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Based on record review and interview, the hospital failed to ensure that after placing patients into seclusion the registered nurse that performed the face to face assessment consulted the attending physician for 2 (#13, #14) of 2 patients sampled for seclusion.

Findings:

Review of the hospital's policy titled Seclusion and Restraint Use revealed in part:
RNs as permitted by state law, who conduct the 1 hour face to face evaluation will receive additional education and training that demonstrates they are qualified to conduct a physical and behavioral assessment of the patient that addresses the patients immediate situation, the patients reaction to the interventions, the patients' medical and behavioral condition and the need to terminate the restraint or seclusion. If conducted by a designated RN, RN must document the evaluation in the MD progress notes to include notification of the physician of the evaluation result.

Patient #13
Review of patient #13's medical record revealed she had been placed into seclusion on 2/27/19 at 9:15 p.m. for spitting on a nurse and throwing books at the MHTs. Further review revealed the 1-hour face-to-face evaluation was completed on 2/27/19 at 10:05 p.m. There was no documentation of consulting the physician after the 1-hour face-to-face evaluation by S7RN.

Patient #14
Review of patient #14's medical record revealed he had been placed into seclusion on 3/28/19 at 5:25 a.m. for increased paranoia and agitation. Further review revealed the 1-hour face-to-face evaluation was completed on 3/28/19 at 6:20 a.m. There was no documentation of consulting the physician after the 1-hour face-to-face evaluation by S7RN.

In an interview on 4/23/19 at 2:25 p.m. with S5Psych/DON, she said if the patient is released from seclusion within an hour, the nurse does not have to call the physician. She said the only time they call after the initial order is if they need to reorder the restraints. She verified the nurses do not consult the physician with the results of their 1-hour face-to-face assessment.

39791


Based on record review and interview, the hospital failed to ensure the direct care staff received the education, training and demonstrated knowledge in the use on non-physical intervention skills for the 6 (S2DON, S3ADON, S14MHT, S17LPN, S18LPN, S19LPN) of the 6 employee personnel files reviewed.

Findings:

On 04/23/19 a review of the personnel files for S2DON, S3ADON, S14MHT, S17LPN, S18LPN and S19LPN failed to reveal documented current education, training and demonstration in the use of non-physical intervention skills.

On 04/23/19 at 3:45 p.m. S1Administrator verified the above staff are required to maintain current education, training and demonstration in the use of non-physical intervention skills.
She also verified the personnel files of said staff did not contain documented current education, training and demonstration in the use of non-physical intervention skills.

39791


Based on record review and interviews, the hospital failed to ensure the nursing staff were certified in the use of cardiopulmonary resuscitation (CPR) evidenced by having 6 (S5Psych/DON, S10RN, S11RN, 12LPN, S13LPN, and S15MHT) of 16 employed nurses reviewed with no documented evidence of current CPR certification.

Findings:

On 04/23/19 upon initial review of the employee files S5Psych/DON, S10RN, S11RN, 12LPN, S13LPN, and S15MHT revealed no documented evidence of current CPR certification.

In an interview on 04/24/19 at 3:45 p.m. S1Administrator verified the employee files of S5Psych/DON, S10RN, S11RN, 12LPN, S13LPN, and S15MHT did not have current CPR certification.

An interview on 04/24/19 at 9:00 a.m. S1Administrator revealed the hospital does not have a policy regarding CPR, but that all direct patient staff are required to have CPR.

Based on record review and interview, the hospital failed to meet the requirements of the Condition of Participation for Nursing Services as evidenced by the hospital failing to ensure the RN supervised and evaluated the care of each patient by failing to ensure physicians orders were obtained for admission for 1 (#6) of 1 record reviewed for admit orders. This deficient practice is evidenced by the RN or LPN selecting admission orders from a pre-printed order sheet for all admissions and not calling the admitting physician to receive the admission orders.
(See Findings in A0395).

Based on record reviews, and interviews, the hospital failed to ensure the RN supervised and evaluated the care of each patient as evidenced by failing to ensure physicians orders were obtained for admission for 1 (#6) of 1 record reviewed for admit orders. This deficient practice is evidenced by the RN or LPN selecting admission orders from a pre-printed order sheet for all admissions and not calling the admitting physician to receive the admission orders.

Findings:

Review of the hospital's Physician Admission Orders revealed they were preprinted with choices to be selected such as the type of diet, labs, therapeutic labs, addiction protocols, and PRN non-emergent medications.

Patient #6
Review of patient #6's Physician Admission Orders dated 4/8/19 at 11:00 a.m. revealed the following orders had been chosen on the preprinted form: No added sodium diet, CMP, CBC, LFT, TSH, U/A with culture and sensitivity, Alcohol level, 2 Ibuprophen 200mg every 4 hours as needed, 2 Tylenol 325mg by mouth every 4 hours as needed for pain or temp >100, and Mylanta 10ml by mouth every 4 hours as needed for indigestion. The order was signed by S6LPN as a VRBO from S8Psychiatrist.

A request was made on 4/8/19 at 12:45 p.m. to S5Psych/DON for a protocol or policy for selecting items on the Physician Admission Orders but none was provided.

In an interview on 4/23/19 at 12:45 p.m. with S5Psych/DON, she said when patients are admitted the nurses filled out the Physician admission orders based on the discharge paperwork from the hospital that transferred them. She said the physician would review the orders when he got to the hospital. She verified they would call the physician and let him know there was an admission, but they did not go over the orders with him. She said when he reviewed the orders when he arrived at the hospital, he would sometimes change some things.

In an interview on 4/23/19 at 1:00 p.m. with S4Psych/ADON, she verified when a patient was admitted one of the nurses, either the RN or LPN would make selections on the Physician Admission Orders sheet based on discharge information from the transferring hospital. She said they did not call the physician to obtain the orders. She said the physician would review the order sheet when he did rounds.

In an interview on 4/23/19 at 1:15 p.m. with S6LPN, she said she had completed the preprinted Physician Admission Orders for Patient #6. She said she selected his labs, diet, addiction protocols and PRN medications based upon the transferring hospitals paperwork. She also verified she did not contact the physician for the orders because he would review them when he made rounds. S6LPN also verified she signed the orders as a verbal order that had been read back to the physician, but she had not actually done so.


30364

Failed to ensure that a competency skills assessment checklist was developed for respiratory care services for staff who provided respiratory care services to patients as evidenced by no documentation of a respiratory competency skills assessment for 16 (S2DON, S3ADON, S4Psych/ADON, S5Psych/DON, S6LPN, S7RN, S10RN, S11RN, S12LPN, S13LPN, S16LPN, S17LPN, S18LPN, S19LPN, S22RN, and S23RN) of 16 direct patient care nurses employee files reviewed for respiratory care competency.
Findings:

Review of the employee personnel files for S2DON, S3ADON, S4Psych/ADON, S5Psych/DON, S6LPN, S7RN, S10RN, S11RN, S12LPN, S13LPN, S16LPN, S17LPN, S18LPN, S19LPN, S22RN, and S23RN revealed no documented evidence of a respiratory care competency skills assessment that had been performed for the nurses who provided respiratory care to patients; in the management of oxygen tanks, nasal cannulas, hand-held nebulizers, and inhalers.

In an interview on 04/23/19 at 9:00 a.m. with S1Administrator, she verified the nurses were responsible for the delivery of respiratory care services for the patients who require respiratory care services to include: management of oxygen tanks, nasal cannulas, hand-held nebulizers, and inhalers. S1Administrator indicated that the hospital's nursing staff were not being assessed or evaluated for respiratory care skills competency upon hire or annually. She further revealed she was aware of this and did not follow through with the training.

Based on record review, and interview, the hospital failed to ensure a medical history and physical examination was completed as evidenced by failing to complete the cranial nerve assessment for 6 (#3, #4, #5, #6, #7, and #8) of 12 sampled records reviewed for history and physical examinations from a total sample of 16.

Findings:

Review of the policy titled Assessment, Reference Number 1000, revised 08/20/15 revealed in part: The Physician (H&P): Performs a comprehensive physical examination including neurological and cranial nerves I-XII.

Patient #3
Review of patient #3's medical record revealed the patient was admitted on 04/16/19 with a diagnosis of Suicidal Ideation, Anxiety, and Depression. Review of the History and Physical dated 04/16/19 revealed no documentation for the assessment of cranial nerves I and II.

Patient #4
Review of patient #4's medical record revealed the patient was admitted on 04/16/19 with a diagnosis of Schizophrenia, Bipolar, and Delusional. Review of the History and Physical dated 04/17/19 revealed no documentation for the assessment of cranial nerve I.

Patient #5
Review of patient #5's medical record revealed the patient was admitted on 04/16/19 with a diagnosis of Suicidal Ideation, Anxiety, and Depression. Review of the History and Physical dated 04/17/19 revealed no documentation for the assessment of cranial nerve I.

Patient #6
Review of patient #6's medical record revealed the patient was admitted on 04/18/19 with a diagnosis of Schizoaffective Disorder. Review of the History and Physical dated 04/18/19 revealed no documentation for the assessment of cranial nerves I and II.

Patient #7
Review of patient #7's medical record revealed the patient was admitted on 04/20/19 with a diagnosis of Suicidal Ideation, Anxiety, and Depression. Review of the History and Physical dated 04/21/19 revealed no documentation for the assessment of cranial nerve I.

Patient #8
Review of patient #8's medical record revealed the patient was admitted on 04/20/19 with a diagnosis of Paranoia. Review of the History and Physical dated 04/21/19 revealed no documentation for the assessment of cranial nerve I.

Interview on 04/23/19 at 2:20 p.m. with S9Assisst/Administrator confirmed the physicians should be completing the history and physicals on all patients.

Based on observation and interview, the hospital failed to ensure outdated, mislabeled, or otherwise unusable drugs and biologicals were not available for patient use.

Review of the policy titled "Automated Dispensing Machine: Disposal of Unused and Wasted Medications" dated January 2019 revealed in part: Medications and devices scheduled to expire on any day in the following month shall be removed from stock.....Facility personnel authorized to remove medications from the automated dispensing machine for administration shall monitor the expiration dates of medications and devices to ensure compliance with the provisions hereof.

An observation on 04/22/19 at 3:30 p.m. of the Emergency Department medication refrigerator revealed a 3ml bottle of Humulin N 100units/ml with an expiration date of 03/2019.

An interview on 04/22/19 at 3:30 p.m. with S2DON and S3ADON verified the expired 3ml bottle of Humulin N 100units/ml and this was the only bottle of Humulin N available for patient use.