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Based on observations, interviews, record review, Quality Review documents and review of the facility's policy/procedure it was determined the facility failed to ensure necessary care and services were provided to patients in order to meet their needs for one patient (#22) in a selected sampled of twenty-two and six unsampled patients (A, B, C, D, E and F). The facility failed to ensure their policy and procedures were implemented to ensure safety and appropriate supervision to prevent access to contraband or items that could be used for self-harm. The facility failed to ensure appropriate supervision to prevent access to contraband or items which could cause potential harm was afforded to Patient #22 who had been assessed as requiring supervision for suicidal precautions. On 10/23/12, Patient #22 successfully removed a metal plate from the wall and cut him/herself without staff knowledge. While the facility notified the physician and initatied increased supervision, Patient #22 was able to access plastic cutlery and was successfully in cutting him/herself while in the bathroom having line of site supervision. There was no evidence that the facility had taken action to ensure the Patient did not have access to contraband or items that could potentially be hazardous to him/herself. Furthermore, the facility failed to ensure pencils identified as contraband was not accessible to patients of the facility without direct supervision. Pencils were observed during tour accessible in patient rooms without staff present monitor access. Additionally, the facility failed to obtain laboratory services and electrocardiographs (EKG) as ordered by the physician for six patients. While the facility had identified this quality issue, multiple interventions implemented over a four month period by the facility to correct these failures were unsuccessful.

These failures resulted in non-compliance with the Condition of Participation. Refer to Tag A-392.

Based on observations, interviews, record review, Quality Review documents and review of the facility's policy/procedure it was determined the facility failed to ensure necessary care and services were provided to patients in order to meet their needs for one patient (#22) in a selected sampled of twenty-two and six unsampled patients (A, B, C, D, E and F). The facility failed to ensure their policy and procedures were implemented to ensure safety and appropriate supervision to prevent access to contraband or items that could be used for self-harm. The facility failed to ensure appropriate supervision to prevent access to contraband or items which could cause potential harm was afforded to Patient #22 who had been assessed as requiring supervision for suicidal precautions. On 10/23/12, Patient #22 successfully removed a metal plate from the wall and cut him/herself without staff knowledge. While the facility notified the physician and initatied increased supervision, Patient #22 was able to access plastic cutlery and was successfully in cutting him/herself while in the bathroom having line of site supervision. There was no evidence that the facility had taken action to ensure the Patient did not have access to contraband or items that could potentially be hazardous to him/herself. Furthermore, the facility failed to ensure pencils identified as contraband was not accessible to patients of the facility without direct supervision. Pencils were observed during tour accessible in patient rooms without staff present monitor access. Additionally, the facility failed to obtain laboratory services and electrocardiographs (EKG) as ordered by the physician for six patients. While the facility had identified this quality issue, multiple interventions implemented over a four month period by the facility to correct these failures were unsuccessful.

Findings include:

1. A Review of the Levels of Observation/Special Precautions policy which defines Level II supervision as "15 minute with Precaution (Requires a Precaution level) staff will make direct visual contact with the patient and document on the Patient Observation Sheet every 15 minutes. Individual precautions will be ordered by the physician and followed by all staff. Staff will be vigilant for potential risk factors identified for specific patient's levels of precautions. Sleeping patients will be observed at close enough proximity to confirm they are in no physical distress. Level III - Line-of-Sight Observation: The patient will remain in direct view of the assigned staff member at all times. Staff will document on the Patient Observation Sheet every 15 minutes. When patients shower, change clothes or use the bathroom, the staff will remain outside the bedroom or bathroom door with the door slightly opened and visually check the patient at least every 30 seconds. Staff will attempt to maintain the patient's privacy as much as possible; however, the safety of the patient must be the main consideration. Staff assigned to line of sight must hand-off responsibility for maintaining observation of the assigned patient(s) for any break. Level IV - One -to- One Observation: A specified and dedicated staff member within approximately one arm's length of the patient on 1:1 observation. This continuous direct visual observation will continue even when patients shower change clothes or use the bathroom. Patients on 1:1 remain on the unit at all times".

A Review of the policy/procedure for "Safe Environment" revealed the policy of the facility is to maintain a safe and therapeutic environment for patients, visitors, and staff. In order to achieve this, routine searches are conducted on all patients on admission. In addition, any item brought into the facility after admission will be searched as well. Other searches (patient, room, and unity) are completed routinely or at the discretion of the Nurse or designee. A search is conducted when there is reasonable cause to believe a patients may possess a item which is potentially hazardous. A search is conducted when there is a special observation/precaution and a physician order obtained. A personal search is completed when there is suspicion that the patient has a hazardous item, there is an increase in the level of special observation, there are missing items or the nurse has communicated to the physician that a search may be necessary. The nurse or designee will conduct a room search daily and when there is a reasonable cause to believe the patient may possess an item which is potentially dangerous. If contraband is suspected on the patient unit, it may be preferable to conduct a unit-wide search rather than a single patient room search. Writing instruments are considered contraband (pens, pencils, crayons, markers, etc.) are not permitted to be used by the patient without supervision and can only be used in the group room. Any other items deemed potentially dangerous by staff is considered contraband.

A review of the medical record revealed the facility admitted Patient #22, on 10/16/12, with a diagnosis of major depressive disorder, recurrent impulse control, and attention deficit hyperactive disorder. The facility assessed and determined that Patient #22 required level 2 and suicide precautions supervision which required staff observation to monitor for safety and changes (15 minute checks) on 10/23/12.

An interview with Mental Health Technicians (MHT) #2, on 10/26/12 at approximately 4:00 PM, revealed on 10/23/12 he conducted his first check at 3:00 PM when he found patient #22 cutting himself/herself with a metal electrical outlet cover plate. MHT #2 stated he took the metal plate to the nurse, notified her that he had found Patient #22 cutting himself/herself in the bathroom of patient room 310, had stopped patient #22 and showed her where patient #22 had cut himself/herself. He stated the physician was contacted for instructions at which time the physician ordered the facility to provide on Line-of-Site (LOS) supervision at approximately 6:45 PM. He reported Patient #22 was on special care from day shift so he/she could not do any extras other than groups and that Patient #22 was not on LOS when he/she was cutting himself/herself. Additionally, MHT #2 stated he kept patient #22 with him at all times and he remained his/her LOS provider. He further stated they were worried about the screw and the plate, that the screw was still in the wall and the metal plate was bent in half but on an angle. Patient #22 was able to remove the metal plate from the wall without removing the screw. Maintenance was called and put a new metal plate on the wall. After the incident and the change in the Patient's assessed level of supervision there was no evidence that the facility had taken action to ensure that the Patient did not have access to contraband or items that could potentially be used to harm him/herself per their Safe Environment policy.


After the incident on 10/23/12, the facility staff was providing LOS observation which continued on 10/24/12 per physician orders. An interview with MHT #1, on 10/26/12 at approximately 6:35 PM, revealed the assignment was to provide LOS and special care supervision. The MHT stated on 10/24/12 Patient #22 went to the bathroom, stating he/she had to have a bowel movement. The privacy curtain was pulled but you could see Patient #22's feet and the MHT was conversing with Patient #22 while using the bathroom. MHT #1 reported he pulled the curtain back every 30 seconds, looked in and made eye contact with the patient. Each time the MHT looked in, Patient #22 would cover his/her genital area with his/her hands. Patient #22 was in the bathroom approximately 15 minutes. MHT #1 reported that approximately 2 - 3 minutes after Patient #22 had finished using the bathroom, Patient #22 stated he/she had to tell him something, then reached into his/her pocket and pulled out a white plastic section of a spoon which he/she had used to cut the initials FOE on his/her left hand. After the incident, he/she was placed on 1:1 supervision. MHT #1 stated he was unaware of the facility having any type of supervision for the plastic dinnerware when patients go into the dining room.


During an interview with RN #4, on 10/29/12 at approximately 10:55 AM, she stated when a patient is on LOS while the patient is in the bathroom staff are to check on the patient every 30 seconds. She stated that Patient #22 was in the bathroom on LOS when he/she cut himself/herself. Patients on special care (LOS) do not leave the unit, their meals are brought to them on the unit. She also reported it was her understanding that Patient #22 had obtained the piece of plastic used to cut himself/herself a couple of days before as Patient #22 was able to go to the cafeteria on 10/22/12 and 10/23/12.

The facility could provide no documented evidence that they had taken action to ensure that Patient #22 had no access to contraband or items that he/she could harm him/herself with per the facility's Safe Environment policy, despite the facility having initiated suicide precaution observations upon admission and having two incidents of cutting him/herself.



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2. On initial tour on 10/24/12 at 3:50 PM, in a patients room 113b, two pencils (contraband) were observed on a bedside table, one pencil was lying in a journal and another was found in a container sitting on the bedside table.

On tour 10/25/12 at 9:58 AM, in patient rooms 200, 206, 214, and 211 found pencils (contraband). Pencils were noted on bedside tables laying in open and placed in journals.

A interview with MHT #9, on 10/25/12 at 9:55 AM, she stated room checks had not been performed today. Tour of room 200 revealed the only item in the room was a pencil on the desk. MHT #9 stated the patient had just been discharged and the room had not been searched or cleaned since the discharge.

A interview with Director of Admissions, on 10/25/12 at 10:09 AM, who was present during tour stated she would not have expected to find any pencils in the patient's rooms.

A interview with MHT #8, on 10/25/12 at 10:11 AM, who was present during tour stated they try to monitor use of pencils during journaling in groups and therapy rooms. States he tries to monitor use of pencils on regular checks when they are working individually in their rooms. States he would not expect to see any pencils laying in rooms unattended. Room searches are completed on first shift everyday, says he usually finds several pencils daily. He stated patients in rooms 206, 211, and 214 have assignments from therapy and during chemically dependency (CD) which requires use of pencils in group and individual therapy.

A interview with the Director of Nursing (DON), on 10/26/12 at 8:45 AM, revealed patients are not suppose to have pencils in their rooms they are considered contraband, the nurses and the MHT are responsible to ensure patients do not have pencils (contraband) without supervision.

An interview with Director of Clinical Services, on 10/24/12 at 3:50 PM, who was present the during initial tour revealed patients are not suppose to have pencils in their room, pencils are considered contraband, and patients are only allowed to use them under direct supervision. She was unsure as to how the patient had possession of the pencils. The facility's policy/procedures state patients are not suppose to have pencils in room they are considered contraband.



3. A review of the facility's "Nursing Services Plan" revealed the facility utilizes the principles of psychiatric nursing as outlined by the American Nurses Association Standard of Psychiatric and Mental Health Nursing Practice along with the Kentucky Nurse Practice Act. The patient and his/her significant others are vital participants in the treatment process. The nurse ensures continuous patient/family contact, serves to identify, communicate and influence the outcome of problems in the actual or potential realms. Every patient is assigned a nurse who is responsible for the coordination and documentation of care. Nurses engage in a number of activities to provide quality patient care. Activities critical to the provision of patient care include transcription and implementations of physician orders.


A review of a closed record revealed the facility admitted Patient A on 07/17/12 with diagnoses to include Major Depression and Impulse Control Disorder NOS. Review of Patient A's admission physician orders, dated 07/17/12, revealed the attending psychiatrist ordered a urine test for pregnancy. Review of labs and a Healthcare Peer Report revealed the facility did not ensure the pregnancy test was obtained during the patient's stay.

A review of a closed record revealed the facility admitted Patient B, on 08/09/12, with diagnoses to include Major Depression, recurrent with psychosis. Review of Patient B's admission physician orders, dated 08/09/12, revealed the attending psychiatrist ordered a urinalysis, pregnancy test and a electrocardiography (EKG). Review of the labs and a Healthcare Peer Report revealed the facility did not ensure that the urinalysis, pregnancy test, or EKG was obtained during the patient's stay.

A review of a closed record revealed the facility admitted Patient C, on 9/10/12, with diagnoses to include Depressive Disorder. Review of Patient C's admission physician orders, dated 9/10/12, revealed the attending psychiatrist ordered an EKG and Toxicology report. Review of the labs and the Healthcare Peer Report revealed the facility did not ensure the EKG was obtained during the patient's stay.

A review of a closed record revealed the facility admitted Patient D, on 8/16/12, with diagnoses to include Depressive Disorder not otherwise specified (NOS). Review of Patient D's physician orders dated 9/05/12 revealed the attending psychiatrist ordered a Depakote level and a Urine Culture and Sensitivity (C&S) the morning the patient was discharged to home. Review of the labs and the Healthcare Peer Report revealed the facility did not ensure that either the Depakote level or Urine C&S were ever collected or completed.


A review of a closed record revealed the facility admitted Patient E, on 7/3/12, with a diagnoses of Attention Deficit Disorder, Intermittent Explosive Disorder, and Mood Disorder. Review of Patient #E's physician's orders, dated 7/3/12, revealed the attending physician ordered a Urine Toxicology Screen, Complete Blood Count (CBC). and Urine Analysis (UA). Further review of Patient E's medical record revealed there was no documented evidence the labs had been completed; however, there was a written statement from the facility's quality reviewer (Health Information) that the patient did not receive the aforementioned labs.

A review of a closed record revealed the facility admitted Patient F, on 7/18/12, with diagnoses of Alcohol Dependence and Depressive Disorder. Review of Patient F's medical record revealed the attending physician's order for an EKG dated 7/18/12. Further review of Patient F's medical record revealed a written statement from the facility's quality reviewer (Health information) stating he/she had never received the EKG.

A interview with the Director of Nursing (DON), on 10/24/12 at 8:45 AM, revealed our labs and EKG's should be obtained as the physician orders indicate and the nurses are responsible to follow up to ensure physician orders are carried out. Our policy states that labs, EKG's, treatments are done as ordered by the physician and nurses are responsible for carrying out the physicians order. She stated she and the facility was aware of these failures and was trying different interventions. She stated resolution to the problem had proven unsuccessful. Further interview, on 10/25/12 at 10:00 AM, revealed while reviewing the Health Care Peer Review Report, in July 2012 the facility failed to obtain sixteen labs and/or EKGS; in August 2012 there were twelve failures; and there were twenty two failures to obtain labs and/or EKGs for patients in September 2012.

An interview with the Risk Manager/Performance Improvement Director, on 10/25/12 at 3:10 PM, revealed the facility had known about the nurses failure to obtain labs and or EKG's as ordered by the physician for four months. The number of failures to obtain labs and or EKG's had totalled twelve for the month of September 2012; however, review of the Healthcare Peer Review report revealed there were 22 patients who failed to have physician orders followed for obtaining labs and or EKG's. If there had been any harm as a result of these failures it would have been captured on another report titled Life Threatening Change in Condition. There had been no notification made to the attending physician and or the patient/legal representative that the facility failed to obtain labs and or EKG's as ordered by the physician.

The facility failed to ensure Nursing Services that met the ongoing needs of the patient related to the failure to provide adequate supervision and failed to obtain laboratory services and electrocardiographs (EKG) as ordered by the physician for six patients (A, B, C, D, E and F) outside of the selected sample of 22. This failure was identified by the facility four months ago and has been an ongoing problem. Multiple interventions implemented by the facility to correct these failure were unsuccessful and the facility still has an ongoing problem with failure to carry out physician orders as detailed in the record reviews.

These failures resulted in the determination of non-compliance at the Condition of Participation related to Nursing Services.








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Based on observation, interview and record review it was determined the Condition of Participation: Physical Environment was not met. The facility failed to maintain the physical environment to ensure the safety and well-being of patients.

A Life Safety Code survey was initiated on 10/24/12 and concluded on 10/24/12. Life Safety Code deficiencies were cited that determined the Condition for Participation for Physical Environment at 42 CFR 482.41 was not met under A710.

Refer to LSC tags: were K62, K 50, K45, K147, K47, K56, K27, K66, K18, K29, and K70.

Based on observation, interview and record review, it was determined the facility failed to maintain the physical environment to ensure the safety and well-being of patients.

A Life Safety Code survey was initiated on 10/24/12 and concluded on 10/24/12. Life Safety Code deficiencies were cited at 42 CFR 482.11.

Refer to LSC tags: K62, K 50, K45, K147, K47, K56, K27, K66, K18, K29, and K70.

Based on observations, interviews and review of the facility's policy/procedures, it was determine the facility failed to store food under appropriate conditions to include appropriate food temperatures. Observations on tour revealed there was no thermometer located in the interior of the walk-in refrigerator and staff was utilizing the exterior thermometer to make a determination of the interior temperatures of the stored foods. Interviews with staff revealed the interior thermometer had been missing for 2 days and staff had been documenting the exterior temperatures on the Refrigerator Temperature Log sheet since then.

Findings include:

A review of the "Dietary Services" policy/procedure (dated 11/03/08), revealed thermometers will be placed in the warmest area of the walk in refrigerator and will be used to check temperatures. Refrigerator and frozen foods will be stored properly for optimal product safety.

An observation, on 10/24/12 at 11:15 AM, revealed the walk in refrigerator had no thermometer located in the interior of the refrigerator. Review of the Refrigerator Temperature Log sheet revealed initials and temperatures documented for days 10/23-24/12 by staff who were on duty during the initial kitchen tour.

An interview with the Dietary Manager, on 10/24/12 at 11:50 AM, revealed the interior thermometer was missing and staff should not be looking at the exterior thermometer to make a determination of the temperature of the foods in the walk in refrigerator. Policy/procedure states the interior thermometer should be placed in the warmest area of the walk in refrigerator and used to check food temperatures.

An interview with Cook #1, on 10/24/12 at 11:45 AM, revealed the interior thermometer in the walk in refrigerator had been missing for a couple of days. She looked at the exterior thermometer on the outside of the walk in refrigerator and documented the temperatures she found, and those were her initials on the Refrigerator Temperature Log sheet where she documented the food temperatures this morning.

Interview with Cook #2, on 10/24/12 at 12:10 PM, revealed he looked at the thermometer on the outside of the walk in refrigerator to determine the interior food temperatures and those were his initials on the Refrigerator Temperature Log sheet dated 10/23/12 on the afternoon shift. He was aware the facility's policy/procedure said to look at the interior thermometer, however, the interior thermometer was gone.