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Based on records reviewed and interviews, for 3 of 14 sampled patients (Patient #6, Patient #7, and Patient #8), the hospital failed to ensure that the patients were provided the standardized notice, "An Important Message from Medicare" (IM), within 2 days of admission.

Findings include:

The Surveyor interviewed the Chief Clinical Officer (CCO) at 9:17 A.M. on 05/25/17. The CCO said the IM notice should be in the clinical records for Patient #6, Patient #7 and Patient #8. The CCO said the IM notice should be issued on admission, prior to discharge, and when the patient's Medicare benefit exhausted.

1. Patient #6 was admitted to the Hospital in April 2017.

Campus W's Flash Short Report, dated 05/25/17, and Patient #6's clinical record, indicated that he/she had Medicare.

There was no documentation at the time of survey that Patient #6 was issued an IM notice at any time during his/her admission to the Hospital.

2. Patient #7 was admitted to the Hospital in May 2017.

Campus W's Flash Short Report, dated 05/25/17, and Patient #7's clinical record, indicated that he/she had Medicare.

The Chief of Clinical Services (CCS) was present at the time the Surveyor's review of Patient #7's clinical record. The CCS also reviewed the clinical record and was unable to locate the IM notice.

There was no documentation at the time of survey that Patient #7 was issued an IM notice at any time during his/her admission to the Hospital.

3. Patient #8 was admitted to the Hospital in February 2017.

Campus W's Flash Short Report, dated 05/25/17, and Patient #8's clinical record, indicated that he/she had Medicare.

The CCO also reviewed Patient #8's clinical record and was unable to locate the IM notice.

The CCS said the IM notice was possibly in Patient #8's overflow clinical record. The overflow record was provided to the Surveyor and no IM notice was located in the overflow clinical record.

There was no documentation at the time of survey that Patient #8 was issued an IM notice at any time during his/her admission to the Hospital.

Based on record review, the Hospital failed to have information in their complaint/grievance policy regarding how to contact the Quality Improvement Organization regarding complaints.

Findings include:

The Hospital's policy and procedure titled Patient Complaint/Grievance Process, dated February 2017, did not contain a procedure of how a patient was to contact the Quality Improvement Organization if they had a complaint regarding quality of care or disagreed with a coverage decision.

Based on observations, interviews and documents reviewed the Hospital failed to provide reasonable personal privacy for 3 of 6 patients (Patients #11, #12 and 1 Non-Sampled Patient) observed at Campus P in a total sample of 14 patients during initial admission activities.

Findings include:

Hospital policy titled Patient Rights, dated 2/2016, indicated that the Hospital supported, protected, recognized and respected the patient's personal dignity at all times.

Campus P's Inpatient Adult Program Patient & Family Handbook, dated 3/31/17, and Campus P's Inpatient Adolescent Services Patient & Family Handbook (date illegible), indicated one of the Six Fundamental Rights for Patients was the right to humane psychological and physical environment.

The Comprehensive Interdisciplinary Assessment form, dated 5/24/17, documented as completed by a Registered Nurse at 2:30 P.M. and documented as completed by a Physician at 3:00 P.M., indicated the Physician admitted Patient #11 to the Hospital for psychiatric treatment of suicidality. The Patient Intake, Unit Orientation section of the Comprehensive Interdisciplinary Assessment, dated 5/24/17 at 1:55 P.M. and documented as completed by a MHA, indicated Patient #11's vital signs, weight, belongings search conducted and removal of shoelaces, boots and other high risk items were performed.

The Comprehensive Interdisciplinary Assessment form, dated 5/24/17, documented as completed by a Registered Nurse at 6:00 P.M. and documented as completed by a Physician at 8:00 P.M., indicated the Physician admitted Patient #12 to the Hospital for psychiatric treatment of suicidality. The Patient Intake, Unit Orientation section of the Comprehensive Interdisciplinary assessment, dated 5/24/17 (not timed) and documented as completed by a Mental Health Associate (MHA), indicated Patient #4's vital signs, weight, belongings search conducted and removal of shoelaces, boots and other high risk items were performed.

The Surveyors observed people who were witness to initial admission activities in Patient Care Units #4 and #5 and these people were not involved in the care of Patients #11, #12 and Non-Sampled Patient #3.

The Surveyors observed, at 1:45 P.M. on 5/24/17, Patient #11's initial admission activities to Patient Care Unit #4. The Surveyors observed Emergency Medical Technicians (EMTs) bring Patient #11 on an ambulance stretcher onto Patient Care Unit #4. The Surveyors observed Patient #11 was moved to and seated on a chair in the hallway outside MHA's desk on Patient Care Unit #4. The Surveyors observed Patient #11's initial admission process consisted of the following activities: verbal report between the EMTs and a Registered Nurse (RN), MHA's obtaining Patient #11's vital signs and security check of Patient #11's belongings including medications. The Surveyors observed other patients observing Patient #11's initial activities that were in easy view to other patients and Hospital staff including housekeeping staff not involved with the care of Patient #11. The Surveyors observed 11 people not involved in the care of Patients #11 that were witness to Patients #11's initial admission activities to Patient Care Unit #4. The Surveyors observed Patient #3's initial admission activities while seated in a chair in the hallway outside the MHA desk for 20 minutes.

The Surveyors observed, at 4:30 P.M. on 5/24/17, Patient #4's initial admission activities to Patient Care Unit #5. The Surveyors observed Patient #4 moving off the ambulance stretcher, clothed in two hospital gowns, one covering Patient #4's front side and one hospital gown covering Patient #4's back side. The Surveyors observed Patient #4's inner legs to upper thighs exposed while Patient #4 moved off the ambulance stretcher to a chair in the hallway outside the MHA's desk.

The Surveyors observed, at 9:10 A.M. on 5/25/17, another Patient's (Non-Sampled Patient #3) initial admission activities to Patient Care Unit #5 with the Patient seated in a chair in the hallway outside the MHA's desk. The Surveyors observed two patients in the hallway observing the Patient's initial admission activities.

The Surveyors interviewed Patient Care Unit #4's Program Manager #1 at 2:08 P.M. on 5/25/17. Program Manager #1 said standard patient initial admission procedures included that the MHA seated the patient in a chair in the hallway outside the MHA's desk. Program Manager #1 said that the MHA's obtained vital signs, searched the patient belongings and an RN conducted an initial patient mental health assessment. Program Manager #1 said the Hospital conducted these initial patient admission activities with the patient seated in a chair in the hallway outside the MHA's desk because staff paperwork and the vital signs machine was stored at the MHA's desk and for safety reasons.

The Surveyors interviewed Program Manager #2 (West 2) at 4:30 P.M. on 5/14/17. Program Manager #2 said MHAs and RNs provided initial admission activities for patients seated in a chair outside the MHA's desk. Program Manager #2 said initial patient admission activities included the MHA obtaining vital signs and patient belongings searches and the RN conducting initial patient assessment observations. Program Manager #2 said that the Hospital conducted initial patient assessment activities by this procedure for safety reasons. The Surveyors observed seven patients not involved in the care of Patients #12 that were witness to Patients #12's initial admission activities to Patient Care Unit #5. The Surveyors observed seven patients lined up awaiting staff escort to the dining area for dinner who could easily observe Patient #12's initial admission activities.

The Surveyors interviewed Nurse #12 on Patient Care Unit #2 at 9:30 A.M. on 5/25/17. Nurse #12 said MHAs and RNs provided initial admission activities for patients seated in a chair outside the MHA desk. Nurse #12 said initial patient admission activities included the MHA obtaining vital signs and patient belongings searches and the RN conducting initial patient assessment observations. Nurse #12 said staff walked patients to a storage room where a scale was stored and obtained the patient's weight.

The Surveyors observed, on Patient Care Unit #2 at 9:30 A.M., that people not involved in the care of a patient being weighed had opportunity to witness this potential personal patient care activity because equipment (housekeeping cleaning equipment, an electrocardiogram machine, showering equipment for disabled patients) necessary for their job was stored in the storage room.

The Surveyors interviewed Program Manager #3 (East 1-Adolescent) and Nurse #11 at 9:45 A.M. on 5/15/17. Program Manager #3 said MHAs and RNs provided initial admission activities for patients seated in a chair outside the MHA desk. Nurse #11 said that the MHA brings the patient weighting scale from behind the MHA Desk to the hallway and the MHA weights the patient on the scale while in the hallway.

Based on observations, record reviews and interviews, the Hospital failed to ensure safety for 3 of 5 patients (Patient #1, and Non-Sampled Patient #1 and #2) and to protect against hazards on the child and adolescent units. The Hospital failed to: provide an adequate assessment and monitoring care to Patient #1 post-fall; did not correctly identify Non-Sampled Patient #1 and #2 during medication administration; and ligature points existed on the units posing hanging hazards.

Findings include:

1. Patient #1's Nurse's Note, dated 4/16/17, indicated at approximately 5:30 P.M. a peer hit Patient #1 and he/she fell from a chair and sustained a lump and bruise on his/her forehead.

Review of Patient #1's chart indicated there were no neurological signs documented between 4/16/17 to 4/21/17. Review of Patient #1's vital sign graphic chart indicated that after the incident on 4/16/17, vital signs were obtained once on 4/17/17, and then none until 4/22/17. This documentation was verified by the Risk Manager.

The Surveyor interviewed Nurse #7 on 6/5/17 at 1:00 P.M. Nurse #7 said that, on 4/16/17 at approximately 5:30 P.M., she observed Patient #1 repeatedly poking Patient #2 and then Patient #2 pushed Patient #1, who had been sitting in a chair in the hallway, and he/she fell and hit his/her head against a wall. Nurse #7 said that Patient #1 developed a large bruise on the forehead which swelled like a "big egg." Nurse #7 said she telephoned the Doctor-On-Call (DOC), Physician #1, who arrived to the unit and examined Patient #1. Nurse #7 said that Physician #1 told her that he decided not to send Patient #1 to an emergency department (ED) for further examination. Nurse #7 said she conducted neurological checks throughout the night, held his/her medications and kept him/her awake until later in the shift in order to assess Patient #1's functioning. Nurse #7 said she did not document the neurological values. Nurse #7 said she documented the shift in the nurses's Progress Note with the assistance of the Nursing Supervisor. Nurse #7 said that the nursing note she wrote could no longer be found in the chart.

The Surveyor reviewed Patient #1's chart and determined there was not a nurse's note shift entry written by Nurse #7 dated 4/16/17.

The Surveyor interviewed the Chief Nursing Officer on 6/15/17 at 1:45 P.M. The Chief Nursing Officer said its was standard nursing practice to obtain and document frequent vital and neurological signs for at least the next 24 hours after a patient falls and sustains a head injury such as a hematoma with swelling.

Physician #1's Progress Note, dated 4/16/17, indicated "Patient #1 was struck in the face after agitating a peer," or words to that effect. Physician #1 indicated Patient #1 was in no apparent distress, was alert and fully oriented.

Review of Patient #1's chart indicated that Physician #1 met with him/her again on 4/17/17 and 4/18/17 to examine the head bump and reported that he/she was in no apparent distress.

The Surveyor interviewed Physician #1 on 5/25/17 at 8:00 A.M. Physician #1 said he examined Patient #1 immediately following the incident on 4/16/17 which included a neurological evaluation. Physician #1 said he decided not to transfer Patient #1 to a hospital ED for further evaluation because Patient #1 was stable. Physician #1 said he planned on remaining on the Children's Unit for a few more hours that evening and so could monitor Patient #1 for neurological changes.

The Surveyor interviewed the Chief Medical Officer on 5/24/17 at 10:00 A.M. The Chief Medical Officer said it was standard medical care at the Hospital that, after a patient fell and sustained a head injury, the physician to write an incident note. The Chief Medical Officer said a physician was expected to document speech, behavior, balance, gross neurological signs, and assess for abnormal symptoms. The Chief Medical Officer said the documentation should include a description of the event.

Review of the Hospital's Fall Policy, dated 10/2015, indicated there was no guidance to instruct staff on post-fall policy and procedure.


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2. Campus L's policy titled Medication Administration, dated 4/17, indicated that a patient's identity is confirmed using two of the following identifiers: patient photo identification; patient's full name or patient's date of birth.

The Surveyor observed the medication distribution on Campus L's Adult 2 unit at 1:45 P.M. on 5/24/17. Registered Nurse (RN) #1 called Non-Sampled Patient #1 to receive medications. RN #1 called the Non-Sampled Patient #1 by his/her first name and administered Non-Sampled Patient #1 without confirming the two identifiers as required by the Hospital's policy. Non-Sampled Patient #1's on-line medication record did not contain a photograph.

The Surveyor observed a second medication distribution to Non-Sampled Patient #2 at 1:50 P.M. on 5/24/17. RN #1 asked Non-Sampled Patient #2 his/her date of birth as a single identifier but failed to use the two person identifiers as described in the policy. Non-Sampled Patient #2's on-line medication record did not contain a photograph.

3. The Surveyor observed Campus L's Adolescent Unit and Adult 2 Unit between 8:30 A.M. and 10 A.M. on 5/24/17. The fire doors on both units were equipped with an automatic release system that enabled the doors to close automatically in case of a fire or a fire drill. The magnetic closure device was not mounted flush to the wall thus creating a potential ligature hazard. Also, these same four doors had hinge arms that protruded approximately one foot from the face of the doors which created a potential ligature hazard.

Campus L contained an outdoor patio enclosure for patient use. The Surveyor observed the patio enclosure at 9:20 A.M. on 5/24/17. The roof was constructed of a chain link enclosure strung over piping approximately 10 feet from the ground. There were chairs on the patio that were available for patients but could be moved to access the pipes thus creating a ligature risk.

The Surveyor observed Campus W's Children's Unit at various times on 5/24/17 and 5/25/17. The Children's Unit was unoccupied and closed to new patient admissions and was unstaffed. The Surveyor observed a metal door closer attached to the top inside of the Children's Unit exit door, approximately 80 inches from the floor. The door closer protruded as a ligature risk into the unit hallway approximately 1 foot. The door closure posed an unnecessary risk for hanging.

Based on records reviewed and interviews, for one of 14 sampled patients (Patient #8), the Hospital failed to ensure that on two occasions, the patient was examined by the physician within one hour of the initiation of a mechanical restraint, physical restraint, and/or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others.

Findings include:

Campus W's Seclusion and/or Restraint Use policy, reviewed in 11/2016, indicated that an authorized physician shall examine the patient as soon as possible but no later than one hour of such initiation of mechanical restraint, physical restraint, or seclusion. The policy did not include the examination of patient's after the initiation of a medication restraint.

Patient #8 was admitted to the Hospital in February 2017 with diagnoses which included schizoaffective disorder and borderline personality disorder.

1. The Physician's Order, dated 02/26/17, indicated that Patient #8 was ordered for a physical restraint, mechanical restraint, medication restraint and seclusion due to agitation and assaultive behavior. The order indicated that the medication restraint incl
uded the administration of Haldol (an antipsychotic medication), Ativan (a benzodiazepine medication), and Benadryl (diphenhydramine; an antihistamine medication often given with Haldol to prevent involuntary muscle contractions).

There was no documentation at the time of Survey that Patient #8 was examined by the physician within one hour of the initiation of the restraints.

2. The Physician's Order, dated 04/03/17, indicated that Patient #8 was ordered for a physical restraint due to assaultive behavior towards other patients.

There was no documentation at the time of Survey that Patient #8 was examined by the physician within one hour of the initiation of the restraint.

Based on records reviewed and interviews, for one of 14 sampled patients (Patient #8), the Hospital failed to ensure that on two occasions, the physician documented examination of the patient within one hour of the initiation of a mechanical restraint, physical restraint, and/or seclusion.

Findings include:

Campus W's Seclusion and/or Restraint Use policy, reviewed in 11/2016, indicated that an authorized physician shall examine the patient as soon as possible, but no later than one hour of such initiation of mechanical restraint, physical restraint, or seclusion.

Patient #8 was admitted to the Hospital in February 2017 with diagnoses which included schizoaffective disorder and borderline personality disorder.

1. The Physician's Order, dated 02/26/17, indicated that Patient #8 was ordered for a physical restraint, mechanical restraint, medication restraint, and seclusion due to agitation and assaultive behavior. The order indicated that the medication restraint included the administration of Haldol (an antipsychotic medication), Ativan (a benzodiazepine medication), and Benadryl (diphenhydramine; an antihistamine medication often given with Haldol to prevent involuntary muscle contractions).

There was no documentation at the time of survey that Patient #8 was examined by the physician within one hour of the initiation of the restraints.

2. The Physician's Order, dated 04/03/17, indicated that Patient #8 was ordered for a physical restraint due to assaultive behavior towards other patients.

There was no documentation at the time of survey that Patient #8 was examined by the physician within one hour of the initiation of the restraint.