's staffing grid. Patient admissions occurred on 22 of the 24 days and patient discharges occurred on 18 of the 24 days.***

***Of the entire 30 day period reviewed for Unit IV, the following incidents were documented:

* Patient aggression - 18 episodes (1 of which required emergency room attention)
* Patient sexual misconduct - 1 episode
* Patient self-inflicted injury - 6 episodes
* Patients attempting suicide - 2 episodes
* Patient elopement - 1 episode
* Patient injury - 1 episode

In an interview with staff #D-1 on 4/9/18 when asked about admission assessments, they stated, "It would take about 30 minutes, just for the assessment." When asked about nursing admission assessments on Unit 4 [child adolescent unit] they stated, "The RN leaves the unit and goes to intake to do the nursing assessment." When asked what RN stays on the unit when they have to leave the unit, they stated, "There's not an RN on the unit, then. There are nights when there is no LVN, so if there's an admission and the RN has to leave the unit, there's no nurse on the unit ... We have begged for help."

In an interview with staff #D-2 on 4/9/18 when asked about staffing, they stated, "The weekends, we hurt bad. It's everyday across the board." When asked the most line of sights they've had in one shift, they stated, "Sometimes 12 patients on line of sight and we have to watch the rest of the other patients, too. If they're on 1:1, we'll get extra staff ... They should include more of the line of sights in staffing."

In an interview with staff #D-7 on 4/9/18 when asked how many LOS they had, they stated, "2 LOS and 8 other patients." When what happens when one LOS goes to the restroom, they stated, "I stand in the doorway [of the restroom] so I can watch everyone at once."

In an interview with staff #D-8 on 4/9/18 when asked how many patients they had, they stated, "6 patients, one LOS." When asked if they've ever had multiple LOS at one time, they stated, "Yes." When asked how they watch several at one time, they stated, "That's hard here. If they have to go to the bathroom or something, I'll have them keep the door cracked a little bit and tell them to talk loudly or sing so I know they're OK." When asked if they could remember the most amount of patients they were responsible for, they stated, "All together 15 girls with 6 LOS." When asked if they had to watch a 1:1 with other patients at the same time, they stated, "Multiple times. Once I had one 1:1 with 8 to 12 other patients. It's terrible here. There's no staff. It's not safe ... We're always short staffed. It's stressful."

In an interview with staff #D-28 on 4/10/18 when asked how long admissions take, they stated, "Around an hour." When asked if they get breaks, they laughed and stated, "No, not really."

In an interview with staff #A-22 on 4-10-18, staff #A-22 was asked how many discharges and admissions generally take place during a 12-hour shift. Staff #A-22 replied "Sometimes none, sometimes a lot. Today I have a transfer from another unit and I know I'll be getting an admission aside from the transfer. I've had 1 discharge already and another patient is calling his wife to come pick him up". When asked how long it takes to do an admission, staff #A-22 stated "One and a half to two hours, if I'm not interrupted, but I'm always interrupted, so that's not realistic." When asked how long it takes to prepare a discharge, staff #A-22 stated "Well, I have to do the suicide risk assessment again and do med teaching and some other paperwork, so I'd say 45 minutes".

In an interview with staff #A-23 on 4-10-18, staff #A-23 was asked to name their primary duties. Staff #A-23 stated "Well, I have to give medications, transcribe any new orders, give PRNs [as needed medications] whenever the patients ask for them and obtain consents for psych[oactive] meds. It takes up my whole day".

In an interview with staff #D-6 on 4/10/18 when asked how long their orientation period was, they stated, "I had one day on the unit. I had to teach myself."

In an interview with staff #D-26 on 4/11/18 they stated, "Usually, we're hardly staffed." When asked how long discharges usually take, they stated, "Maybe 15 minutes if everything is OK. You have to get everything in line and make sure doctors and therapists and all the pieces are in place." When asked how long admissions take, they stated, "Way longer. I've never gotten to go through it all at one time. I would say the least amount of time for the initial nursing assessment 30 minutes at a minimum. We do the initial assessment with the parent and child then once we get to the unit, we do the rest. I've never done it straight through, I have never gotten to sit down and get right through it. I guess you can add another 45 minutes for the rest?" When asked what the highest number of admissions and discharges in one shift they could remember, they stated, "11 discharges and 6 admissions." When asked about breaks, they stated, "Breaks. Not really. We can eat really fast sometimes."

In an interview with Staff #D-22 the afternoon of 4/11/2018, staff #D-22 reported that she has work at Cedar Crest for about a year but also did an internship for 2 years at this facility. She stated that she is CPI certified and had completed a refresher CPI course in 6 months. When asked about the staffing on the unit she reported that there was never enough staff. She said she tries not to be involve in the actual restraints or seclusions. She stated, "I do verbal de-escalation, as a therapist getting involved in restraints would hinder my therapeutic process I have with the patients. We hold groups with all the patients. If the milieu is acute about 70% of the patients attend, if the milieu is non acute up to 100% of the patient attend group, sometime it's up to 23-25 patients in group." She was asked if there was another staff member present during group. She stated, "sometimes, maybe half of the time an MHT sits outside the group room. When MHTs are not available and we have acute or actively psychotic patients in the group, I leave the door open in case I need to call for help. This is a 28 bed unit and we are frequently at full capacity with two MHTs. It's outrageous, there is always a fire that needs to be put out. Patients physically intervene because we don't have enough staff on the unit. Sometimes interns are used as subs for staff coverage. The interns are here to learn they shouldn't have to cover the unit because we are short staffed. Psychosocial assessments are due, groups, and patient discharges, everyone is over worked. Sometimes we breakdown and cry, we and make sure the patients don't see us. It's difficult to stay in compliance when you are having to put out fires. The CEO knows what is going on in this hospital. He knows we are understaffed. I've told him our staff are burnt out to the hilt and they are super stretched. I'm also told to clock out for 30 minutes for breaks that I never take. I'm doing notes or some other work during my break. I get in trouble if I don't clock out. I'm told that "Chart Audits" affect my yearly evaluation. They want me to go in later and fix the charts when things are not done or there are incomplete, but I refuse to do it."

In an interview with Staff #D-23 on the afternoon of 4/11/2018, staff #D-23 said she has worked at the facility only a short time but loved her job. When asked about the staffing on the unit she reported that she spends a lot of her time intervening with patients that are upset or aggressive. "There is never enough staff to take care of the patients." She stated, "we are short staffed and everyone is over worked. It is very stressful, I had a breakdown today (staff D23 was tearful during the interview) after being verbally abused by the doctor. The patients don't need to see us breakdown we are supposed to set an example. If patients see us break down, that is a problem. When a "yellow code" is called, staff will come but they don't want to get involved they don't know the patient's history or why they are in the hospital."

In an interview with staff #D-24 on 4/11/18 when asked how staffing was, they stated, "It could be better. Sometimes, it's a little understaffed." When asked on which units, they stated, "Every unit."

In an interview with staff #D-1 on 4/12/18 they stated, "We are telling doctors, 'If you're ordering line of sight, we're not going to do it. We don't have staff."

In an interview with staff #A-18 and #A-19 on 4-12-18, both staff were shown the staffing grid verified by staff #A-20 to be the current grid being used to staff the units. Both staff members stated that they had never seen the grid presented to them by the surveyors and shared with the surveyors a staffing grid they had been given by staff #A-20 and told to use to staff the units. The staffing grid given to staff members #A-18 and #A-19 by staff #A-20 allowed less staff members per patient than the grid verified by staff #A-20 as being the current grid. Staff #A-19 stated that [staff #A-19] was to come in each morning and use the midnight census as the number of patients to use to determine staffing, regardless of how many patients might have been admitted to each unit between midnight and the following morning when staffing was determined.

During a tour of Unit 3 on 04/10/17 the following observations and interviews were completed:

The unit census at the start of the day was 25. Per the Unit Intake Coordinator on the unit, 4 patients had been discharged. At the time of the observation 21 patients were on the unit. The unit was currently staffed with 1 RN, 1 LVN, and 2 MHTS. Per the facility staffing grid (21-25) the unit should have been staffed with 1 RN, 1 LVN, and 3 MHTs. The staff present on the unit did not meet the criteria set by the facility based staffing grid. At the time of the interviews on the unit on 04/10/18 at approximately 3 PM, no additional staff members had been provided to the unit on this date, despite high acuity (including code yellows called for aggressive patients, patient altercations, multiple emergency medications, and a seclusion).

In an interview staff member #C-12 stated that the acuity of the unit was up that day, confirming that two code yellows had been called due to two aggressive patients. "A male and female were going at it and I was trying to keep them apart. One of the male patients stepped in to keep the other male patient away from the female patient. He (male patient) said he'd watch our back." The staff member stated, "we could really use another staff member on days like today." Staff member #C-13 also confirmed that several code yellows were called for that unit and no extra staff had been added to support the acuity. This staff member stated, "we need another staff to assist on days like this". Both staff members reported that Unit 3 is often short staffed.

In an interview with staff member #C-15, they confirmed that the unit had two code yellows and "two silent code yellows, where we will directly call units we know have extra staff to ask for help". This staff member also confirmed the unit is often short staffed, "usually there are only 3 of us working here most days ...sometimes they pull another staff member over". This staff member also confirmed that two patients were involved in a physical altercation and "another male patient grabbed the (other) patient and held him and said to stop it". This staff member verbally re-directed the female down the hallway where "she (the patient) assaulted me." This staff member also confirmed that a patient was placed in seclusion that day.

In interviews, staff members #C-12, C-13, and C-15 all stated that due to acuity issues on the unit a male patient had to step in and physically re-direct another aggressive male patient on the unit. Staff members #C-14 and C-15 also confirmed that multiple emergency medications were administered on the unit that day.
Staff members on Unit 3 were asked about groups (such as goals groups and Nursing Psych Group) listed on the Unit Schedule being completed by nursing and MHT staff. Staff members #C-12, C-14, and C-15 all confirmed that groups not led by therapists are not being consistently held, but stated that therapist-led groups are being held. Staff member #C-15 stated, "with the high census and acuity we don't have the staff to run groups. Even the therapists can't teach a group at times it's so busy ...We're trying to do the best we can, but with this high acuity most of the time we're just de-escalating patients, giving emergency medications, and breaking up fights."

Review of medical records for Unit 3 on 04/10/18 revealed the following documented incidents:
* Patient #C-10 had a note that stated in part, "Pt assisted staff with de-escalation of a physical altercation among a male and female pt today. Male pt became violent and aggressive towards a female pt."
* Patient #C-11 had a note that stated in part, "[Patient #C-11 name) through [sic] a cup at patient. Both patients started to fight with each other and patient (Patient #C-10 name) grabbed (Patient #C-11) and restrained him from hitting other patient and hitting staff member. (Patient #C-11) was taken outside and eventually calmed down." Another note stated, "Pt was at lunch and was demanding a knife so he could cut his food. Pt lashed out and through [sic] tray across dining hall. Pt stormed out of Dining Room and a code (end of note)".

* The following patients received emergency medications on this date: Patient #C-8 had Haldol 10 mg, Ativan 2mg, and Benadryl 100 mg IM ordered X 1 at 1000. Patient #C-10 had Haldol 5 mg, Benadryl 25 mg, and Ativan 2 mg PO ordered X1 at 0930.
* Patient #C-8 was placed in seclusion from 10:00 AM until 10:30 AM due to "violent/aggressive behavior".
* Review of the "Precaution/Observation Checklist" for Patient #C-8 revealed initials that the monitoring of this patient was completed by staff member #C12 from 1000-1030 during the time of this patient's seclusion.
* Review of the "Precaution/Observation Checklist" for Patients #C-9, C-10, and C-11 revealed initials that the monitoring of these patients was completed by staff member #C12 from 1000-1030. During this half hour time frame this staff member was observing a patient #C-8 in seclusion which requires constant line of sight visualization. This staff member would not be able to perform q 15 minutes checks on other patients simultaneously. During the seclusion of Patient #C-8 the unit would have needed another staff member to assist with the observations of the other 20 patients.

During observation on Unit 3 on 04/11/18 the following was noted:
The unit census on that date was 18. The unit was currently staffed with 1 RN, 1 LVN, and 3 MHTS (1 individual staffing as an MHT was the Recreational Therapy Director). Per the facility staffing grid (16-20 patients) the unit should have been staffed with 1 RN, 1 LVN, and 2 MHTs. This unit was appropriately staffed with one extra MHT present.
In an interview with staff member #C-24 they stated that the unit was adequately staffed "today, but usually we don't have enough staff. Half the people working here today don't usually work on this unit."
In an interview with staff member #C-27 confirmed they were the Director of Recreational Therapy, but working as the an MHT on that date. They stated that their interns were running therapy sessions while they worked as an MHT.

During a review of the staffing variance (census/assignment sheet) for Unit II (adults) for 4-9-18 (review was conducted on 4-11-18), it was noted that the census was 19 patients. The unit was staffed with 1 RN, 1 LVN and 1 MHA (staff #A-21). In an interview with staff #A-21 on 4-11-18, [staff #A-21] stated that [staff #A-21] had recently been injured on the job, was under the care of a physician and had been assigned to work on Unit II, despite the physician's restrictions. At the surveyor's request, staff #A-7 provided the surveyor with the physician's restrictions for staff #A-21, which stated "no restraints". Staff #A-7 was asked if the restrictions had been communicated appropriately to administration and to those who staffed the units. Staff #A-7 provided the surveyor with an email dated 4-6-18 that had been sent to staff #A-18, #A-19 and #A-20, informing those staff members of staff #A-21's restrictions. Staff #A-20 was interviewed and asked if staff #A-20 was aware of staff #A-21's restrictions. Staff #A-20 stated "I think I saw something about that". When asked why staff #A-21 had been scheduled to provide direct patient despite restrictions prohibiting staff #A-21 from doing so, staff #A-20 stated "Oh, I don't do staffing". Staff #A-18 and #A-19 were interviewed and asked why staff #A-21 had been assigned to provide direct patient care on Unit II despite restrictions prohibiting staff #A-21 from doing so. Both staff #A-18 and #A-19 stated that they had been instructed to assign staff #A-21 to Unit II but to tell staff #A-21 "not to respond to any codes".

In an interview with staff #A-7, staff #A-7 was asked to provide the surveyors with documentation of all work-related staff injuries for March 2018. Th

Based on review of documentation and interview, it was determined that the registered nurses failed to complete the initial nursing assessment which includes the initial treatment plan within 8 hours of the patient's admission to the hospital. Six (6) out of Ten (10) clinical records were incomplete.

Finding were:

Facility based policy 900.2.3 titled, "Scope of Assessment by Discipline" states in part,
"A thorough, multi-disciplinary assessment will be completed for each patient admitted to Cedar Crest Hospital & RTC. It shall be initiated prior to the time of admission.
The purpose of the assessment period is to insure that the treatment team has all necessary assessment information, including the patient's clinical needs, and need for additional specialized assessment, in order to create a written, comprehensive master treatment plan.

B. Nursing Assessment: The purpose of the nursing assessment component of the integrated assessment is to determine the patient's general health, any immediate health problems that could adversely affect the treatment of the patient and any medications the patient is currently using, and an abnormal involuntary movement evaluation. The assessment is completed by a registered nurse. The nursing assessment must be completed within 8 hours."

In a review of 10 (ten) patient discharge medical records revealed 6 (six) "Initial Nursing Treatment Plan" were missing or had a blank form filed with the Initial Nursing Assessment documents. The following records were not incompliance.
D1, D8, D9, D18, D19, and D20.

The above deficiencies were confirmed by the interim Director of Nursing on the afternoon of 4/12/2018.

Based on observation, staff interview and facility record review, the hospital failed to ensure activity areas/sites were accessible and available to meet the patient's individual needs for 1 of 1 patients whose observed activities were reviewed [Patient #8]. This deficient practice had the potential to affect all male adolescent patients at the hospital.

Findings were:

Facility policy #1000.53 entitled "Outdoor Recreational Activities," last reviewed 10/15, included the following:
"POLICY: Cedar Crest Staff facilitate the therapeutic use of outdoor recreational activities and safety regarding hospital & RTC (residential treatment center) grounds ...
PROCEDURE:
1. Recreational (Activity) Therapy Staff and Nursing Staff shall monitor and facilitate outdoor recreational activities per unit/program schedule ...
2.5 AT (activity therapy) Staff and all Staff shall monitor hospital & RTC environment of care (EC) grounds for safety or treatment risks ..."

A review of the Precaution/Observation Checklists for Patient #B8 revealed he had been noted as "OS" - outside - on 4/10/18 from 3:45 p.m. to 4:15 p.m. and on 3/25/18 from 12:30 to 12:45 p.m. These were the only dates/times when the patient had been noted to be outside during his entire stay at Cedar Crest Hospital. Patient #8 was admitted on 3/24/18.

In an interview with Patient #B8, patient on Unit #4, on the afternoon of 4/11/18 on the unit, when asked whether the adolescent boys have been using the boys' patio, he stated, "I've been here about 18 days. We haven't been allowed any time on the patio. Yesterday was the first day since I've been here that we went outside for any amount of time. It was nice to go out. We were supposed to spend time in the gym, but the gym was full I think. I don't know. So we were allowed to just kind of run around in the green area next to the gym. But officially, we haven't been allowed on the patio or outside at all, except to walk back and forth to the cafeteria and gym. The lock on the door to the patio wasn't working very well, so we were sneaking out there occasionally anyway. One guy eloped - maybe two weeks ago now ...and now the lock is fixed. But we aren't allowed to use the patio ..."

In an interview with Staff #10, RN on Unit #4, on the afternoon of 4/11/18 on the unit, when asked whether the adolescent boys have been using the boys' patio, she stated, "Oh no, we're not letting them out there." When asked whether the boys had been allowed outside time within the last two weeks, she stated, "They go at least once a day either before or after lunch. They go to the big field outside of Unit 3." When asked whether the time outside would be reflected on the observation check sheets, she stated, "Well, that I don't know about. I'm not sure that will show up on those sheets."