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Based on observations and interview the hospital failed to ensure patients who were placed in the Seclusion/Restraint room remained safe and did not have access to: 1. removable ceiling tiles; 2. bare brick walls; 3. unprotected lighting fixtures. Patients who had access to the Seclusion/Restraint room had a means of escaping, a ligature point, and a use of a potential weapon. The Seclusion/Restraint room presented an unsafe environment for psychiatric patients who may require its use.

Findings:

Observations conducted, 06/12/2019 at 10:25 AM, revealed removable ceiling tiles, bare brick walls, unprotected light fixtures, and a protruding metal box identified by Staff #B as a covered electrical outlet.

The removable ceiling tiles could afford the suicidal patient or elopement prone patient an avenue for a ligature point or escape respectively. The suicidal patient could remove the ceiling tiles affording them a ligature point (i.e. the strapping or beam between the ceiling tiles). The elopement prone patient could remove the ceiling tiles and escape through the ceiling to an unsecured area of the psychiatric hospital and leave the premises.

The bare brick wall could be used as a weapon by the patient; the brick wall was rough, and lacked padding. Any staff member in the Seclusion/Restraint room could be at risk of injury by the patient as well as the patient themselves. Hitting one's head into the bare brick wall could cause a severe injury.

The lighting in the Seclusion/Restraint room consisted of one fluorescent lighting fixture and one incandescent fixture. Neither of the lighting fixtures had protective screening around them; a patient could potentially break the fixtures thereby having access to a weapon or object to cause self-injury in case of a suicidal patient.

There was a protruding metal box on the back wall that could be used as a means for self-harm by a suicidal patient as well.

Interviews, 06/12/2019 at 10:35 AM, with Staff #s A and B, revealed the Seclusion/Restraint room was "usually never used"; instead the hospital staff used "verbal de-escalation techniques" to "calm" the patient "instead of using the room". Staff #s A and B did agree that removable ceiling tiles, bare brick walls, unprotected lighting fixtures and the protruding metal box in the Seclusion/Restraint room would pose a safety problem.

Based on medical record reviews and interview, the hospital failed to ensure all physician orders were dated and timed when authenticated.

Findings:

Review of 4 of 8 medical records (Patients 1,2,3,7) revealed Staff #S failed to place the date and time of authentication on the Physician orders.

Interview, 06/12/19 at 2:40 PM, with Staff #E confirmed Staff #S failed to place the date and time of authentication on physician orders for 4 of 8 medical records reviewed (Patient #s 1,2,3,7).

Based on record review and interview the hospital failed to ensure informed consent for psychoactive medications were completed as evidenced by a lack of documented symptoms of the patients who required these medications.

Findings:

Review of 5 of 8 medical records (#s 1,2,3,7,8), revealed a form titled "CONSENT TO TREATMENT WITH PSYCHOACTIVE MEDICATION". Continued review of this form revealed a list of medication group names that the healthcare provider would mark for administration to the patient based upon their symptoms. Further review of the form revealed directly under the list of medication group names was the statement: "Dr.___________ has explained to me in simple, non-technical language that I have an emotional problem manifested by the following symptoms:_____________________________________________________" Patient #s 1, 2, 3, 7, 8 medical records contained this informed consent form (Consent to treatment with psychoactive medication); however, Staff #R failed to document each patients (#s 1,2,3,7,8) individual manifested symptoms that required the use of psychoactive medications. (The blank areas indicated above were to be completed by the ordering provider.)

Interview, 06/13/2019 4:30 PM, with Staff #R confirmed there lacked documented symptoms on patient #1, 2, 3, 7, 8's consent forms and the emotional problem/s symptoms manifested by each patient should have been documented.

Based on review and interview the hospital failed to ensure the dietitian and the medical staff approved the current therapeutic diet manual.
Findings:

A review of the Medical Staff Meeting Minutes from 06/19/2018 through 04/16/2019 revealed the medical staff failed to address or approve the hospital's therapeutic dietary manual. A review of all pages in the therapeutic dietary manual failed to reveal signature pages indicating that the manual was approved.

In interview on 06/12/19 at 1:30 PM the staff F, dietary manager stated the therapeutic dietary manual had not been approved.

Based on review and interview the infection control officer failed to develop a system for investigating and controlling infections by ensuring by not:
1. tracking organisms that caused infections and
2. evaluating the effectiveness of treatments.
Findings:

A review of the infection control log from July 2018 through March 2019 revealed the infection control officer failed to list organism that caused infections. Further review revealed the infection control log did not addressed wheather or not patients were free of signs and symptoms of infections.

On 06/12/19 at 2;00 PM the infection control officer stated she was unaware that organisms were to be monitored.

Based on reviews of hospital policies and procedures, the organizational chart and medical records along with an interview, the hospital failed to ensure the services of a psychologist were available to patients.

Findings:

Review of a hospital policy and procedure titled, "Inpatient Case Management Assignments", effective date of 04-26-10, Section No: 6-00-00.A revealed: "POLICY: It is the policy of Carl Albert Community Mental Health Center that each consumer admitted to the Inpatient Unit will be assigned a Psychological Assistant and a Social Worker for Case Management."

Review of the organizational chart revealed there failed to be documented evidence the hospital had the services of a psychologist.

Review of personnel and contracted services revealed there failed to be a psychologist on staff or as a contracted service.

Interview, 06/12/2019 at 4:00 PM, with Staff #A revealed when questioned if the hospital had a psychologist on staff or contracted to provide services, Staff #A confirmed the hospital lacked the services of a Psychologist.

Based on observations, interviews and record reviews the hospital failed to:

I. Employ or have a contract with a qualified therapeutic activity therapist to provide supervison and/or document active treatment for 8 of 8 patients (#s 1-8). Specifically the hospital did not have a Therapeutic Activity Therapist to complete therapeutic activities assessments to ensure appropriate input into the formulation of the patients (#1-8) Individual Plan of Care/Integrated Service Plan, as well as offering therapeutic activities. This failure: 1. results in patients not receiving a full complement of therapies, patients not being properly assessed regarding needs and capabilities, and patients not receiving individualized and goal-directed therapeutic activities; and 2. results in a lack of structured therapeutic activities provided by qualified staff, which potentially hampers patients' progress in obtaining their optimal level of functioning.

Findings:

Observations, 06/12/2019 at 10:50 AM, revealed inpatients were in the hospital gym and were encouraged to try and put the basketball into the net/hoop, and listening to the "radio".

Review of a patient schedule, dated Wednesday 6-12-2019, revealed "10:15-11:00 Interactive Recreation".

Observations, 06/13/2019 at 9:50 AM, revealed all 15 inpatients were sitting, lying or standing in the area referred to as the "day-room". According to the posted activity schedule, dated Thursday 6-13-2019, from 9:30-10:15 all inpatients were to be in a group titled "5-Step Grounding". Continued observations, 06/13/19 at 9:55 AM, revealed all patients were asked to go to the outside sitting area for activity therapy once the surveyor entered the area. Staff G was observed passing what seemed to be a form for the patients to sign. Observations continued until 10:15 AM at which time the patients returned to the inside. The total time for the scheduled 45 minute activity therapy group actually turned out to be 15 minutes. Staff #K was asked what the 5-Step Grounding group involved; Staff #K stated "I'm not certain".

Interview, 06/12/19 at 11:00 AM, with Staff #G revealed when asked what qualifications were required to be the therapeutic recreation activity director, Staff #G replied, "I have a bachelors degree in health science", but no therapeutic recreation education.

Interview, 06/13/2019 at 4:55 PM, with Staff #G revealed Staff #G was not a Therapeutic Activity Therapist but the duties included performance of patient assessments and conducting several activity groups daily Monday through Friday and alternated Saturdays with Staff # T. Staff #G stated her education was a Bachelor in Health Science and the Director of Nursing was her supervisor.

Staff #T was identified as the other provider of Therapeutic Activities and had the credentialing of Occupational Therapy Assistant (OTA). Review of Staff #T's information file revealed there lacked documented evidence of supervision by an Occupational Therapist, rather the Director of Nursing was the supervisor.

Reviews of Staff #G and T's information files revealed there lacked documentation of their competency to perform therapeutic activity assessments.

The hospital failed to provide qualified therapeutic activity therapists to address the individual needs of patients for 8 of 8 patients (#1-8). There lacked documented evidence that 1. regularly scheduled individualized activity therapies were available on Sundays and 2. the activity therapies provided during the week were provided under the supervision of a qualified Recreational Activity Therapist.

Interviews, 06/12/19 at 10:55 AM, with Staff #s A and B revealed they were not aware of the requirements for a therapeutic recreation activity director.

The hospital failed to ensure a therapeutic recreational activity director was hired or contracted to provide services required for patients to reach their individual optimal levels of functioning.

Based on observations, interviews and record reviews the hospital failed to:

I. Employ a sufficient number of qualified therapeutic activities staff to provide and document active treatment for 8 of 8 patients (#s 1-8). Specifically the hospital did not have a Therapeutic Activity Therapist to complete therapeutic activities assessments to ensure appropriate input into the formulation of the patients (#1-8) Individual Plan of Care/Integrated Service Plan, as well as offering therapeutic activities. This failure results in patients not receiving a full complement of therapies, patients not being properly assessed regarding needs and capabilities, and patients not receiving individualized and goal-directed therapeutic activities.

II. Provide documented evidence showing Staff # G and T's competency to provide therapeutic activity groups. This failure results in a lack of structured therapeutic activities provided by qualified staff, which potentially hampers patients' progress in obtaining their optimal level of functioning.

Findings:

Observations, 06/12/2019 at 10:50 AM, revealed inpatients were in the hospital gym and were encouraged to try and put the basketball into the net/hoop, and listening to the "radio".

Review of a patient schedule, dated Wednesday 6-12-2019, revealed "10:15-11:00 Interactive Recreation".

Observations, 06/13/2019 at 9:50 AM, revealed all 15 inpatients were sitting, lying or standing in the area referred to as the "day-room". According to the posted activity schedule, dated Thursday 6-13-2019, from 9:30-10:15 all inpatients were to be in a group titled "5-Step Grounding". Continued observations, 06/13/19 at 9:55 AM, revealed all patients were asked to go to the outside sitting area for activity therapy once the surveyor entered the area. Staff G was observed passing what seemed to be a form for the patients to sign. Observations continued until 10:15 AM at which time the patients returned to the inside. The total time for the scheduled 45 minute activity therapy group actually turned out to be 15 minutes. Staff #K was asked what the 5-Step Grounding group involved; Staff #K stated "I'm not certain".

Interview, 06/12/19 at 11:00 AM, with Staff #G revealed when asked what qualifications were required to be the therapeutic recreation activity director, Staff #G replied, "I have a bachelors degree in health science", but no therapeutic recreation education.

Interview, 06/13/2019 at 4:55 PM, with Staff #G revealed Staff #G was not a Therapeutic Activity Therapist but the duties included performance of patient assessments and conducting several activity groups daily Monday through Friday and alternated Saturdays with Staff # T. Staff #G stated her education was a Bachelor in Health Science and the Director of Nursing was her supervisor.

Staff #T was identified as the other provider of Therapeutic Activities and had the credentialing of Occupational Therapy Assistant (OTA). Review of Staff #T's information file revealed there lacked documented evidence of supervision by an Occupational Therapist, rather the Director of Nursing was the supervisor.

Reviews of Staff #G and T's information files revealed there lacked documentation of their competency to perform therapeutic activity assessments.

The hospital failed to provide qualified therapeutic activity therapists to address the individual needs of patients for 8 of 8 patients (#1-8). There lacked documented evidence that 1. regularly scheduled individualized activity therapies were available on Sundays and 2. the activity therapies provided during the week were provided under the supervision of a qualified Recreational Activity Therapist.

Interviews, 06/12/19 at 10:55 AM, with Staff #s A and B revealed they were not aware of the requirements for a therapeutic recreation activity director.

The hospital failed to ensure a therapeutic recreational activity director was hired or contracted to provide services required for patients to reach their individual optimal levels of functioning.