HospitalInspections.org

Based on MR review of 9 out of 9 out of a total of 30 MR reviewed (Pt.s # 3, 4, 15, 11, 20, 22, 23, 25, and 27), P/P review, and staff interview (B, C, D) this facility failed to ensure that Medicare recipients are notified of their discharge appeal rights by presenting them with the MDA form within 48 hours of admission and 48 hours of discharge. Failure to ensure Medicare recipients are informed of ther discharge appeal rights has the potential to affect all Medicare recipients receiving services from this facility.

Findings include:

Review on 3/27/13 in the AM titled Hospital Medicare Admission Information, dated 6/12, states under 1. "If patient is eligible for Medicare (upon admission or during course of stay) issue IM (MDA) to the beneficiary or his/her representative* if incompetent. Every effort should be made to ensure the client has comprehension of the contents of the notice...* NOTICE TO REPRESENTATIVE NON-PRESENT 1. When it is necessary to give IM notice to a Representative who can not be present in -person at the hospital within 2 days of admission or discharge- use the "Notice Delivery to Beneficiary's Representative form ES-42. Complete the form following the detailed instructions contained within."

An interview was conducted with ESC D, also a Clinical Social Worker, on 3/26/2013 at 2:11 p.m. regarding the MDA form. ESC D stated that Social Services/DCP does not get the MDA form signed on admission or discharge and thought maybe admitting staff did.

A MR review was conducted on Pt. #22's closed MR on 3/27/2013 at 8:45 a.m. Pt. #22 is a Medicare recipient and the MDA form is not signed by the Pt. within 48 hours of admission or discharge. Review of this finding was done with RN C on 3/27/2013 at 11:40 a.m. RN C acknowledged that these forms are not completed.

A MR review was conducted on Pt. #23's closed MR on 3/27/2013 at 9:40 a.m. Pt. #23 is a Medicare recipient and the MDA form is not signed by the Pt. within 48 hours of admission or discharge. Review of this finding was done with RN C on 3/27/2013 at 11:40 a.m. RN C acknowledged that these forms are not completed.



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Pt #3's MR review on 3/26/13 at 9:50 AM revealed Pt #3 is on Medicare and was admitted on 2/26/13. The MDA dated 2/26/13 states "unable to sign due to Guardian". There is no guardian signature acknowledging receipt of the MDA within 48 hours of admission. This is confirmed in interview with RN C on 3/26/13 at 4:45 PM.

Pt #4's MR review on 3/25/13 at 1:35 PM revealed Pt #4 admitted on 3/20/13 is on Medicare. There is no MDA in the MR with Pt signature acknowledging receipt of the MDA notice. This is confirmed in interview with RN C on 3/25/13 at 3:15 PM.

Pt #15's MR review on 3/26/13 at 12:40 PM revealed Pt #15 admitted on 3/25/13 is on Medicare. The MDA is dated 3/25/13 states "unable" in the Pt signature area. This is confirmed in interview with ESC D on 3/26/13 at 2:45 PM.

Pt #20's MR review on 3/26/13 at 11:50 AM revealed Pt #20 admitted on 1/27/13 is on Medicare. There is no MDA in the MR with Pt signature acknowledging receipt of the MDA notice. This is confirmed in interview with RN C on 3/26/13 at 4:45 PM.

Pt #25's MR review on 3/27/13 at 10:20 AM revealed Pt #25 admitted on 12/7/12 is on Medicare. There is no MDA in the MR with Pt signature acknowledging receipt of the MDA notice. This is confirmed in interview with RN B on 3/27/13 at 11:40 PM.





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Per MR review of Pt. #11 beginning at 3:17 p.m. on 3/26/13, Pt. #11 was admitted on n12/4/12 and discharged on 1/3/13. No IM (Important Message) from Medicare about rights form was found in the record. When this finding was discussed with Interim DON (Director of Nursing) B during an interview beginning at 11:40 a.m. on 3/27/13, B said, " Yes I see, it ' s the same with other records. "

Per MR review of Pt. #27 beginning at 10:20 a.m. on 3/27/13, Pt. #27 was admitted on 12/11/12 and discharged on 3/27/13. A 2 page IM form was found, but page 2 of the form for staff to sign and date initial and follow-up issuance was not signed and dated. The areas were left blank. During an interview with Interim DON B beginning at 11:40 a.m. on 3/27/13, when B was shown page 2 of the IM form B said, " Oh, that page did not get filled out. "

Based on MR review of 6 out of 30 MR reviewed (Pt.s #4, 16, 17, 18, 19, and 26), P/P review, and staff interview (U), this facility failed to obtain documentation in the MR regarding Advanced Directives. Failure to document information regarding Advanced Directives has the potential to affect all patients receiving care in this facility, including the 14 (averaged) patients present during the course of the survey.

Findings include:

Review on 3/27/13 in the AM of facility policy titled Advance Directives/Anatomical Gift Donation, dated 12/10, states under Inpatient Admission 1. "Determine the patient's Advance Directive/Anatomical Gift donation status on admission. 2. Document status on the Advance Directive Inventory Form 22 43."

An interview with MR staff U was done on 3/27/2013 at 10:50 a.m. U stated that the facility has paper copies of the AD information which was not provided with the rest of the MRs as requested and that the lack of disclosure of this information was an oversight by the facility staff.

Pt #4's MR review on 3/25/13 at 1:35 PM revealed Pt #4 was admitted on 3/20/13. There is no documentation of an AD in the MR. This is confirmed in interview with RN C on 3/25/13 at 3:15 PM.




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A MR review was conducted on Pt. #16's closed MR on 3/25/2013 at 2:45 p.m. There is no evidence provided that Pt. #16 was asked about Advanced Directives in the MR.

A MR review was conducted on Pt. #17's closed MR on 3/25/2013 at 3:20 p.m. There is no evidence provided that Pt. #17 was asked about Advanced Directives in the MR.

A MR review was conducted on Pt. #18's closed MR on 3/26/2013 at 11:43 a.m. There is no evidence provided that Pt. #18 was asked about Advanced Directives in the MR.

A MR review was conducted on Pt. #19's closed MR on 3/26/2013 at 2:53 p.m.. There is no evidence provided that Pt. #19 was asked about Advanced Directives in the MR.

A MR review was conducted on Pt. #26's closed MR on 3/27/2013 at 10:55 a.m. There is no evidence provided that Pt. #26 was asked about Advanced Directives in the MR.

Copies of the paper documents on AD data collection were obtained from Admin A on 3/27/2013 at 12:30 p.m. with the statement, "This is what we have."

The above patients did not have copies of this document provided prior to survey exit on 3/27/2013 at 1:00 p.m.

Based on tour and interview with staff, in 1 of 1 interview (G) the facility failed to ensure Pt bathrooms contain no hazards allowing for self harm. Failure to provide a safe environment for patients has the potential to affect all patients receiving treatment in this facility, including the 14 (averaged) patients at the time of the survey.

Findings include:

Per tour of the facility on 3/25/13 between 12:30 PM and 1:05 PM with RNs D and G, Pt room 113's bathroom has a grab bar, next to the toilet, that is not breakaway and allows for an item to be tied or hooked through, and a risk for potential self harm. Per interview with RN G on 3/25/13 at approximately 12:40 PM, RN G stated the grab bar had not been noticed prior to this tour, and agreed it could be a risk to Pts.

Based on MR review in 14 of 30 MR reviewed (Pt. #1, 2, 3, 4, 5, 6, 8, 9, 11, 13, 14, 19, 21 and 22) and 2 of 2 Staff interviews (B, C), this facility failed to develop a Care Plan/Treatment Plan (CP/TP) that was individualized to the needs of the patient and included problems specific to each patient. Failure to develop individualized CP/TP has the potential to affect all patients in the facility, including the 14 (averaged) patients during the course of the survey.

Findings include:

In an interview with RN C on 3/25/13 at 3:15 PM. when discussing the similarities of the care plan content despite different patient diagnoses, RN C agreed that CP/TPs appeared to be "canned" and were not individualized to each patient.

A MR review for Pt. #19 was completed on 3/26/2013 at 2:53 p.m. Pt #19 was admitted with a diagnosis of Pathological Gambling. The treatment plan does not address gambling. This finding was reviewed with Charge RN C on 3/27/2013 at 11:40 a.m. who stated that the treatment plan does not address Pt. #19's Pathological Gambling.

A MR review for Pt. #22 was completed on 3/27/2013 at 8:45 a.m. Pt #22 was admitted with a diagnosis of Seizure Disorder, among several other issues. The treatment plan does not address the seizure disorder. This finding was reviewed with Charge RN C on 3/27/2013 at 11:40 a.m. who stated that the treatment plan does not address Pt. #22's Seizure Disorder.


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Per interview with RN B on 3/25/13 at 3:15 PM RN B stated the CP/TPs for Pts #1 and 4 have different diagnoses and should have different CP/TPs. Per interview with RN B on 3/26/13 at 4:45 PM, RN B stated the CP/TPs for Pts #1, 2, 5, 13, 14 and 21 have identical CP/TPs for danger to self, and there should be unique goals and interventions for each Pt.

Pt #3's MR review on 3/26/13 at 9:50 AM reveals the CP/TPs for controlling aggressive behavior, no self harm and "free of wound dehiscence (reopening wound)" have no date, time or initials of initiation of interventions and no target dates. This is confirmed in interview with RN C on 3/26/13 at 4:45 PM.

Pt #4's MR review on 3/25/13 at 1:35 PM reveals the CP/TP for homicide ideations and coping plans, have identical interventions as Pt #1's, who has danger to self and coping plans, and are not unique to Pt #4's problems. This is confirmed in interview with RN C on 3/25/13 at 3:15 PM.

Pt #5's MR review on 3/26/13 at 2:45 PM revealed the CP/TP for danger to self is identical to Pt #1 and #2's CP/TP for danger to self, and not unique to Pt #5's problems. This is confirmed in interview with RN C on 3/26/13/ at 4:45 PM.

Pt #13's MR review on 3/26/13 at 1:00 PM revealed the CP/TP for danger to self is identical to Pt #1's and Pt #2's CP/TP for danger to self, and not unique to Pt #13's problems. This is confirmed in interview with RN C on 3/26/13 at 4:45 PM.

Pt #14's MR review on 3/26/13 at 12:30 PM revealed the CP/TP for danger to self is identical to Pt #1's and Pt #2's CP/TP for danger to self, and not unique to Pt #14's problems. This is confirmed in interview with RN C on 3/26/13 at 4:45 PM.

Pt #21's MR review on 3/27/13 at 1-0:00 AM revealed the CP/TP for danger to self is identical to Pt #1's and Pt #2's CP/TP for danger to self, and not unique to Pt #21's problems. This is confirmed in interview with RN B on 3/27/13 at 11:40 AM.


05409

Per MR review of Pt. #6 beginning at 1:05 p.m. on 3/25/13, #6 was admitted on 3/23/13. Physician orders reveal that at 8:50 a.m. on 3/23/13, a verbal order was obtained for a restraint chair for up to 4 hours for #6's verbal aggression and refusal to follow direction and resisting transport to unit. At 9:05 a.m. on 3/23/13 a verbal order for Haldol 5 mg and Ativan 4 mg was obtained for PT. #6's physical aggression, yelling at staff, and resisting staff. At 9:30 a.m. on 3/23/13, a verbal order was obtained to place Pt. #6 in the seclusion room for #6's verbal aggression, refusal to follow direction, and resisting staff. Review of progress notes for 3/23/13 and 3/24/13 reveal that #6 is refusing group activities.
The treatment plan which was completed on 3/24/13 has 1 problem identified, " Inability to care for self. "Pt. #6's aggressive and resistive behavior are not identified on the plan nor are the use of restraints and seclusion. The plan does not include a plan for activity attendance. The treatment plan is not individualized to meet the needs of Pt. #6. During interview with Interim DON B beginning at 11:40 a.m. on 3/27/13 when the treatment plan of Pt. #6 not being individualized was mentioned, B replied, " Yes, I see that. It ' s the same as other records. "


Per MR review of Pt. #8 beginning at 2:55 p.m. on 3/25/13, Pt. #8 was admitted on 3/18/13. According to the psychiatric evaluation completed on 3/20/13, Pt. #8 was hearing voices telling #8 to hit people. Verbalized, " Punch that guy over there. " Risk assessment reveals physical aggression. Treatment recommendations include controlling physically dangerous behavior with redirection, time out, voluntary seclusion, separation from peers, use of 2 five point restraints, and Haldol and Lorazepam for acute agitation.
Physician orders include 1:20 p.m. on 3/18/13: Haldol and Ativan (Lorazepam) for acute aggression. At 9:30 a.m. on 3/20/13: Restraint chair for up to 4 hours for acute agitation and aggression. The treatment plan completed on 3/18/13 with updates to present on 3/25/13 do not include the physical aggressive behaviors and use of medications and restraints. During interview with Interim DON B beginning at 11:40 a.m. on 3/27/13 when the treatment plan of Pt. #6 not being individualized was mentioned, B replied, " Yes, I see that. It ' s the same as other records. "

Per MR review of Pt. #9 beginning at 3:17 p.m. on 3/25/13, Pt. #9 was admitted on 3/18/13. According to the psychiatric evaluation completed on 3/19/13, Pt. #9 has impulsive travel, judgment impaired, and making poor decisions. There is concern about #9 ' s capacity to manage self-care safely and independently. Under Diagnosis Axis IV, it says, " Inadequate support network. " The treatment plan completed on 3/19/13 and with current updates on 3/25/13 reveal that the IV diagnosis is listed under the diagnoses, but the plan does not identify the problem of inadequate support network. There is no plan for appropriate support upon discharge. The plan does not identify the problem of incapacity to care for self independently. The treatment plan has 2 problems identified: Psychosis and compliance with medications. During an interview with Interim DON B beginning at 11:40 a.m. on 3/27/13, when informed treatment plan for Pt. #11 not complete/individualized, B said, "Yes, I see."


Per MR review of Pt. #11 beginning at 10:45 a.m. on 3/26/13, Pt. #11 was admitted on 12/4/12. According to the psychiatric examination completed on 12/5/12, Pt. #11 was unkempt and had considerable weight loss upon admission.
Review of the treatment plan originated on 12/4/12 with updates throughout stay ending on 1/3/13, reveals that unkemptness and weight loss are not identified on the treatment plan. During an interview with Interim DON B beginning at 11:40 a.m. on 3/27/13, when informed treatment plan for Pt. #11 not complete/individualized, B said, "Yes, I see."

Based on observation, review of P&P and interview with staff (H), in 1 of 2 staff observed performing medication passes (F) the facility failed to ensure aseptic technique and Pt identifiers when preparing and administering medication. Failure to follow safety precautions when administering medications has the potential to affect all patients in the facility including the 14 (averaged) patients present during the course of the survey.

Findings include:

Review of facility policy on 3/26/13 in the PM titled Medication -Administration, Allergies, and Occurrence Reporting dated 4/11, states under F. Medication Administration #4 "Identify the patient prior to medication administration by date of birth and picture ID or name band including date of birth compared to the medication administration record...7. "Crushing of medications is allowed based on patient need and in accordance with information from the Pharmacist that such crushing of a medication is allowed..."

Per observation on 3/25/13 at 3:40 PM, LPN F obtained a plastic coated capsule from the automated medication dispenser, removed the coating aseptically allowing the contents to drop in a medicine cup. LPN F proceeded to use the small end of the pestle, that was sitting in the mortar on top of the medication cart, and crushed the medication in the cup, replacing the pestle in the mortar without the benefit of cleaning the pestle prior to or after crushing the medication. LPN F finished preparing the medication with thicken liquids and entered Pt #3's room. Pt #3 is autistic, LPN F did not bring a photograph or look for wrist band to identify the Pt prior to giving the medication, rather stated Pt #3's first name. Pt #3 did not respond to the name, but cooperated with taking the medications.

LPN F returned to the medication room, washed, and obtained a medication for Pt # 7. LPN F walked up to Pt #7 in the day room, stated Pt #7's first name and did not ask for any further identification via the Pt nor photograph.

Per interview with Pharmacist H on 3/26/13 at 3:10 PM, Pharmacist H stated pills should be crushed using a small plastic bag and pulverizer, but did not provide a policy related to this expectation.

Based on 1 of 1 observation and 2 of 2 staff interviews (C and I) the facility failed to ensure MRs are kept secure and unavailable to unauthorized Pts, visitors and staff. Failure to secure MRs from unauthorized users has the potential to affect all patients recieivng care in the facility including the 14 (averaged) patients during the course of the survey.

Findings include:

Per interview with RN C on 3/27/13 at 11:00 AM, there is no policy addressing confidentiality of MRs in the hospital.

On 3/26/13 at 12:50 PM, MRs for Pts #2 and #15 were observed on a table in an unsecured meeting room next to the kitchenette. An attempt to lock the door by RN I was unsuccessful.

Per interview with RN I on 3/26/13 at 12:50 PM the door should be secure and records not left alone. Per interview with RN C on 3/27/13 at 11:00 AM the lock on the door to the meeting room was broken and staff should have known not to leave the MRs in an unsecured room.

Based on MR review, Medical Staff Rules and Regulations this facility failed to keep MRs that contained supporting documentation that would justify the patient's hospitalization evidenced by incomplete H&Ps in 10 out of 30 MR reviewed (Pt.s #1, 2, 4, 14, 16, 22, 26, 28, 29, and 30). Failure to complete documentation that would support hospitalization has the potential to affect all patients receiving care in the facility including the 14 (averaged) patients present during the course of the survey.

Findings include:

The Medical Staff Rules and Regs, dated October 2, 2008, were reviewed on 3/26/2013 in the a.m. Page 4 of the Rules and Regs states in part, "#10. Medical History and exam: Seven days prior to admission or within 24 hours of admission. Neurological exam, including cranial nerves, must be addressed in exam."

Page 6 of the Rules and Regs states in part, "A physical exam is required for all admissions within 24 hours of admission."

A MR review was conducted on Pt. #16's closed MR on 3/25/2013 at 2:45 p.m. Pt. #16 was admitted to the facility on 7/27/2012 and discharged on 7/30/2012. The medical H&P is incomplete and does not include current medical illnesses, past medical/surgical history, and psychiatric/mental status.

A MR review was conducted on Pt. #22's closed MR on 3/27/2013 at 8:45 a.m. On page 3 of 5 the ears, nose, throat, neck, and carotid arteries/pedal pulses are not remarked on making the H&P incomplete.

A MR review was conducted on Pt. #26's closed MR on 3/27/2013 at 10:12 a.m. Pt. #26 was admitted to the facility in a catatonic state (unresponsive) on 2/13/2013 and was discharged ambulatory and responsive on 2/21/2013. The medical H&P was not completed on admission due to Pt. #26 being unable to participate in questioning, and was not revisited for completion throughout Pt. #26's stay in the facility. The result of this was no medical H&P for this hospitalization.

A MR review was conducted on Pt. #30's closed MR on 3/30/2013 at 10 :55 a.m. Pt. #30 was admitted to the facility on 2/12/2013 and discharged on 2/27/2013. Upon admission Pt. #30 was not cooperative with the admission H&P and refused to allow it to be completed. There is no evidence of further attempts to complete the H&P at a later date. The result of this was an incomplete medical H&P for this hospitalization.

These findings, for Pt.s #16, 22, 26, and 30, were reviewed with RN C on 3/27/2013 at 11:40 a.m. who stated, "You are correct that was not completed," regarding completed information on the H&Ps.



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Pt #1's MR review on 3/25/13 at 1:10 PM revealed the H&P completed on 3/21/13 has for Review of Systems WNL (within normal limits) for Constitutional: "WNL denies all" with an arrow drawn down through the space to document results for Eyes, ENT (ear, nose, throat) Cardiovascular, Respiratory/allergies, Gastrointestinal, Endocrine, Hematology/Oncology, Urinary, Reproductive, Musculoskeletal and Skin. There is no documentation for Neurological or Psychiatric/Mental Status under Review of Systems. For Physical Examination, WNL for Eyes, with an arrow down through the space to document Ears, Nose and Throat. This is confirmed in interview with RN C on 3/25/13 at 2:25 PM.

Pt #2's MR review on 3/25/13 at 3:00 PM revealed the H&P completed on 3/21/13 has for Review of Systems WNL (within normal limits) for Constitutional: "WNL denies all" with an arrow drawn down through the space to document results for Eyes, ENT, Cardiovascular, Respiratory/allergies, Gastrointestinal, Endocrine, Hematology/Oncology, Urinary, Reproductive, Musculoskeletal and Skin. There is no documentation for Neurological or Psychiatric/Mental Status under Review of Systems. For Physical Examination, WNL for Eyes, with an arrow down through the space to document Ears, Nose and Throat. This is confirmed in interview with RN C on 3/25/13 at 3:15 PM.

Pt #4's MR review on 3/25/13 at 1:35 PM revealed the H&P completed on 3/21/13 has a line drawn down through "intact" for the cranial nerves II through XII rather than indicating individually if the testing was completed. This is confirmed in interview with RN B on 3/25/13 at 3:15 PM.

Pt #14's MR review on 3/26/13 at 11:50 AM revealed the H&P completed on 12/27/13 has no documentation the cranial nerves II, IV, VI, IX and X were tested. This is confirmed in interview with RN C on 3/26/13 at 4:45 PM.

Pt #28's MR review on 3/27/13 at 10:40 AM revealed the H&P completed on 1/7/13 has a line drawn down through "intact" for the cranial nerves II through XII rather than indicating individually if the testing was completed. This was confirmed in interview with RN A on 3/27/13 at 11:40 AM.

Pt #29's MR review on 3/27/13 at 11:00 AM revealed the H&P completed on 2/21/13 has for Review of Systems an arrow drawn down through the space to document results for Cardiovascular, Respiratory/allergies, Gastrointestinal, Endocrine, Hematology/Oncology, Urinary, Reproductive, Musculoskeletal and Skin. There is no documentation for Neurological or Psychiatric/Mental Status under Review of Systems. This is confirmed in interview with RN A on 3/27/13 at 11:40 PM.

Based on MR review, P/P review, Medical Staff Rules and Regulations (Regs) and 2 of 2 staff interviews (C, B) this facility failed to maintain MRs that are complete and legible in 13 out of 30 MR reviewed (Pt.s # 3, 5, 6, 7, 8, 9, 10, 11, 16, 17, 18, 20, and 24). Failure to keep complete and legible MRs has the potential to affect all patients receiving care in this facility including the 14 (averaged) patients present during the course of the survey.

Findings include:

The Medical Staff Rules and Regs, dated October 2, 2008, were reviewed on 3/26/2013 in the a.m. Page 2 states in part, "Orders written by the Physician or Advanced Practice Nurse Practitioner on the patient's chart must be time, dated, and authenticated."

The facility policy titled, "Physician Orders, Transcription and Faxing of Orders," dated April 2011, was reviewed on 3/27/2013 in the a.m. The policy states in part that approved providers should, "Write orders within the scope of practice on the physician order sheet to outline the plan of care for the patient, including the following:...date and time of the order...sign order, including title."

Review on 3/27/13 in the AM of facility policy titled Patient Monitoring in the Behavioral Health Hospital dated 7/12 states under 1.c. "...Indicate 15-minute, 30-minute, or Hourly observations on the left column of the form as assigned."

Review of the facility's policy titled, "Consent for Hospital Treatment & Acknowledgment of Presence," dated December 1, 2010, was reviewed on 3/26/2013 at 7:45 a.m. The policy states in part, "Present Consent for Treatment (form HS-16) to patients during the admission assessment when determined that inpatient admission is indicated....Have the patient sign with staff witness signature. Staff also witness-sign if an involuntary patient refuses to sign."

Review of the facility's policy titled, "Nursing History and Assessment," dated May 2011, was reviewed on 3/27/2013 at 3:30 p.m. The policy states in part, "Licensed Nurse 1. Complete Inpatient Nursing Assessment (HS-102) within 2-hours of admission to the unit. 2. address all areas, 3. Sign, date, and time after completion, 4. Include narratives, when needed."

Examples of monitoring Pts:
Pt #3's MR review on 3/26/13 at 9:50 AM revealed Pt #3 is on 15 minute checks for safety. The Patient Monitoring/Hourly Rounding Record for 3/11/13 has no documentation of Pt #3 whereabouts from 10:30 AM to 11:15 AM. This is confirmed in interview with RN C on 3/26/13 at 4:45 PM.

Pt #5's MR review on 3/26/13 at 2:45 PM revealed Pt #5 is on 15 minute checks for safety. The Patient Monitoring/Hourly Rounding Record for 3/25/13 has no documentation of of who was monitoring Pt #3's whereabouts from 7:30 AM to 8:45 AM. This is confirmed in interview with RN C on 3/25/13 at 3:15 PM.

Pt #20's MR review on 3/26/13 at 11:50 AM revealed Pt #20 is on 15 minute checks for safety. The Patient Monitoring/Hourly Rounding Record for 12/27/13 has no documentation of who was monitoring Pt #20 between 8:00 AM to 8:45 AM and 11:00 AM to 11:45 AM. This is confirmed in interview with RN C on 3/26/13 at 4:45 PM.





05409

Physician authentication not complete signature
Per MR review of Pt. #7 beginning at 2:00 p.m. on 3/25/13, review of the psychiatric examination completed on 3/18/13 reveals a curved letter resembling a G, and not a full signature.

Per interview with Interim DON B beginning at 11:40 a.m. on 3/27/13, when shown the signature, B said, "Yes, I see."


Per MR review of Pt. #8 beginning at 2:55 p.m. on 3/25/13, review of the psychiatric examination completed on 3/20/13 reveals that the physician signature is a curved letter resembling a G, and not a full signature.

Per interview with Interim DON B beginning at 11:40 a.m. on 3/27/13, when shown the signature, B said, "Yes, I see."

Per MR review of Pt. #9 beginning at 3:17 p.m. on 3/25/13, review of the psychiatric examination completed on 3/19/13 reveals a slanted vertical line for the physician signature and not a full signature.

Per interview with Interim DON B at 3:57 p.m. on 3/25/13 when B was shown the exam physician signature, B said, "Yes, I see that."

Per MR review of Pt. #10 beginning at 9:30 a.m. on 3/26/13, review of the psychiatric evaluation reveals the physician signed with a curved letter resembling a G and not a full signature.

Per interview with Interim DON B beginning at 11:40 a.m. on 3/27/13, when shown the signature, B said, "Yes, I see."

Per MR review of Pt. #11 beginning at 10:45 a.m. on 3/26/13, review of psychiatric examination completed on 12/6/12 reveals a single curved mark for a physician signature rather than a full physician signature.

Per interview with Interim DON B beginning at 11:40 a.m. on 3/27/13, when shown the signature, B said, "Yes, I see."

Per review of Pt. #24's MR beginning at 9:45 a.m. on 3/27/13, review of the psychiatric examination completed on 1/18/13 reveals a physician signature had a mark resembling an upside down comma and not a full physician signature.

Per interview with Interim DON B beginning at 11:40 a.m. on 3/27/13, when shown the signature, B said, "Yes, I see."


Lack of pt. signature
Per MR review of Pt. #6 beginning at 1:05 p.m. on 3/25/13 Pt. #6 was admitted on 3/23/13. The consent for treatment form was unsigned. Review of the personal possession/belongings form from admission revealed that Pt. #6 had not signed and dated the form.

Per interview with RN C at 1:50 p.m. on 3/25/13, when C was shown the lacking consent signature and the lacking signature on the personal belongings form C said, "We should have put that the pt. refused to sign it." RN C then checked the daily progress notes and said that the refusal to sign was not documented in the progress notes.


Per MR review of Pt. #8 beginning at 2:55 p.m. on 3/25/13, review of the personal belongings form reveals that Pt. #8 did not sign the form. There is no documentation to support that Pt. #8 refused to sign.

During an interview with Interim DON B beginning at 11:40 a.m. on 3/27/13, when shown the lack of signature, B said, "Yes, I see".



26711

Incomplete documentation
A MR review was conducted on Pt. #16's closed MR on 3/25/2013 at 2:45 p.m. There is a restraint order form that does not include the time the RN examining the patient documented the evaluation or the time the MD signed the restraint order form.. On 7/28/12 there are 3 MD orders that do not include the time they were written in the MR. Pt. #16's consent for inpatient care is not signed by the Pt. or a witness indicating that the content was discussed with Pt. #16. The discharge summary does not include a time the MD co-signed the document. An MD progress note dated 7/29/12 is not timed. The Activities Inventory list is not signed, dated, or timed by the staff who completed it. The Nursing History and Assessment multi-page form is incomplete on page 1, 2, 3, 1/2 of page 4, page 5 (this page has a notation "unable to complete on adm"), 6, and page 7 again indicates the patient was unable to answer questions at the time of admission. The Nursing History and Assessment was not re-visited resulting in none being completed for Pt. #16 during this admission.

A MR review was conducted on Pt. #17's closed MR on 3/25/2013 at 3:20 p.m. There is a restraint order form from 12/30/12 that is incomplete and does not include any information regarding the release of restraint/seclusion or the time the physician signed for the restraint to be discontinued. The restraint was discontinued on 12/30/12 at 5:00 a.m. and the release order was not signed by the MD until 1/3/2013.

A MR review was conducted on Pt. #18's closed MR on 3/26/2013 at 11:43 a.m. There are restraint order forms on 9/14/12, 9/16/12 (not signed until 9/19/12), 9/17/12, 9/19/12, and 9/20/12 that do not include the time the MD signed the release order for the restraint/seclusion.

In an interview with RN C on 3/27/2013 at 11:40 a.m. the findings for Pt. #16, 17 and 18 were discussed and RN C stated, "You are right, this is not completed."

Based on P/P review and MR review this facility failed to obtain MD authentication on VO/TO within stated policy guidelines (48 hours) in 8 out of 30 MR reviewed (Pt.s # 1, 2, 3, 4, 5, 6, 8, and 12). Failure to have properly authenticated VO/TO has the potential to affect all patients receiving care in this facility including the 14 (averaged) patients present during the course of the survey.

Findings include:

The Medical Staff Rules and Regs, dated October 2, 2008, were reviewed on 3/26/2013 in the a.m. Page 2 states in part, "All verbal and telephone orders must be authenticated, dated, and timed by the ordering provider, within 48 hours as outlined by State and Federal regulations." (at the time of the survey the facility did not have a variance granting 48 hours for verbal order authentication)

The facility policy titled, "Physician Orders, Transcription and Faxing of Orders," dated April 2011, was reviewed on 3/27/2013 in the a.m. The policy states in part, "Sign, date, and time telephone or verbal orders (limited to emergency or urgent situations) within 48 hours as required by state and federal regulations."

Physician verbal/telephone orders not dated and or timed when signed
Per MR review of Pt. #6 beginning at 1:05 p.m. on 3/25/13, review of physician orders reveal the following: On 3/23/13 4 verbal orders were not dated and timed when signed: an order for a restraint chair at 8:50 a.m., an order for Haldol and Ativan at 9:05 a.m., an order for seclusion at 9:30 a.m. and an order to give Haldol and Ativan at that time.

During interview beginning at 3:57 p.m. on 3/25/13 when Interim DON B was shown the 3/23/13 verbal orders, B said, "Yes" when asked if could see that the orders were not dated and timed.

Per MR review of Pt. #8 beginning at 2:55 p.m. on 3/25/13, Pt. #8 was admitted on 3/18/13. Review of physician orders reveal that on 3/18/13 a telephone order was obtained at 3:20 p.m. for Haldol and Ativan. The physician did not date and time when signing the order.

During interview beginning at 3:57 p.m. on 3/25/13 when Interim DON B was shown the 3/18/13 verbal orders, B said, "Yes" when asked if could see that the orders were not dated and timed.


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Examples of orders:

Pt #1's MR review on 3/25/13 at 1:10 PM revealed there is a VO written on 3/21/13 that is not authenticated by the MD. This is confirmed in interview with RN C on 3/25/13 at 3:15 PM.

Pt #2's MR review on 3/25/13 at 3:00 PM revealed there are TOs written on 3/21/13 that are not authenticated by the MD. This is confirmed in interview with RN C on 3/25/13 at 3:15 PM.

Pt #3's MR review on 3/26/13 at 9:50 AM revealed the admission orders are TOs written on 2/26/13 and are not authenticated by the MD. This is confirmed in interview with RN C on 3/26/13 at 4:45 PM.

Pt #4's MR review on 3/25/13 at 1:35 AM revealed the admission orders are TOs written on 3/19/13 and 3/20/13 that are not authenticated by the MD. This is confirmed in interview with RN C on 3/25/13 at 3:15 PM.

Pt #5's MR review on 3/26/13 at 2:15 PM revealed the admission orders are TOs written on 3/24/13 and are not authenticated by the MD. A TO written on 3/24/13 is not authenticated by the MD with a time. This is confirmed in interview with RN C on 3/25/13 at 2:15 PM.

Pt #12's MR review on 3/26/13 at 10:00 AM revealed there are VOs written on 3/25/13 that are not authenticated by the MD with a time. This is confirmed in interview with RN C on 3/26/13 at 4:45 PM.

Based on observation and 1 of 1 staff interview (A), this facility failed to ensure that all items on the emergency response cart are usable and have not expired. Failure to have usable items on the emergency response cart has the potential to affect all patients in need of these items, including the 14 (averaged) patients present during the time of the survey.

Findings include:

A tour of the Crisis Intervention office was completed on 3/26/2013 at 9:52 a.m. accompanied by Admin A.

The facility's emergency response cart is located in this area and was found to have glucose test strips which expired 6/30/12 and glucose control solution which expired 10/31/12.

Per interview with Admin A at the time of the observation, A stated, "that is clearly outdated." According to Admin A the emergency cart is checked daily and when asked if it was safe to say staff have not been checking the strips/solution daily Admin A responded, "yes."

Based on tour of the kitchen and inpatient unit, temperature log reviews, policy and procedure reviews, and 2 of 2 staff interviews (B, N), the facility failed to record cooler, freezer and dish washing temperatures as per policy. Ensure filters are changed when soiled.
Ensure 4 of 4 fans in the meat cooler are free of dust. Ensure that 2 of 3 walls in the small cart wash room are maintained such that surfaces can be cleaned and sanitized. Ensure that flooring in the chemical supply room are maintained such that surfaces can be cleaned and sanitized. Ensure that food in 1 of 1 kitchenettes on the unit had food substances dated. This has the potential to affect all 14 (averaged) of 14 Pts. in this 16 bed facility.

Findings include:

A tour of the kitchen from 11:30 a.m. to 12:25 p.m. on 3/26/13 revealed the following:

Surfaces that are not intact or clean
The meat cooler has 4 fans near the ceiling on the right side all of which are dirty with dust debris.
The chemical supply room has 8 chipped tiles and 10 cracked tiles which are not surfaces that can be properly cleaned or sanitized as are not intact.
The small cart wash room has 2 of the 3 walls in which paint is chipped off exposing bare cement walls which are not intact and cannot be properly cleaned or sanitized.
The filters over the grill are clogged and dirty with grease.

During the tour RD N nodded in agreement that the tiles were not intact when tiles were pointed out, RD N stated during the tour that the paint on the walls of the small cart wash room did not hold up as it was supposed to. During the tour RD N stated that housekeeping is responsible for changing the filters above the grill and stated that the filters should have been changed and were not.

Refrigerator temperatures
Facility policy dated 8/9/12 labeled "Safe Food Handling and Sanitation", states "Temperatures of all refrigerators, walk-in cooler, walk-in freezer will be recorded twice daily."

Per review of temperature logs beginning at 1:35 p.m. on 3/26/13 temperatures from 1/1/13 through 3/25/13 reveal the following:

On 1/3/13 the temperature of refrigerator #15 was not checked on the morning shift and the milk chest and refrigerator #2 temperatures were not checked on the afternoon shift.
On 1/8/13 the milk chest temperature was not checked on the morning shift.
On 1/26/13 refrigerator #16 temperature was not checked on the afternoon shift.
On 1/28/13 the milk chest temperature was not checked on the afternoon shift.
On 1/30/13 the milk chest temperature was not checked on the afternoon shift.
On 2/11/13 refrigerator #12 temperature was not checked on the afternoon shift.
On 2/12/13 the milk chest and refrigerator #11 temperatures were not checked on the afternoon shift.
On 3/3/13 the milk chest temperature was not checked on the morning shift.
On 3/19/13 the milk chest temperature was not checked on the afternoon shift.
On 3/21/13 the milk chest temperature was not checked on the afternoon shift.

Dish Washing Temperatures
Policy dated 8/9/12 entitled, "Safe Food Handling and Sanitation" states, that wash and rinse temperatures of the dish machine are to be recorded with each meal after the system has run for at least 10 minutes. Wash temperature, Rinse temperature, final rinse temperature, and pressure are 3 times per day.

Review of the dish machine temperature log beginning at 1:45 p.m. on 3/26/13, logs from 1/1/13 to 1/25/13 reveal the following:

On 1/9/13 the wash, rinse, final rinse, and pressure were not recorded with the noon and supper meals. On 1/13/13 the wash, rinse, final rinse, and pressure were not recorded at the breakfast meal. On 1/16/13 the wash, rinse, final rinse, and pressure were scribbled out as not done or not correct. On 1/26/13 the pressure was not checked at the noon meal.
On 2/1/13 the wash, rinse, final rinse, and pressure were not checked at the noon meal.
On 2/2/13 the wash, rinse, final rinse, and pressure were not checked at the breakfast and noon meals. On 2/3/13 the wash, rinse, final rinse, and pressure were not checked at the breakfast and supper meals. On 2/6/13 the wash, rinse, final rinse, and pressure were not checked at the supper meal. On 2/7/13 the wash, rinse, final rinse, and pressure were not checked at the noon meal. On 2/17/13 the wash, rinse, final rinse, and pressure were not checked at the breakfast and noon meals. On 2/19/13 the wash, rinse, final rinse, and pressure were not checked at the supper meal. On 2/21/13 the wash, rinse, final rinse, and pressure were not checked at the noon meal. On 3/5/13 the wash, rinse, final rinse, and pressure were not checked at the noon and supper meals. On 3/12/13 the wash, rinse, final rinse, and pressure were not checked at the supper meal. On 3/19/13 the wash, rinse, final rinse, and pressure were not checked at the supper meal.















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Review on 3/27/13 in the AM of facility policy title Refrigeration of Foods and Medications, dated 6/10, states on an attachment with a list of perishable and non-perishable foods the following: "Ice Cream 4 oz (ounce) container-1 month...Ready-to-Eat Deli-Foods Brought in by family, friends or ordered by resident-For example: potato or seafood salad, soups, prepared entrees-24 hours...Supplements Opened Containers-1 day."

Per tour of the facility on 3/24/13 at 1:00 PM, with RN B, the kitchenette refrigerator contained 3 Styrofoam containers of food, and six plastic containers of food items with Pt names and no date to monitor for discard. The freezer contained undated ice cream in single serve size and an open gallon of ice cream with no open date. There is an open bag of potato chips in the upper cupboard next to the refrigerator. In interview on 3/25/13 at 1:00 PM, RN B stated the food in the Styrofoam container is brought from home and the other food is used for a Pt that requires thickened food, and agreed all the containers of food should be labeled with a date.

Based on policy and procedure reviews, and 2 of 2 staff interviews (C, N), the facility failed to ensure that a medical director approved diet manual is available for use. This has the potential to affect all 14 (averaged) of 14 Pts. in this 16 bed facility.

Findings include:

During an interview with RD N beginning at 1:10 p.m. on 3/26/13, RD was asked about a diet manual approved by the medical director and stated that there are diet manuals available for reference including (other hospitals) and thinks there may be a binder in the food supervisor's office, but the supervisor is on vacation and does not have access to the office. When asked where the menus used came from, RD N said that the RD staff made them up and they were not taken form a manual. Per RD N there is a typed sheet with special diets that staff can follow.

Per interview with RN C beginning at 9:10 a.m. on 3/27/13, when C was asked where a dietary manual was for staff use on the unit, C replied, "I don't know." RN C stated that the facility does not have a diet manual on the unit for special diets.

On the morning of 3/27/13, policy dated 8/9/12 labeled "Diet Manual and Diet Order Terminology", states under diet terminology what general, mechanical soft, pureed, renal, cardiac, consistent carbohydrate, and 1400 calorie diet mean,what supplements, thickened fluids, fluid restriction, and liberalize means. This is not a diet manual to use for reference for specific needs. There is no definition of what a gluten free diet is.

Based on tour and observation, staff interview, and record review, this hospital failed to maintain a safe and secure building. This deficiency has the potential to affect all patients, staff and visitors.

Findings include:

K25: Smoke Compartment walls and doors were not smoke tight w/ratings.
K41: There was not a door from the sleeping room to a corridor or have a door leading directly to grade.
K56: Sprinkler system was not compliant to NFPA 13 minimum standards.
K67: The HVAC system did not meet the minimum standards on NFPA 90A

Please refer to the full description and findings within the specific K-tag deficiencies within the appropriate building found later in this report.

The cumulative effect of these deficiencies has the potential to affect the safety of all patients receiving services at the hospital.

Based on tour and observation, staff interview, and record review, this hospital failed to maintain a safe and secure building. This deficiency has the potential to affect all patients, staff and visitors.

Findings include:

K25: Smoke Compartment walls and doors were not smoke tight w/ratings.
K41: There was not a door from the sleeping room to a corridor or have a door leading directly to grade.
K56: Sprinkler system was not compliant to NFPA 13 minimum standards.
K67: The HVAC system did not meet the minimum standards on NFPA 90A

Please refer to the full description and findings within the specific K-tag deficiencies within the appropriate building found later in this report.

The cumulative effect of these deficiencies has the potential to affect the safety of all patients receiving services at the hospital.

Based on MR reviews, 1 out of 1 staff interview (D) and P/P review this facility failed to demonstrate an effective DCP process as evidenced by lack of ongoing DCP documentation in 24 out of 24 MR's reviewed of Pt's requiring DCP (Pt's #1, 2, 3, 4, 6, 7, 8, 9, 10, 11, 16, 17, 18, 19, and 21-30) out of a total of 30 MR reviewed. Failure to demonstrate an effective DCP process has the potential to affect all patients receiving care in this facility, including 14 (averaged) patients present during the course of this survey.

Findings include:

1. The facility failed to document on-going discharge planning for their vulnerable patient population (see tag 806).




The cumulative affect of this deficiency has the potential to affect all patients in this facility.

Based on MR reviews, 2 out of 2 staff interviews (D, S) and P/P review this facility failed to document DCP which would include discussing the plan with the patient, reassessing the discharge plan, and counseling the patient to prepare them for post-discharge care on an ongoing basis in 24 out of 24 MR's reviewed of Pt's requiring DCP (Pt's #1, 2, 3, 4, 6, 7, 8, 9, 10, 11, 16, 17, 18, 19, and 21-30) out of a total of 30 MR reviewed. Failure to document DCP has the potential to affect all patients receiving care in this facility, including the 14 (averaged) patients present during the course of this survey.

Findings include;

The facility policy titled, "Clinical Protocol for Discharge/Discharge Planning Evaluation," dated October 2010, was reviewed on 3/27/2013 at 10:30 a.m. The policy states in part on page 2, "The Discharge plan should be documented in the clinical notes which include the existence of a plan and what steps were taken to implement the plan."

MR reviews were conducted on Pt.s 1-30's open and closed MRs from 3/25/2013 at approximately 2:30 p.m.-4:00 p.m., on 3/26/2013 from approximately 9:00 a.m.-4:00 p.m. and on 3/27/2013 from approximately 9:00 a.m.-11:15 a.m.

There is no evidence in the MR of documented DCP throughout the Pt stays for Pt's #1, 2, 3, 4, 6, 7, 8, 9, 10, 11, 16, 17, 18, 19, and 21-30.

Per interview with SW S on 3/25/13 at 2:25 PM, there is no documentation in the MRs of discharge planning.

An interview with ESC D was conducted on 3/26/2013 at 2:11 p.m. When asked where DCP's document their involvement with patients for DCP activities in the medical record ESC D responded, "We don't, if we did it would be on a progress note."

Based on 1 of 1 staff interview (A) and P/P review, this facility failed to ensure they had trained designated requesters to approach patients/families for requesting organ and/or tissue donation. Failure to have trained designated requesters has the potential to affect all patients/families who are approached for possible donation, including the 14 (averaged) patients during the course of the survey.

Findings include:

The facility policy titled, "Advanced Directives/Anatomical Gift Donation," dated December 2011, was reviewed on 3/26/2013 at 8:29 a.m. The policy states in part on page 3, "Designated Requestor-a staff member or physician who has been formerly trained and certified by the Organ Procurement training team to approach patients or the patient's family/guardian concerning anatomomical gift donation."

In an interview with Admin A on 3/26/2013 at 8:06 a.m., when asked who would approach the family regarding donation in the event of death, Admin A responded that the nursing staff would approach the family.

Admin A went on to say that staff are trained in the basics for approaching families regarding organ donation in orientation by the lead nurse, however there will be no records of this training.

Admin A was unaware that designated requesters had to be formerly trained by the OPO and stated that none of the staff has had this training.

Based on MR review of 9 out of 9 out of a total of 30 MR reviewed (Pt.s # 3, 4, 15, 11, 20, 22, 23, 25, and 27), P/P review, and staff interview (B, C, D) this facility failed to ensure that Medicare recipients are notified of their discharge appeal rights by presenting them with the MDA form within 48 hours of admission and 48 hours of discharge. Failure to ensure Medicare recipients are informed of ther discharge appeal rights has the potential to affect all Medicare recipients receiving services from this facility.

Findings include:

Review on 3/27/13 in the AM titled Hospital Medicare Admission Information, dated 6/12, states under 1. "If patient is eligible for Medicare (upon admission or during course of stay) issue IM (MDA) to the beneficiary or his/her representative* if incompetent. Every effort should be made to ensure the client has comprehension of the contents of the notice...* NOTICE TO REPRESENTATIVE NON-PRESENT 1. When it is necessary to give IM notice to a Representative who can not be present in -person at the hospital within 2 days of admission or discharge- use the "Notice Delivery to Beneficiary's Representative form ES-42. Complete the form following the detailed instructions contained within."

An interview was conducted with ESC D, also a Clinical Social Worker, on 3/26/2013 at 2:11 p.m. regarding the MDA form. ESC D stated that Social Services/DCP does not get the MDA form signed on admission or discharge and thought maybe admitting staff did.

A MR review was conducted on Pt. #22's closed MR on 3/27/2013 at 8:45 a.m. Pt. #22 is a Medicare recipient and the MDA form is not signed by the Pt. within 48 hours of admission or discharge. Review of this finding was done with RN C on 3/27/2013 at 11:40 a.m. RN C acknowledged that these forms are not completed.

A MR review was conducted on Pt. #23's closed MR on 3/27/2013 at 9:40 a.m. Pt. #23 is a Medicare recipient and the MDA form is not signed by the Pt. within 48 hours of admission or discharge. Review of this finding was done with RN C on 3/27/2013 at 11:40 a.m. RN C acknowledged that these forms are not completed.



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Pt #3's MR review on 3/26/13 at 9:50 AM revealed Pt #3 is on Medicare and was admitted on 2/26/13. The MDA dated 2/26/13 states "unable to sign due to Guardian". There is no guardian signature acknowledging receipt of the MDA within 48 hours of admission. This is confirmed in interview with RN C on 3/26/13 at 4:45 PM.

Pt #4's MR review on 3/25/13 at 1:35 PM revealed Pt #4 admitted on 3/20/13 is on Medicare. There is no MDA in the MR with Pt signature acknowledging receipt of the MDA notice. This is confirmed in interview with RN C on 3/25/13 at 3:15 PM.

Pt #15's MR review on 3/26/13 at 12:40 PM revealed Pt #15 admitted on 3/25/13 is on Medicare. The MDA is dated 3/25/13 states "unable" in the Pt signature area. This is confirmed in interview with ESC D on 3/26/13 at 2:45 PM.

Pt #20's MR review on 3/26/13 at 11:50 AM revealed Pt #20 admitted on 1/27/13 is on Medicare. There is no MDA in the MR with Pt signature acknowledging receipt of the MDA notice. This is confirmed in interview with RN C on 3/26/13 at 4:45 PM.

Pt #25's MR review on 3/27/13 at 10:20 AM revealed Pt #25 admitted on 12/7/12 is on Medicare. There is no MDA in the MR with Pt signature acknowledging receipt of the MDA notice. This is confirmed in interview with RN B on 3/27/13 at 11:40 PM.





05409


Per MR review of Pt. #11 beginning at 3:17 p.m. on 3/26/13, Pt. #11 was admitted on n12/4/12 and discharged on 1/3/13. No IM (Important Message) from Medicare about rights form was found in the record. When this finding was discussed with Interim DON (Director of Nursing) B during an interview beginning at 11:40 a.m. on 3/27/13, B said, " Yes I see, it ' s the same with other records. "

Per MR review of Pt. #27 beginning at 10:20 a.m. on 3/27/13, Pt. #27 was admitted on 12/11/12 and discharged on 3/27/13. A 2 page IM form was found, but page 2 of the form for staff to sign and date initial and follow-up issuance was not signed and dated. The areas were left blank. During an interview with Interim DON B beginning at 11:40 a.m. on 3/27/13, when B was shown page 2 of the IM form B said, " Oh, that page did not get filled out. "

Based on MR review of 6 out of 30 MR reviewed (Pt.s #4, 16, 17, 18, 19, and 26), P/P review, and staff interview (U), this facility failed to obtain documentation in the MR regarding Advanced Directives. Failure to document information regarding Advanced Directives has the potential to affect all patients receiving care in this facility, including the 14 (averaged) patients present during the course of the survey.

Findings include:

Review on 3/27/13 in the AM of facility policy titled Advance Directives/Anatomical Gift Donation, dated 12/10, states under Inpatient Admission 1. "Determine the patient's Advance Directive/Anatomical Gift donation status on admission. 2. Document status on the Advance Directive Inventory Form 22 43."

An interview with MR staff U was done on 3/27/2013 at 10:50 a.m. U stated that the facility has paper copies of the AD information which was not provided with the rest of the MRs as requested and that the lack of disclosure of this information was an oversight by the facility staff.

Pt #4's MR review on 3/25/13 at 1:35 PM revealed Pt #4 was admitted on 3/20/13. There is no documentation of an AD in the MR. This is confirmed in interview with RN C on 3/25/13 at 3:15 PM.




26711

A MR review was conducted on Pt. #16's closed MR on 3/25/2013 at 2:45 p.m. There is no evidence provided that Pt. #16 was asked about Advanced Directives in the MR.

A MR review was conducted on Pt. #17's closed MR on 3/25/2013 at 3:20 p.m. There is no evidence provided that Pt. #17 was asked about Advanced Directives in the MR.

A MR review was conducted on Pt. #18's closed MR on 3/26/2013 at 11:43 a.m. There is no evidence provided that Pt. #18 was asked about Advanced Directives in the MR.

A MR review was conducted on Pt. #19's closed MR on 3/26/2013 at 2:53 p.m.. There is no evidence provided that Pt. #19 was asked about Advanced Directives in the MR.

A MR review was conducted on Pt. #26's closed MR on 3/27/2013 at 10:55 a.m. There is no evidence provided that Pt. #26 was asked about Advanced Directives in the MR.

Copies of the paper documents on AD data collection were obtained from Admin A on 3/27/2013 at 12:30 p.m. with the statement, "This is what we have."

The above patients did not have copies of this document provided prior to survey exit on 3/27/2013 at 1:00 p.m.

Based on tour and interview with staff, in 1 of 1 interview (G) the facility failed to ensure Pt bathrooms contain no hazards allowing for self harm. Failure to provide a safe environment for patients has the potential to affect all patients receiving treatment in this facility, including the 14 (averaged) patients at the time of the survey.

Findings include:

Per tour of the facility on 3/25/13 between 12:30 PM and 1:05 PM with RNs D and G, Pt room 113's bathroom has a grab bar, next to the toilet, that is not breakaway and allows for an item to be tied or hooked through, and a risk for potential self harm. Per interview with RN G on 3/25/13 at approximately 12:40 PM, RN G stated the grab bar had not been noticed prior to this tour, and agreed it could be a risk to Pts.

Based on MR review in 14 of 30 MR reviewed (Pt. #1, 2, 3, 4, 5, 6, 8, 9, 11, 13, 14, 19, 21 and 22) and 2 of 2 Staff interviews (B, C), this facility failed to develop a Care Plan/Treatment Plan (CP/TP) that was individualized to the needs of the patient and included problems specific to each patient. Failure to develop individualized CP/TP has the potential to affect all patients in the facility, including the 14 (averaged) patients during the course of the survey.

Findings include:

In an interview with RN C on 3/25/13 at 3:15 PM. when discussing the similarities of the care plan content despite different patient diagnoses, RN C agreed that CP/TPs appeared to be "canned" and were not individualized to each patient.

A MR review for Pt. #19 was completed on 3/26/2013 at 2:53 p.m. Pt #19 was admitted with a diagnosis of Pathological Gambling. The treatment plan does not address gambling. This finding was reviewed with Charge RN C on 3/27/2013 at 11:40 a.m. who stated that the treatment plan does not address Pt. #19's Pathological Gambling.

A MR review for Pt. #22 was completed on 3/27/2013 at 8:45 a.m. Pt #22 was admitted with a diagnosis of Seizure Disorder, among several other issues. The treatment plan does not address the seizure disorder. This finding was reviewed with Charge RN C on 3/27/2013 at 11:40 a.m. who stated that the treatment plan does not address Pt. #22's Seizure Disorder.


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Per interview with RN B on 3/25/13 at 3:15 PM RN B stated the CP/TPs for Pts #1 and 4 have different diagnoses and should have different CP/TPs. Per interview with RN B on 3/26/13 at 4:45 PM, RN B stated the CP/TPs for Pts #1, 2, 5, 13, 14 and 21 have identical CP/TPs for danger to self, and there should be unique goals and interventions for each Pt.

Pt #3's MR review on 3/26/13 at 9:50 AM reveals the CP/TPs for controlling aggressive behavior, no self harm and "free of wound dehiscence (reopening wound)" have no date, time or initials of initiation of interventions and no target dates. This is confirmed in interview with RN C on 3/26/13 at 4:45 PM.

Pt #4's MR review on 3/25/13 at 1:35 PM reveals the CP/TP for homicide ideations and coping plans, have identical interventions as Pt #1's, who has danger to self and coping plans, and are not unique to Pt #4's problems. This is confirmed in interview with RN C on 3/25/13 at 3:15 PM.

Pt #5's MR review on 3/26/13 at 2:45 PM revealed the CP/TP for danger to self is identical to Pt #1 and #2's CP/TP for danger to self, and not unique to Pt #5's problems. This is confirmed in interview with RN C on 3/26/13/ at 4:45 PM.

Pt #13's MR review on 3/26/13 at 1:00 PM revealed the CP/TP for danger to self is identical to Pt #1's and Pt #2's CP/TP for danger to self, and not unique to Pt #13's problems. This is confirmed in interview with RN C on 3/26/13 at 4:45 PM.

Pt #14's MR review on 3/26/13 at 12:30 PM revealed the CP/TP for danger to self is identical to Pt #1's and Pt #2's CP/TP for danger to self, and not unique to Pt #14's problems. This is confirmed in interview with RN C on 3/26/13 at 4:45 PM.

Pt #21's MR review on 3/27/13 at 1-0:00 AM revealed the CP/TP for danger to self is identical to Pt #1's and Pt #2's CP/TP for danger to self, and not unique to Pt #21's problems. This is confirmed in interview with RN B on 3/27/13 at 11:40 AM.


05409

Per MR review of Pt. #6 beginning at 1:05 p.m. on 3/25/13, #6 was admitted on 3/23/13. Physician orders reveal that at 8:50 a.m. on 3/23/13, a verbal order was obtained for a restraint chair for up to 4 hours for #6's verbal aggression and refusal to follow direction and resisting transport to unit. At 9:05 a.m. on 3/23/13 a verbal order for Haldol 5 mg and Ativan 4 mg was obtained for PT. #6's physical aggression, yelling at staff, and resisting staff. At 9:30 a.m. on 3/23/13, a verbal order was obtained to place Pt. #6 in the seclusion room for #6's verbal aggression, refusal to follow direction, and resisting staff. Review of progress notes for 3/23/13 and 3/24/13 reveal that #6 is refusing group activities.
The treatment plan which was completed on 3/24/13 has 1 problem identified, " Inability to care for self. "Pt. #6's aggressive and resistive behavior are not identified on the plan nor are the use of restraints and seclusion. The plan does not include a plan for activity attendance. The treatment plan is not individualized to meet the needs of Pt. #6. During interview with Interim DON B beginning at 11:40 a.m. on 3/27/13 when the treatment plan of Pt. #6 not being individualized was mentioned, B replied, " Yes, I see that. It ' s the same as other records. "


Per MR review of Pt. #8 beginning at 2:55 p.m. on 3/25/13, Pt. #8 was admitted on 3/18/13. According to the psychiatric evaluation completed on 3/20/13, Pt. #8 was hearing voices telling #8 to hit people. Verbalized, " Punch that guy over there. " Risk assessment reveals physical aggression. Treatment recommendations include controlling physically dangerous behavior with redirection, time out, voluntary seclusion, separation from peers, use of 2 five point restraints, and Haldol and Lorazepam for acute agitation.
Physician orders include 1:20 p.m. on 3/18/13: Haldol and Ativan (Lorazepam) for acute aggression. At 9:30 a.m. on 3/20/13: Restraint chair for up to 4 hours for acute agitation and aggression. The treatment plan completed on 3/18/13 with updates to present on 3/25/13 do not include the physical aggressive behaviors and use of medications and restraints. During interview with Interim DON B beginning at 11:40 a.m. on 3/27/13 when the treatment plan of Pt. #6 not being individualized was mentioned, B replied, " Yes, I see that. It ' s the same as other records. "

Per MR review of Pt. #9 beginning at 3:17 p.m. on 3/25/13, Pt. #9 was admitted on 3/18/13. According to the psychiatric evaluation completed on 3/19/13, Pt. #9 has impulsive travel, judgment impaired, and making poor decisions. There is concern about #9 ' s capacity to manage self-care safely and independently. Under Diagnosis Axis IV, it says, " Inadequate support network. " The treatment plan completed on 3/19/13 and with current updates on 3/25/13 reveal that the IV diagnosis is listed under the diagnoses, but the plan does not identify the problem of inadequate support network. There is no plan for appropriate support upon discharge. The plan does not identify the problem of incapacity to care for self independently. The treatment plan has 2 problems identified: Psychosis and compliance with medications. During an interview with Interim DON B beginning at 11:40 a.m. on 3/27/13, when informed treatment plan for Pt. #11 not complete/individualized, B said, "Yes, I see."


Per MR review of Pt. #11 beginning at 10:45 a.m. on 3/26/13, Pt. #11 was admitted on 12/4/12. According to the psychiatric examination completed on 12/5/12, Pt. #11 was unkempt and had considerable weight loss upon admission.
Review of the treatment plan originated on 12/4/12 with updates throughout stay ending on 1/3/13, reveals that unkemptness and weight loss are not identified on the treatment plan. During an interview with Interim DON B beginning at 11:40 a.m. on 3/27/13, when informed treatment plan for Pt. #11 not complete/individualized, B said, "Yes, I see."

Based on observation, review of P&P and interview with staff (H), in 1 of 2 staff observed performing medication passes (F) the facility failed to ensure aseptic technique and Pt identifiers when preparing and administering medication. Failure to follow safety precautions when administering medications has the potential to affect all patients in the facility including the 14 (averaged) patients present during the course of the survey.

Findings include:

Review of facility policy on 3/26/13 in the PM titled Medication -Administration, Allergies, and Occurrence Reporting dated 4/11, states under F. Medication Administration #4 "Identify the patient prior to medication administration by date of birth and picture ID or name band including date of birth compared to the medication administration record...7. "Crushing of medications is allowed based on patient need and in accordance with information from the Pharmacist that such crushing of a medication is allowed..."

Per observation on 3/25/13 at 3:40 PM, LPN F obtained a plastic coated capsule from the automated medication dispenser, removed the coating aseptically allowing the contents to drop in a medicine cup. LPN F proceeded to use the small end of the pestle, that was sitting in the mortar on top of the medication cart, and crushed the medication in the cup, replacing the pestle in the mortar without the benefit of cleaning the pestle prior to or after crushing the medication. LPN F finished preparing the medication with thicken liquids and entered Pt #3's room. Pt #3 is autistic, LPN F did not bring a photograph or look for wrist band to identify the Pt prior to giving the medication, rather stated Pt #3's first name. Pt #3 did not respond to the name, but cooperated with taking the medications.

LPN F returned to the medication room, washed, and obtained a medication for Pt # 7. LPN F walked up to Pt #7 in the day room, stated Pt #7's first name and did not ask for any further identification via the Pt nor photograph.

Per interview with Pharmacist H on 3/26/13 at 3:10 PM, Pharmacist H stated pills should be crushed using a small plastic bag and pulverizer, but did not provide a policy related to this expectation.

Based on 1 of 1 observation and 2 of 2 staff interviews (C and I) the facility failed to ensure MRs are kept secure and unavailable to unauthorized Pts, visitors and staff. Failure to secure MRs from unauthorized users has the potential to affect all patients recieivng care in the facility including the 14 (averaged) patients during the course of the survey.

Findings include:

Per interview with RN C on 3/27/13 at 11:00 AM, there is no policy addressing confidentiality of MRs in the hospital.

On 3/26/13 at 12:50 PM, MRs for Pts #2 and #15 were observed on a table in an unsecured meeting room next to the kitchenette. An attempt to lock the door by RN I was unsuccessful.

Per interview with RN I on 3/26/13 at 12:50 PM the door should be secure and records not left alone. Per interview with RN C on 3/27/13 at 11:00 AM the lock on the door to the meeting room was broken and staff should have known not to leave the MRs in an unsecured room.

Based on MR review, Medical Staff Rules and Regulations this facility failed to keep MRs that contained supporting documentation that would justify the patient's hospitalization evidenced by incomplete H&Ps in 10 out of 30 MR reviewed (Pt.s #1, 2, 4, 14, 16, 22, 26, 28, 29, and 30). Failure to complete documentation that would support hospitalization has the potential to affect all patients receiving care in the facility including the 14 (averaged) patients present during the course of the survey.

Findings include:

The Medical Staff Rules and Regs, dated October 2, 2008, were reviewed on 3/26/2013 in the a.m. Page 4 of the Rules and Regs states in part, "#10. Medical History and exam: Seven days prior to admission or within 24 hours of admission. Neurological exam, including cranial nerves, must be addressed in exam."

Page 6 of the Rules and Regs states in part, "A physical exam is required for all admissions within 24 hours of admission."

A MR review was conducted on Pt. #16's closed MR on 3/25/2013 at 2:45 p.m. Pt. #16 was admitted to the facility on 7/27/2012 and discharged on 7/30/2012. The medical H&P is incomplete and does not include current medical illnesses, past medical/surgical history, and psychiatric/mental status.

A MR review was conducted on Pt. #22's closed MR on 3/27/2013 at 8:45 a.m. On page 3 of 5 the ears, nose, throat, neck, and carotid arteries/pedal pulses are not remarked on making the H&P incomplete.

A MR review was conducted on Pt. #26's closed MR on 3/27/2013 at 10:12 a.m. Pt. #26 was admitted to the facility in a catatonic state (unresponsive) on 2/13/2013 and was discharged ambulatory and responsive on 2/21/2013. The medical H&P was not completed on admission due to Pt. #26 being unable to participate in questioning, and was not revisited for completion throughout Pt. #26's stay in the facility. The result of this was no medical H&P for this hospitalization.

A MR review was conducted on Pt. #30's closed MR on 3/30/2013 at 10 :55 a.m. Pt. #30 was admitted to the facility on 2/12/2013 and discharged on 2/27/2013. Upon admission Pt. #30 was not cooperative with the admission H&P and refused to allow it to be completed. There is no evidence of further attempts to complete the H&P at a later date. The result of this was an incomplete medical H&P for this hospitalization.

These findings, for Pt.s #16, 22, 26, and 30, were reviewed with RN C on 3/27/2013 at 11:40 a.m. who stated, "You are correct that was not completed," regarding completed information on the H&Ps.



18816


Pt #1's MR review on 3/25/13 at 1:10 PM revealed the H&P completed on 3/21/13 has for Review of Systems WNL (within normal limits) for Constitutional: "WNL denies all" with an arrow drawn down through the space to document results for Eyes, ENT (ear, nose, throat) Cardiovascular, Respiratory/allergies, Gastrointestinal, Endocrine, Hematology/Oncology, Urinary, Reproductive, Musculoskeletal and Skin. There is no documentation for Neurological or Psychiatric/Mental Status under Review of Systems. For Physical Examination, WNL for Eyes, with an arrow down through the space to document Ears, Nose and Throat. This is confirmed in interview with RN C on 3/25/13 at 2:25 PM.

Pt #2's MR review on 3/25/13 at 3:00 PM revealed the H&P completed on 3/21/13 has for Review of Systems WNL (within normal limits) for Constitutional: "WNL denies all" with an arrow drawn down through the space to document results for Eyes, ENT, Cardiovascular, Respiratory/allergies, Gastrointestinal, Endocrine, Hematology/Oncology, Urinary, Reproductive, Musculoskeletal and Skin. There is no documentation for Neurological or Psychiatric/Mental Status under Review of Systems. For Physical Examination, WNL for Eyes, with an arrow down through the space to document Ears, Nose and Throat. This is confirmed in interview with RN C on 3/25/13 at 3:15 PM.

Pt #4's MR review on 3/25/13 at 1:35 PM revealed the H&P completed on 3/21/13 has a line drawn down through "intact" for the cranial nerves II through XII rather than indicating individually if the testing was completed. This is confirmed in interview with RN B on 3/25/13 at 3:15 PM.

Pt #14's MR review on 3/26/13 at 11:50 AM revealed the H&P completed on 12/27/13 has no documentation the cranial nerves II, IV, VI, IX and X were tested. This is confirmed in interview with RN C on 3/26/13 at 4:45 PM.

Pt #28's MR review on 3/27/13 at 10:40 AM revealed the H&P completed on 1/7/13 has a line drawn down through "intact" for the cranial nerves II through XII rather than indicating individually if the testing was completed. This was confirmed in interview with RN A on 3/27/13 at 11:40 AM.

Pt #29's MR review on 3/27/13 at 11:00 AM revealed the H&P completed on 2/21/13 has for Review of Systems an arrow drawn down through the space to document results for Cardiovascular, Respiratory/allergies, Gastrointestinal, Endocrine, Hematology/Oncology, Urinary, Reproductive, Musculoskeletal and Skin. There is no documentation for Neurological or Psychiatric/Mental Status under Review of Systems. This is confirmed in interview with RN A on 3/27/13 at 11:40 PM.

Based on MR review, P/P review, Medical Staff Rules and Regulations (Regs) and 2 of 2 staff interviews (C, B) this facility failed to maintain MRs that are complete and legible in 13 out of 30 MR reviewed (Pt.s # 3, 5, 6, 7, 8, 9, 10, 11, 16, 17, 18, 20, and 24). Failure to keep complete and legible MRs has the potential to affect all patients receiving care in this facility including the 14 (averaged) patients present during the course of the survey.

Findings include:

The Medical Staff Rules and Regs, dated October 2, 2008, were reviewed on 3/26/2013 in the a.m. Page 2 states in part, "Orders written by the Physician or Advanced Practice Nurse Practitioner on the patient's chart must be time, dated, and authenticated."

The facility policy titled, "Physician Orders, Transcription and Faxing of Orders," dated April 2011, was reviewed on 3/27/2013 in the a.m. The policy states in part that approved providers should, "Write orders within the scope of practice on the physician order sheet to outline the plan of care for the patient, including the following:...date and time of the order...sign order, including title."

Review on 3/27/13 in the AM of facility policy titled Patient Monitoring in the Behavioral Health Hospital dated 7/12 states under 1.c. "...Indicate 15-minute, 30-minute, or Hourly observations on the left column of the form as assigned."

Review of the facility's policy titled, "Consent for Hospital Treatment & Acknowledgment of Presence," dated December 1, 2010, was reviewed on 3/26/2013 at 7:45 a.m. The policy states in part, "Present Consent for Treatment (form HS-16) to patients during the admission assessment when determined that inpatient admission is indicated....Have the patient sign with staff witness signature. Staff also witness-sign if an involuntary patient refuses to sign."

Review of the facility's policy titled, "Nursing History and Assessment," dated May 2011, was reviewed on 3/27/2013 at 3:30 p.m. The policy states in part, "Licensed Nurse 1. Complete Inpatient Nursing Assessment (HS-102) within 2-hours of admission to the unit. 2. address all areas, 3. Sign, date, and time after completion, 4. Include narratives, when needed."

Examples of monitoring Pts:
Pt #3's MR review on 3/26/13 at 9:50 AM revealed Pt #3 is on 15 minute checks for safety. The Patient Monitoring/Hourly Rounding Record for 3/11/13 has no documentation of Pt #3 whereabouts from 10:30 AM to 11:15 AM. This is confirmed in interview with RN C on 3/26/13 at 4:45 PM.

Pt #5's MR review on 3/26/13 at 2:45 PM revealed Pt #5 is on 15 minute checks for safety. The Patient Monitoring/Hourly Rounding Record for 3/25/13 has no documentation of of who was monitoring Pt #3's whereabouts from 7:30 AM to 8:45 AM. This is confirmed in interview with RN C on 3/25/13 at 3:15 PM.

Pt #20's MR review on 3/26/13 at 11:50 AM revealed Pt #20 is on 15 minute checks for safety. The Patient Monitoring/Hourly Rounding Record for 12/27/13 has no documentation of who was monitoring Pt #20 between 8:00 AM to 8:45 AM and 11:00 AM to 11:45 AM. This is confirmed in interview with RN C on 3/26/13 at 4:45 PM.





05409

Physician authentication not complete signature
Per MR review of Pt. #7 beginning at 2:00 p.m. on 3/25/13, review of the psychiatric examination completed on 3/18/13 reveals a curved letter resembling a G, and not a full signature.

Per interview with Interim DON B beginning at 11:40 a.m. on 3/27/13, when shown the signature, B said, "Yes, I see."


Per MR review of Pt. #8 beginning at 2:55 p.m. on 3/25/13, review of the psychiatric examination completed on 3/20/13 reveals that the physician signature is a curved letter resembling a G, and not a full signature.

Per interview with Interim DON B beginning at 11:40 a.m. on 3/27/13, when shown the signature, B said, "Yes, I see."

Per MR review of Pt. #9 beginning at 3:17 p.m. on 3/25/13, review of the psychiatric examination completed on 3/19/13 reveals a slanted vertical line for the physician signature and not a full signature.

Per interview with Interim DON B at 3:57 p.m. on 3/25/13 when B was shown the exam physician signature, B said, "Yes, I see that."

Per MR review of Pt. #10 beginning at 9:30 a.m. on 3/26/13, review of the psychiatric evaluation reveals the physician signed with a curved letter resembling a G and not a full signature.

Per interview with Interim DON B beginning at 11:40 a.m. on 3/27/13, when shown the signature, B said, "Yes, I see."

Per MR review of Pt. #11 beginning at 10:45 a.m. on 3/26/13, review of psychiatric examination completed on 12/6/12 reveals a single curved mark for a physician signature rather than a full physician signature.

Per interview with Interim DON B beginning at 11:40 a.m. on 3/27/13, when shown the signature, B said, "Yes, I see."

Per review of Pt. #24's MR beginning at 9:45 a.m. on 3/27/13, review of the psychiatric examination completed on 1/18/13 reveals a physician signature had a mark resembling an upside down comma and not a full physician signature.

Per interview with Interim DON B beginning at 11:40 a.m. on 3/27/13, when shown the signature, B said, "Yes, I see."


Lack of pt. signature
Per MR review of Pt. #6 beginning at 1:05 p.m. on 3/25/13 Pt. #6 was admitted on 3/23/13. The consent for treatment form was unsigned. Review of the personal possession/belongings form from admission revealed that Pt. #6 had not signed and dated the form.

Per interview with RN C at 1:50 p.m. on 3/25/13, when C was shown the lacking consent signature and the lacking signature on the personal belongings form C said, "We should have put that the pt. refused to sign it." RN C then checked the daily progress notes and said that the refusal to sign was not documented in the progress notes.


Per MR review of Pt. #8 beginning at 2:55 p.m. on 3/25/13, review of the personal belongings form reveals that Pt. #8 did not sign the form. There is no documentation to support that Pt. #8 refused to sign.

During an interview with Interim DON B beginning at 11:40 a.m. on 3/27/13, when shown the lack of signature, B said, "Yes, I see".



26711

Incomplete documentation
A MR review was conducted on Pt. #16's closed MR on 3/25/2013 at 2:45 p.m. There is a restraint order form that does not include the time the RN examining the patient documented the evaluation or the time the MD signed the restraint order form.. On 7/28/12 there are 3 MD orders that do not include the time they were written in the MR. Pt. #16's consent for inpatient care is not signed by the Pt. or a witness indicating that the content was discussed with Pt. #16. The discharge summary does not include a time the MD co-signed the document. An MD progress note dated 7/29/12 is not timed. The Activities Inventory list is not signed, dated, or timed by the staff who completed it. The Nursing History and Assessment multi-page form is incomplete on page 1, 2, 3, 1/2 of page 4, page 5 (this page has a notation "unable to complete on adm"), 6, and page 7 again indicates the patient was unable to answer questions at the time of admission. The Nursing History and Assessment was not re-visited resulting in none being completed for Pt. #16 during this admission.

A MR review was conducted on Pt. #17's closed MR on 3/25/2013 at 3:20 p.m. There is a restraint order form from 12/30/12 that is incomplete and does not include any information regarding the release of restraint/seclusion or the time the physician signed for the restraint to be discontinued. The restraint was discontinued on 12/30/12 at 5:00 a.m. and the release order was not signed by the MD until 1/3/2013.

A MR review was conducted on Pt. #18's closed MR on 3/26/2013 at 11:43 a.m. There are restraint order forms on 9/14/12, 9/16/12 (not signed until 9/19/12), 9/17/12, 9/19/12, and 9/20/12 that do not include the time the MD signed the release order for the restraint/seclusion.

In an interview with RN C on 3/27/2013 at 11:40 a.m. the findings for Pt. #16, 17 and 18 were discussed and RN C stated, "You are right, this is not completed."

Based on P/P review and MR review this facility failed to obtain MD authentication on VO/TO within stated policy guidelines (48 hours) in 8 out of 30 MR reviewed (Pt.s # 1, 2, 3, 4, 5, 6, 8, and 12). Failure to have properly authenticated VO/TO has the potential to affect all patients receiving care in this facility including the 14 (averaged) patients present during the course of the survey.

Findings include:

The Medical Staff Rules and Regs, dated October 2, 2008, were reviewed on 3/26/2013 in the a.m. Page 2 states in part, "All verbal and telephone orders must be authenticated, dated, and timed by the ordering provider, within 48 hours as outlined by State and Federal regulations." (at the time of the survey the facility did not have a variance granting 48 hours for verbal order authentication)

The facility policy titled, "Physician Orders, Transcription and Faxing of Orders," dated April 2011, was reviewed on 3/27/2013 in the a.m. The policy states in part, "Sign, date, and time telephone or verbal orders (limited to emergency or urgent situations) within 48 hours as required by state and federal regulations."

Physician verbal/telephone orders not dated and or timed when signed
Per MR review of Pt. #6 beginning at 1:05 p.m. on 3/25/13, review of physician orders reveal the following: On 3/23/13 4 verbal orders were not dated and timed when signed: an order for a restraint chair at 8:50 a.m., an order for Haldol and Ativan at 9:05 a.m., an order for seclusion at 9:30 a.m. and an order to give Haldol and Ativan at that time.

During interview beginning at 3:57 p.m. on 3/25/13 when Interim DON B was shown the 3/23/13 verbal orders, B said, "Yes" when asked if could see that the orders were not dated and timed.

Per MR review of Pt. #8 beginning at 2:55 p.m. on 3/25/13, Pt. #8 was admitted on 3/18/13. Review of physician orders reveal that on 3/18/13 a telephone order was obtained at 3:20 p.m. for Haldol and Ativan. The physician did not date and time when signing the order.

During interview beginning at 3:57 p.m. on 3/25/13 when Interim DON B was shown the 3/18/13 verbal orders, B said, "Yes" when asked if could see that the orders were not dated and timed.


18816

Examples of orders:

Pt #1's MR review on 3/25/13 at 1:10 PM revealed there is a VO written on 3/21/13 that is not authenticated by the MD. This is confirmed in interview with RN C on 3/25/13 at 3:15 PM.

Pt #2's MR review on 3/25/13 at 3:00 PM revealed there are TOs written on 3/21/13 that are not authenticated by the MD. This is confirmed in interview with RN C on 3/25/13 at 3:15 PM.

Pt #3's MR review on 3/26/13 at 9:50 AM revealed the admission orders are TOs written on 2/26/13 and are not authenticated by the MD. This is confirmed in interview with RN C on 3/26/13 at 4:45 PM.

Pt #4's MR review on 3/25/13 at 1:35 AM revealed the admission orders are TOs written on 3/19/13 and 3/20/13 that are not authenticated by the MD. This is confirmed in interview with RN C on 3/25/13 at 3:15 PM.

Pt #5's MR review on 3/26/13 at 2:15 PM revealed the admission orders are TOs written on 3/24/13 and are not authenticated by the MD. A TO written on 3/24/13 is not authenticated by the MD with a time. This is confirmed in interview with RN C on 3/25/13 at 2:15 PM.

Pt #12's MR review on 3/26/13 at 10:00 AM revealed there are VOs written on 3/25/13 that are not authenticated by the MD with a time. This is confirmed in interview with RN C on 3/26/13 at 4:45 PM.

Based on observation and 1 of 1 staff interview (A), this facility failed to ensure that all items on the emergency response cart are usable and have not expired. Failure to have usable items on the emergency response cart has the potential to affect all patients in need of these items, including the 14 (averaged) patients present during the time of the survey.

Findings include:

A tour of the Crisis Intervention office was completed on 3/26/2013 at 9:52 a.m. accompanied by Admin A.

The facility's emergency response cart is located in this area and was found to have glucose test strips which expired 6/30/12 and glucose control solution which expired 10/31/12.

Per interview with Admin A at the time of the observation, A stated, "that is clearly outdated." According to Admin A the emergency cart is checked daily and when asked if it was safe to say staff have not been checking the strips/solution daily Admin A responded, "yes."

Based on tour of the kitchen and inpatient unit, temperature log reviews, policy and procedure reviews, and 2 of 2 staff interviews (B, N), the facility failed to record cooler, freezer and dish washing temperatures as per policy. Ensure filters are changed when soiled.
Ensure 4 of 4 fans in the meat cooler are free of dust. Ensure that 2 of 3 walls in the small cart wash room are maintained such that surfaces can be cleaned and sanitized. Ensure that flooring in the chemical supply room are maintained such that surfaces can be cleaned and sanitized. Ensure that food in 1 of 1 kitchenettes on the unit had food substances dated. This has the potential to affect all 14 (averaged) of 14 Pts. in this 16 bed facility.

Findings include:

A tour of the kitchen from 11:30 a.m. to 12:25 p.m. on 3/26/13 revealed the following:

Surfaces that are not intact or clean
The meat cooler has 4 fans near the ceiling on the right side all of which are dirty with dust debris.
The chemical supply room has 8 chipped tiles and 10 cracked tiles which are not surfaces that can be properly cleaned or sanitized as are not intact.
The small cart wash room has 2 of the 3 walls in which paint is chipped off exposing bare cement walls which are not intact and cannot be properly cleaned or sanitized.
The filters over the grill are clogged and dirty with grease.

During the tour RD N nodded in agreement that the tiles were not intact when tiles were pointed out, RD N stated during the tour that the paint on the walls of the small cart wash room did not hold up as it was supposed to. During the tour RD N stated that housekeeping is responsible for changing the filters above the grill and stated that the filters should have been changed and were not.

Refrigerator temperatures
Facility policy dated 8/9/12 labeled "Safe Food Handling and Sanitation", states "Temperatures of all refrigerators, walk-in cooler, walk-in freezer will be recorded twice daily."

Per review of temperature logs beginning at 1:35 p.m. on 3/26/13 temperatures from 1/1/13 through 3/25/13 reveal the following:

On 1/3/13 the temperature of refrigerator #15 was not checked on the morning shift and the milk chest and refrigerator #2 temperatures were not checked on the afternoon shift.
On 1/8/13 the milk chest temperature was not checked on the morning shift.
On 1/26/13 refrigerator #16 temperature was not checked on the afternoon shift.
On 1/28/13 the milk chest temperature was not checked on the afternoon shift.
On 1/30/13 the milk chest temperature was not checked on the afternoon shift.
On 2/11/13 refrigerator #12 temperature was not checked on the afternoon shift.
On 2/12/13 the milk chest and refrigerator #11 temperatures were not checked on the afternoon shift.
On 3/3/13 the milk chest temperature was not checked on the morning shift.
On 3/19/13 the milk chest temperature was not checked on the afternoon shift.
On 3/21/13 the milk chest temperature was not checked on the afternoon shift.

Dish Washing Temperatures
Policy dated 8/9/12 entitled, "Safe Food Handling and Sanitation" states, that wash and rinse temperatures of the dish machine are to be recorded with each meal after the system has run for at least 10 minutes. Wash temperature, Rinse temperature, final rinse temperature, and pressure are 3 times per day.

Review of the dish machine temperature log beginning at 1:45 p.m. on 3/26/13, logs from 1/1/13 to 1/25/13 reveal the following:

On 1/9/13 the wash, rinse, final rinse, and pressure were not recorded with the noon and supper meals. On 1/13/13 the wash, rinse, final rinse, and pressure were not recorded at the breakfast meal. On 1/16/13 the wash, rinse, final rinse, and pressure were scribbled out as not done or not correct. On 1/26/13 the pressure was not checked at the noon meal.
On 2/1/13 the wash, rinse, final rinse, and pressure were not checked at the noon meal.
On 2/2/13 the wash, rinse, final rinse, and pressure were not checked at the breakfast and noon meals. On 2/3/13 the wash, rinse, final rinse, and pressure were not checked at the breakfast and supper meals. On 2/6/13 the wash, rinse, final rinse, and pressure were not checked at the supper meal. On 2/7/13 the wash, rinse, final rinse, and pressure were not checked at the noon meal. On 2/17/13 the wash, rinse, final rinse, and pressure were not checked at the breakfast and noon meals. On 2/19/13 the wash, rinse, final rinse, and pressure were not checked at the supper meal. On 2/21/13 the wash, rinse, final rinse, and pressure were not checked at the noon meal. On 3/5/13 the wash, rinse, final rinse, and pressure were not checked at the noon and supper meals. On 3/12/13 the wash, rinse, final rinse, and pressure were not checked at the supper meal. On 3/19/13 the wash, rinse, final rinse, and pressure were not checked at the supper meal.















18816

Review on 3/27/13 in the AM of facility policy title Refrigeration of Foods and Medications, dated 6/10, states on an attachment with a list of perishable and non-perishable foods the following: "Ice Cream 4 oz (ounce) container-1 month...Ready-to-Eat Deli-Foods Brought in by family, friends or ordered by resident-For example: potato or seafood salad, soups, prepared entrees-24 hours...Supplements Opened Containers-1 day."

Per tour of the facility on 3/24/13 at 1:00 PM, with RN B, the kitchenette refrigerator contained 3 Styrofoam containers of food, and six plastic containers of food items with Pt names and no date to monitor for discard. The freezer contained undated ice cream in single serve size and an open gallon of ice cream with no open date. There is an open bag of potato chips in the upper cupboard next to the refrigerator. In interview on 3/25/13 at 1:00 PM, RN B stated the food in the Styrofoam container is brought from home and the other food is used for a Pt that requires thickened food, and agreed all the containers of food should be labeled with a date.

Based on policy and procedure reviews, and 2 of 2 staff interviews (C, N), the facility failed to ensure that a medical director approved diet manual is available for use. This has the potential to affect all 14 (averaged) of 14 Pts. in this 16 bed facility.

Findings include:

During an interview with RD N beginning at 1:10 p.m. on 3/26/13, RD was asked about a diet manual approved by the medical director and stated that there are diet manuals available for reference including (other hospitals) and thinks there may be a binder in the food supervisor's office, but the supervisor is on vacation and does not have access to the office. When asked where the menus used came from, RD N said that the RD staff made them up and they were not taken form a manual. Per RD N there is a typed sheet with special diets that staff can follow.

Per interview with RN C beginning at 9:10 a.m. on 3/27/13, when C was asked where a dietary manual was for staff use on the unit, C replied, "I don't know." RN C stated that the facility does not have a diet manual on the unit for special diets.

On the morning of 3/27/13, policy dated 8/9/12 labeled "Diet Manual and Diet Order Terminology", states under diet terminology what general, mechanical soft, pureed, renal, cardiac, consistent carbohydrate, and 1400 calorie diet mean,what supplements, thickened fluids, fluid restriction, and liberalize means. This is not a diet manual to use for reference for specific needs. There is no definition of what a gluten free diet is.

Based on tour and observation, staff interview, and record review, this hospital failed to maintain a safe and secure building. This deficiency has the potential to affect all patients, staff and visitors.

Findings include:

K25: Smoke Compartment walls and doors were not smoke tight w/ratings.
K41: There was not a door from the sleeping room to a corridor or have a door leading directly to grade.
K56: Sprinkler system was not compliant to NFPA 13 minimum standards.
K67: The HVAC system did not meet the minimum standards on NFPA 90A

Please refer to the full description and findings within the specific K-tag deficiencies within the appropriate building found later in this report.

The cumulative effect of these deficiencies has the potential to affect the safety of all patients receiving services at the hospital.

Based on tour and observation, staff interview, and record review, this hospital failed to maintain a safe and secure building. This deficiency has the potential to affect all patients, staff and visitors.

Findings include:

K25: Smoke Compartment walls and doors were not smoke tight w/ratings.
K41: There was not a door from the sleeping room to a corridor or have a door leading directly to grade.
K56: Sprinkler system was not compliant to NFPA 13 minimum standards.
K67: The HVAC system did not meet the minimum standards on NFPA 90A

Please refer to the full description and findings within the specific K-tag deficiencies within the appropriate building found later in this report.

The cumulative effect of these deficiencies has the potential to affect the safety of all patients receiving services at the hospital.

Based on MR reviews, 1 out of 1 staff interview (D) and P/P review this facility failed to demonstrate an effective DCP process as evidenced by lack of ongoing DCP documentation in 24 out of 24 MR's reviewed of Pt's requiring DCP (Pt's #1, 2, 3, 4, 6, 7, 8, 9, 10, 11, 16, 17, 18, 19, and 21-30) out of a total of 30 MR reviewed. Failure to demonstrate an effective DCP process has the potential to affect all patients receiving care in this facility, including 14 (averaged) patients present during the course of this survey.

Findings include:

1. The facility failed to document on-going discharge planning for their vulnerable patient population (see tag 806).




The cumulative affect of this deficiency has the potential to affect all patients in this facility.

Based on MR reviews, 2 out of 2 staff interviews (D, S) and P/P review this facility failed to document DCP which would include discussing the plan with the patient, reassessing the discharge plan, and counseling the patient to prepare them for post-discharge care on an ongoing basis in 24 out of 24 MR's reviewed of Pt's requiring DCP (Pt's #1, 2, 3, 4, 6, 7, 8, 9, 10, 11, 16, 17, 18, 19, and 21-30) out of a total of 30 MR reviewed. Failure to document DCP has the potential to affect all patients receiving care in this facility, including the 14 (averaged) patients present during the course of this survey.

Findings include;

The facility policy titled, "Clinical Protocol for Discharge/Discharge Planning Evaluation," dated October 2010, was reviewed on 3/27/2013 at 10:30 a.m. The policy states in part on page 2, "The Discharge plan should be documented in the clinical notes which include the existence of a plan and what steps were taken to implement the plan."

MR reviews were conducted on Pt.s 1-30's open and closed MRs from 3/25/2013 at approximately 2:30 p.m.-4:00 p.m., on 3/26/2013 from approximately 9:00 a.m.-4:00 p.m. and on 3/27/2013 from approximately 9:00 a.m.-11:15 a.m.

There is no evidence in the MR of documented DCP throughout the Pt stays for Pt's #1, 2, 3, 4, 6, 7, 8, 9, 10, 11, 16, 17, 18, 19, and 21-30.

Per interview with SW S on 3/25/13 at 2:25 PM, there is no documentation in the MRs of discharge planning.

An interview with ESC D was conducted on 3/26/2013 at 2:11 p.m. When asked where DCP's document their involvement with patients for DCP activities in the medical record ESC D responded, "We don't, if we did it would be on a progress note."

Based on 1 of 1 staff interview (A) and P/P review, this facility failed to ensure they had trained designated requesters to approach patients/families for requesting organ and/or tissue donation. Failure to have trained designated requesters has the potential to affect all patients/families who are approached for possible donation, including the 14 (averaged) patients during the course of the survey.

Findings include:

The facility policy titled, "Advanced Directives/Anatomical Gift Donation," dated December 2011, was reviewed on 3/26/2013 at 8:29 a.m. The policy states in part on page 3, "Designated Requestor-a staff member or physician who has been formerly trained and certified by the Organ Procurement training team to approach patients or the patient's family/guardian concerning anatomomical gift donation."

In an interview with Admin A on 3/26/2013 at 8:06 a.m., when asked who would approach the family regarding donation in the event of death, Admin A responded that the nursing staff would approach the family.

Admin A went on to say that staff are trained in the basics for approaching families regarding organ donation in orientation by the lead nurse, however there will be no records of this training.

Admin A was unaware that designated requesters had to be formerly trained by the OPO and stated that none of the staff has had this training.