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Based on review of medical records, review of Security Sitters sign in sheet and interview it was determined the facility failed to update the treatment plan and incorporate into the patient's treatment plan a need for 1:1 observation by a security guard/ sitter. The facility did not include the patient, physician or family in the implementation of this addition to the treatment plan. This had the potential to affect all patients served by the facility and did affect Medical record (MR) # 1 and 2.

Findings include:

1. MR # 1 was admitted to the psychiatric unit 8/23/13 with diagnoses of Dementia with Psychosis and Bipolar Disorder Type I Mixed.

The Master Problem list initiated 8/23/13 as part of the Multidisciplinary Treatment Team plan included 1. Risk of Violence, 2. Psychotic Symptoms Hallucinations and 3. Fall risk.

The interventions to address the Risk of Violence included:

Physician- assess/adjust medication efficacy during each visit and as needed.
Monitor and educate regarding precautions, risks, benefits and side effects of medications each visit.
Obtain informed consent for psychoactive medications prior to initiating each medication.

Activity- Monitor for signs/symptoms (s/s) of risk for violence and report to appropriate personnel.

Nursing- Use de-escalation techniques to prevent aggressive acting out or violent episodes whenever signs of escalation appear.
Use non-violent crisis prevention techniques when less restrictive interventions have been unsuccessful.

Social Worker/Therapist- Encourage group x 5 days with focus on emotions, coping, cognitive stimulation. Coordinate discharge planning placement.

A review of the medical record revealed effective 8/30/13 starting at 10:00 AM a guard was assigned to this patient confirmed from the Security Sitters sign in sheet. The 15 Minute Check/ 1:1 Observation Check Sheet documented starting at 12:00 noon the guard was present with the patient in the dayroom.

The Senior Care Daily Nursing Assessment documented under Safety Precautions:
8/30/13 through 9/4/13 -15 minute checks.
9/5/13, 9/6/13, 9/7/13, 9/8/13, 9/9/13, 9/10/13, and 9/12/13 have 1:1 observation and 15 minute checks marked.
9/11/13-1:1 observation (guard) and 15 minute checks.
9/13/13, 9/14/13, 9/15/13,9/17/13, - 15 minute checks
9/16/13 and 9/18/13 have 1:1 observation marked.

Based on the above documentation the nurses are not consistent in what they call the use of the guards/sitters only routine 15 minute checks or whether 1:1 observation. An order is required for the use of 1:1 observation.

The medical record failed to have any documentation regarding the use of the guards with the patients 24 hours a day. There was no documentation the physician was included in the decision, the family, the Program Director or the treatment team, only the Registered Nurse decide and called the security for a guard to be assigned. There was no documentation of what guard was assigned to what patient or who made that decision.

The Master Treatment Plan update dated 9/4/13 Problem # 1, " Oriented to self only, cognitively impaired, short term memory is impaired and is not capable of processing information to identify positive coping methods."

Problem # 3, " Continues to get up and attempt to ambulate independently. Review 9/10/13."

The treatment plan failed to include any information related to the use of the guard to keep the patient safe and no change was made to the interventions.

The Master Treatment Plan update dated 9/10/13 Problem # 1 was not addressed.

Problem # 3, " Patient continues to get up and tries to ambulate independently and displays poor safety. Review 9/17/13."

The treatment plan failed to include any information related to the use of the guard to keep the patient safe and no change was made to the interventions.

The Master Treatment Plan update dated 9/17/13 Problem # 1 was not addressed.

Problem # 3, " Continues to get up without assistance and attempt to ambulate independently. Review 9/24/13."

The treatment plan failed to include any information related to the use of the guard to keep the patient safe and no change was made to the interventions.

In an interview 9/19/13 at 9:00 AM with Employee Indentifer (EI) # 1, the Program Director, the above information was confirmed.

2. MR # 2 was admitted to the psychiatric unit 8/16/13 with diagnoses of Dementia with Behavioral Disturbances and Alzheimer's Type Dementia.

The Master Problem list initiated 8/17/13 as part of the Multidisciplinary Treatment Team plan included 1. Risk of Violence,
2. Disruptive/Impulsive Behaviors, 3. Fall risk and 4. Infection.

The interventions to address the Risk of Violence included:

Physician- assess/adjust medication efficacy during each visit and as needed.
Monitor and educate regarding precautions, risks, benefits and side effects of medications each visit.
Obtain informed consent for psychoactive medications prior to initiating each medication.

Activity- Monitor for signs/symptoms (s/s) of risk for violence and report to appropriate personnel.

Nursing- Use de-escalation techniques to prevent aggressive acting out or violent episodes whenever signs of escalation appear.
Use non-violent crisis prevention techniques when less restrictive interventions have been unsuccessful.
Monitor desired and untoward effects of prescribed medication at least PRN (as needed) times per shift.
Provide medication education prior to initiation of therapy and as needed during continuation of it at time of each administration.

Social Worker/Therapist- Encourage group x 5 days with focus on emotions, coping, cognitive stimulation. Coordinate discharge planning placement.
1:1 Therapy PRN times per week to allow ventilation of feelings.

The interventions to address the Disruptive/Impulsive Behavior included:
Physician- assess/adjust medication
3 times a week.
Individual Therapy 3 times per week.
Monitor for therapeutic medication level...
Obtain informed consent for psychoactive medications prior to initiating each medication.

Nurse- Assess and document presence of disruptive behaviors, inattention, hyperactivity, impulsivity each shift.
Provide/maintain safe environment...

A review of the medical record revealed effective 9/12/13 starting at 10:15 AM a guard was assigned to this patient confirmed from the Security Sitters sign in sheet. The 15 Minute Check/ 1:1 Observation Check Sheet documented starting at 10:30 AM the guard was present with the patient in the dayroom who was asleep.

The Senior Care Daily Nursing Assessment documented under Safety Precautions:
9/12/13, 9/16/13 and 9/17/13 -15 minute checks.
9/13/13, 9/14/13 and 9/15/13-1:1 observation and 15 minute checks marked.

Based on the above documentation the nurses are not consistent in what they call the use of the guards/sitters only routine 15 minute checks or whether 1:1 observation. An order is required for the use of 1:1 observation.

The medical record failed to have any documentation regarding the use of the guards with the patients 24 hours a day. There was no documentation the physician was included in the decision, the family, the Program Director or the treatment team, only the Registered Nurse decide and called the security for a guard to be assigned. There was no documentation of what guard was assigned to what patient or who made that decision.

The Master Treatment Plan update dated 9/13/13 Problem # 1, " Has been able to identify 1 positive coping but not able to recall. Will review 9/20/13."

Problem # 2, " Remains hostile, argumentative and physically aggressive with staff. Review 9/20/13."

Problem # 3, " Does not display impulse control by asking for assistance. Review 9/20/13."

The treatment plan failed to include any information related to the use of the guard to keep the patient safe and no change was made to the interventions.

In an interview 9/19/13 at 9:00 AM with Employee Indentifer (EI) # 1, the Program Director, the above information was confirmed.

Based on observation, review of medical records, review of Security Sitter sign in sheets, Security Personnel orientation packet and interview it was determined the facility failed to provide a safe environment to meet the physical and emotional needs of the patients by using untrained personnel to provide one to one direct observation of patients diagnosed with mental illness. This had the potential to affect all patients served by the facility and did affect Medical Record (MR) # 1 and 2.

Findings include:

During a tour of the unit 9/17/13 at 3:00 PM, the surveyor observed sitting in the group room a male with a badge attached to his clothing. The surveyor asked Employee Identifier (EI) # 2, the Nurse manager,who this person was and why he was sitting in the group room. EI # 2 stated that he was a guard that they used them to sit by patients and keep them safe.

During a medication pass 9/18/13 at 8:15 AM, the surveyor observed two men standing out in the hallway beside room 316. The surveyor asked EI # 1, the Program Director, who they were and what they were doing in the hallway. EI # 1 stated that they were waiting for the patients to be changed for breakfast by the mental health workers,that they were sitting/guards on duty for the safety of these two ladies.

Medical Record findings:

1. MR # 1 was admitted to the psychiatric unit 8/23/13 with diagnoses of Dementia with Psychosis and Bipolar Disorder Type I Mixed.

The Master Problem list initiated 8/23/13 as part of the Multidisciplinary Treatment Team plan included Risk of Violence, Psychotic Symptoms Hallucinations and Fall risk.

The interventions to address the Risk of Violence included:

Physician- assess/adjust medication efficacy during each visit and as needed.
Monitor and educate regarding precautions, risks, benefits and side effects of medications each visit.
Obtain informed consent for psychoactive medications prior to initiating each medication.

Activity- Monitor for signs/symptoms (s/s) of risk for violence and report to appropriate personnel.

Nursing- Use de-escalation techniques to prevent aggressive acting out or violent episodes whenever signs of escalation appear.
Use non-violent crisis prevention techniques when less restrictive interventions have been unsuccessful.

Social Worker/Therapist- Encourage group x 5 days with focus on emotions, coping, cognitive stimulation. Coordinate discharge planning placement.

A review of the medical record revealed effective 8/30/13 starting at 10:00 AM a guard was assigned to this patient confirmed from the Security Sitters sign in sheet. The 15 Minute Check/ 1:1 Observation Check Sheet documented starting at 12:00 noon the guard was present with the patient in the dayroom.

The medical record did not have an order for the use of a sitter/guard to be with the patient, no documentation was present in the medical record of contact with the physician or Program Director concerning problems with the patient and no information concerning how the decision was made to have a sitter/guard with the patient.

In an interview 9/18/13 with EI # 1, the Program Director, she was asked for criteria to use a sitter/guard and a policy related to the use of the sitter/guard. EI # 1 stated that the Registered Nurse (RN) made the decision to call for a guard to come stay with the patient. EI # 1 stated they did not have any written criteria or a policy on the use of sitters/guards.

The patient care notes documented by the RN on 8/30/13 at 4:17 PM, " Patient has been restless this shift. Very poor awareness noted this shift. Patient attempts to stand/ambulate without assistance frequently. Gait is very unsteady requires assist for safe ambulation. Staff ambulates with patient 1:1 to maintain patient safety r/t (related to) her impulsive behavior..."

Patient care notes 8/31/13 at 5:26 PM, documented, " Restless highly confused, poor safety, agitated and anxious, wandering... patient has wandered around with guard at times..."

Patient care notes 8/31/13 at 2:59 AM, documented, " Plan: Keep guard in place at this time due to patient's extreme anxiety and restlessness and need to wander as well as safety risk to herself."

MR # 1 had a guard assigned to her 24 hours a day from 8/30/13 through 9/14/13 at 9:40 PM when the physician wrote an order to discontinue 1:1 guard at this time.

Patient care notes 9/16/13 at 4:38 PM, documented, " Pt (patient) has poor safety precautions, she is highly confused, and guard is present."

The guard was resumed 9/16/13 at 9:00 PM confirmed from the Security Sitters sign in sheet. The 15 Minute Check/ 1:1 Observation Check Sheet documented starting at 9:00 PM the guard was present with the patient in her bedroom.

The medical record failed to have any documentation present that the physician was consulted before replacing the guard, there was no change to the interdisciplinary treatment plan,or Program Director concerning problems with the patient and no information concerning how the decision was made to have a sitter/guard with the patient.

The patient continued to have 24 hour sitter/guards at her side through 9/19/13.

In an interview with EI # 1, the Program Director, on 9/19/13 at 9:00 AM the above information was confirmed.

2. MR # 2 was admitted to the psychiatric unit 8/16/13 with diagnoses of Dementia with Behavioral Disturbances and Alzheimer's Type Dementia.

The Master Problem list initiated 8/17/13 as part of the Multidisciplinary Treatment Team plan included Risk of Violence, Disruptive/Impulsive Behaviors, Fall risk and Infection.

The interventions to address the Risk of Violence included:

Physician- assess/adjust medication efficacy during each visit and as needed.
Monitor and educate regarding precautions, risks, benefits and side effects of medications each visit.
Obtain informed consent for psychoactive medications prior to initiating each medication.

Activity- Monitor for signs/symptoms (s/s) of risk for violence and report to appropriate personnel.

Nursing- Use de-escalation techniques to prevent aggressive acting out or violent episodes whenever signs of escalation appear.
Use non-violent crisis prevention techniques when less restrictive interventions have been unsuccessful.
Monitor desired and untoward effects of prescribed medication at least PRN (as needed) times per shift.
Provide medication education prior to initiation of therapy and as needed during continuation of it at time of each administration.

Social Worker/Therapist- Encourage group x 5 days with focus on emotions, coping, cognitive stimulation. Coordinate discharge planning placement.
1:1 Therapy PRN times per week to allow ventilation of feelings.

The interventions to address the Disruptive/Impulsive Behavior included:

Physician- assess/adjust medication
3 times a week.
Individual Therapy 3 times per week.
Monitor for therapeutic medication level.
Obtain informed consent for psychoactive medications prior to initiating each medication.

Nurse- Assess and document presence of disruptive behaviors, inattention, hyperactivity, impulsivity each shift.
Provide/maintain safe environment.

A review of the medical record revealed effective 9/12/13 starting at 10:15 AM a guard was assigned to this patient confirmed from the Security Sitters sign in sheet. The 15 Minute Check/ 1:1 Observation Check Sheet documented starting at 10:30 AM the guard was present with the patient in the dayroom who was asleep.

The medical record did not have an order for the use of a sitter/guard to be with the patient, no documentation was present in the medical record of contact with the physician or Program Director concerning problems with the patient and no information concerning how the decision was made to have a sitter/guard with the patient.

The patient continued to have 24 hour sitter/guards at her side through 9/19/13.

In an interview with EI # 1, the Program Director, on 9/19/13 at 9:00 AM the above information was confirmed.

In an interview 9/18/13 with EI # 4, the Chief Quality Officer and EI # 1, the Program Director the surveyor inquired if the guards had the Crisis Prevention training and Infection Control training.

The surveyor reviewed 4 of the guards personnel training information presented that had sat with the 2 patients above. None of the 4 guards had any documentation of training in the Crisis Prevention or Infection Control in the information provided to the surveyor 9/18/13 at 3:00 PM. The guards are not hospital employees but are contracted through a security service Fyala Security Inc.

A review of the Security Personnel Orientation packet provided to the security personnel when they start and annually according to EI # 4.

The following information is presented to sitters/guards related to Special Considerations for the Senior Care Unit:
All patients are Confidential
Vulnerable Patients
Must treat with respect- patients are sick just as the patient with pneumonia
No electronic devices
No device capable of making a picture is allowed on unit
No equipment/device that could potentially be a weapon allowed on unit.

In an interview with Employee Identifier(EI) # 1, the Program Director, on 9/19/13 at 9:00 AM, the above information was confirmed. EI # 1 stated that the guards were not suppose to touch the patients only sit with them and keep them safe.

Based on review of census reports, observation, security guard orientation packet and security guard sign in sheets, it was determined the Registered Nurse was requesting the use of guards with patients and not trained staff to meet the specialized treatment needs of the patients on the Senior Care Unit. This had the potential to affect all patients served by this facility.

Findings include:

During a tour of the unit 9/17/13 at 3:00 PM, the surveyor observed sitting in the group room a male with a badge attached to his clothing. The surveyor asked Employee Identifier (EI) # 2, the Nurse Manager,who this person was and why he was sitting in the group room. EI # 2 stated that he was a guard that they used them to sit by patients and keep them safe.

During a medication pass 9/18/13 at 8:15 AM, the surveyor observed two men standing out in the hallway beside room 316. The surveyor asked EI # 1, the Program Director, who they were and what they were doing in the hallway. EI # 1 stated that they were waiting for the patients to be changed for breakfast by the Mental Health workers,that they were sitting/guards on duty for the safety of these two ladies.

The surveyor inquired of EI # 1, on 9/19/13 at 8:30 AM, who decided to use these guards, was it physician ordered and what was the criteria for the use of the guards. EI # 1 stated that the Registered Nurse decided when to call for a guard. EI # 1 stated that the physician was not contacted because it was for patient safety and not 1:1 observation. The surveyor inquired who assigned the guards to what patient and EI # 1 did not know.

A review of the census for the following days confirmed the following information:

" 9/2/13- census of 19 patients

Patients in room 316 A had a guard assigned from 7:00 AM-2:00 PM, 2:00 PM-8:00 PM and 8:00 PM-8:00 AM
Room 318 A had a guard assigned from 2:00 AM-2:00 PM
from 2:00 PM-2:00 AM

9/3/13- census of 17 patients
Patients in room 316 A had a guard assigned from 8:00 AM-4:00 PM
from 4:00 PM-12:15 AM
Room 318 A had a guard assigned from 2:00 AM-10:00 AM,
10:00 AM-10:00 PM and 10:00 PM-10:00 AM

9/4/13-census of 17 patients
Patients in room 316 A had a guard assigned from 12:15 AM-8:00 AM, 8:00 AM-8:00 PM and 7:30 PM-8:30 AM
Room 318 A had a guard assigned from 10:00 AM-7:30 PM
from 8:00 PM-4:00 AM

9/5/13-census of 15 patients
Patients in room 313 had a guard assigned from 3:45 AM-3:45 PM, 3:45 PM-11:00 PM and 11:00 PM-11:00 AM
Room 316 A had a guard assigned from 4:00 AM-10:30 AM, 10:30 AM-10:30 PM and 10:30 PM-10:30 AM

9/6/13-census of 13 patients
Patients in room 316 A had a guard assigned from 10:30 AM-4:30 PM from 4:30 PM-4:30 AM
Room 313 had a guard assigned from 11:00 AM-11:00 PM from 11:00 PM- 11:00 AM

9/7/13- census of 13 patients
Patients in room 316 A had a guard assigned from 4:30 AM-10:30 AM, 10:30 AM-10:30 PM and 10:30 PM-5:00 AM
Room 313 had a guard assigned from 11:00 AM-7:00 PM from 7:00 PM- 7:00 AM

9/8/13- census of 15 patients
Patients in room 316 A had a guard assigned from 5:00 AM-5:00 PM from 5:00 PM-12:30 AM
Room 313 had a guard assigned from 7:00 AM-3:00 PM from 3:00 PM- 3:00 AM

9/9/13- census of 17 patients
Patients in room 316 A had a guard assigned from 12:30 AM-12:30 PM from 12:30 PM-12:30 AM
Room 313 had a guard assigned from 12:30 AM-12:30 PM from 12:30 PM- 12:30 AM
Room 302 had a guard assigned from 10:00 PM- 10:00 AM

9/10/13- census of 16 patients
Patients in room 316 A had a guard assigned from 12:30 AM-10:30 AM from 10:30 AM-10:30 PM and from 10:30 PM-8:30 AM
Room 313 had a guard assigned from 8:30 AM-8:30 PM from 8:30 PM- 8:30 AM
Room 302 had a guard assigned from 10:00 AM- 10:00 PM from 10:00 PM-6:00 AM

9/11/13- census of 14 patients
Patients in room 316 A had a guard assigned from 8:30 AM-8:30 PM from 8:30 PM-2:15 A
Room 313 had a guard assigned from 8:30 AM-8:30 PM from 8:30 PM- 8:30 AM
Room 302 had a guard assigned from 6:00 AM- 6:00 PM from 6:00 PM-6:00 AM

9/12/13- census of 13 patients
Patients in room 316 A had a guard assigned from 2:15 AM-2:15 PM
from 2:15 PM-2:15 AM.
Room 302 had a guard assigned from 6:00 AM-6:00 PM
from 6:00 PM-3:00 AM
Room 313 had a guard assigned from 8:30 AM-8:30 PM
from 8:30 PM-8:30 AM
Room 314 A had a guard assigned from 10:15 AM-10:15 PM
from 10:15 PM-11:45 AM
Room 317 had a guard assigned from 3:00 PM-2:00 AM."

The guards failed to have Crisis Prevention Training, Infection Control training and were not required by the facility to have Hepatitis B vaccinations. All staff who work on the Senior care Unit are to have Crisis Prevention training to de-escalate patients and provide care to them in a safe environment.

The assignment of these guards instead of the use of trained Mental Health Workers and nurses was not appropriate to meet the specialized treatment needs of the patients on the Senior Care Unit.

In an interview 9/19/13 at 9:00 AM with EI # 1, the Program Director the above information was confirmed.

Based on observation and interview the facility failed to protect a patient from potential harm related to a patient ingesting food from a breakfast tray another patient had left on the table. This had the potential to affect all patients served by the facility.

Findings include:

On 9/18/13 at 8:50 AM, the surveyor observed Employee Identifier (EI) # 3, a Mental Health Worker (MHW) seat a male patient at the dining table in the group room. A breakfast tray was on the table where another patient had just left the table. The patient reached out and picked up the cup of coffee left on the tray and brought it to his mouth to drink. EI # 3 realized the patient had the coffee and removed the coffee and tray leaving a wrapped muffin on the table. The male patient immediately reached and picked up the muffin which was present on the table. EI # 3 removed the muffin from the patient and brought the patient his breakfast tray.

The MHW failed to protect the patient and prevent a potential infectious process by not removing the food tray from the patients place at the table prior to seating.

Employee Identifier (EI) # 2, the Nurse Manager was present during the time of this incident and confirmed the MHW failed to prevent potential contamination/ infection to a patient.