HospitalInspections.org

Based on record reviews and interview, the hospital failed to meet the requirement of the Condition of Participation of Governing Body as evidenced by:

1) Failing to ensure the governing body was effective in carrying out its responsibilities for the conduct of the hospital as evidenced by failure to have documented evidence of the governing body's awareness of the ongoing activities of the hospital.

Review of the Governing Body meeting minutes of meetings conducted on 01/16/17, 11/16/16, 10/26/16, 10/07/16, 08/01/16, and 06/30/16 revealed no documented evidence of reports presented by any hospital departments including Quality Improvement. The only documented information included approval of physicians to be credentialed.

2) Failing to meet the requirements of the Condition of participation of Patient Rights as evidenced by failing to ensure that each patient received care in a safe setting. The hospital failed to ensure:

a) Patient observations by staff were conducted as ordered by the physician for 6 (#4, #5, #6, #R4, #R5, #R3) of 6 patients observed on the hospital-provided video recording;

b) Identified safety risks that were identified by CMS recognized accrediting organization Survey Team on 01/26/17 had been mitigated; and

c) Patients at risk for danger to self and others received consistent and conclusive suicide risk assessments.

An Immediate Jeopardy situation was identified on 01/31/17 at 4:30 p.m. and reported to S1ADM. The Immediate Jeopardy situation was a result of the hospital failing to ensure that each patient received care in a safe setting as evidenced by:

1) Failing to ensure patient observations by staff were conducted as ordered by the physician for 6 (#4, #5, #6, #R4, #R5, #R3) of 6 patients observed on the hospital-provided video recording;

2) Failing to ensure identified safety risks that were identified by CMS recognized accrediting organization Survey Team on 01/26/17 had been mitigated; and

3) Having patients at risk for danger to self and others with inconsistent and inconclusive suicide risk assessments.

The hospital's plan of removal for the immediate jeopardy situation was not fully implemented at the time of the survey, therefore, the Immediate Jeopardy situation remained in place as of the time of exit on 02/01/17 at 3:35 p.m.

Based on record review and interview, the governing body failed to ensure medical staff members were appointed in accordance with the Medical Staff By-laws as evidenced by failure to have all required documents available for review at the time of appointment/reappointment for 2 (S3MD, S8Psychiatrist) of 2 physician credentialing files reviewed from a total of 11 physicians credentialed by the hospital.

Findings:

Review of the "Medical and Professional Staff Organization Bylaws", presented as the current bylaws by S5COO, revealed that information required included recommendations from three persons other than family or affiliated by marriage for initial appointments and one for reappointment. Further review revealed evidence of a query sent to the NPDB and is also required. There was no documented evidence that the by-laws addressed whether a request for privileges had to be completed and returned with each reappointment application.

S3MD
Review of S3MD's credentialing file revealed his reappointment and medical privileges were approved and appointment recommended by the Medical Executive Committee and the governing body on 06/07/16 with an effective date from 06/07/16 to 06/07/18. Further review revealed the exclusions search was conducted on 10/04/16, after he had been appointed. Further review revealed his request for privileges was dated 05/27/14 with no documented evidence of a current request prior to his appointment. The NPDB query was conducted on 06/08/16, the day after he was appointed. Review of S3MD's file revealed no documented evidence of a peer recommendation as required by the by-laws.

S8Psychiatrist
Review of S8Psychiatrist's credentialing file revealed his appointment and medical privileges were approved and appointment recommended by the Medical Executive Committee and the governing body on 01/27/16 with an effective date from 01/27/16 to 01/27/18. Further review revealed no documented evidence of a third peer recommendation as required by the by-laws.

In a telephone interview on 02/01/17 at 2:12 p.m., S12HRG indicated she was responsible for credentialing corporate-wide. She further indicated previously each hospital in the group was responsible for their own credentialing, but the process was changed, because the facilities weren't doing their own credentialing. S12HRG indicated a request for privileges was supposed to submitted at the time of reappointment. When informed that S3MD didn't have a peer reference, she indicated she didn't know that this was needed. She confirmed that only two references were present for S8Psychiatrist, and she was aware that 3 references were required for initial appointments. S12HRG indicated she found some these findings when she took over the responsibility corporate-wide, but she didn't know how to correct what had been done previously.

Based on observations, record reviews, and interviews, the hospital failed to meet the requirements of the Condition of Participation for Patient Rights as evidenced by failing to ensure that each patient received care in a safe setting. The hospital failed to ensure:

1) Patient observations by staff were conducted as ordered by the physician for 6 (#4, #5, #6, #R4, #R5, #R3) of 6 patients observed on the hospital-provided video recording;

2) Identified safety risks that were identified by CMS recognized accrediting organization Survey Team on 01/26/17 had been mitigated; and

3) Patients at risk for danger to self and others received consistent and conclusive suicide risk assessments.

An Immediate Jeopardy situation was identified on 01/31/17 at 4:30 p.m. and reported to S1ADM. The Immediate Jeopardy situation was a result of the hospital failing to ensure that each patient received care in a safe setting as evidenced by:

1) Failing to ensure patient observations by staff were conducted as ordered by the physician for 6 (#4, #5, #6, #R4, #R5, #R3) of 6 patients observed on the hospital-provided video recording;

2) Failing to ensure identified safety risks that were identified by CMS recognized accrediting organization Survey Team on 01/26/17 had been mitigated; and

3) Having patients at risk for danger to self and others with inconsistent and inconclusive suicide risk assessments.

The hospital presented a plan of removal on 02/01/17 at 9:40 a.m. that included the following:

1) The census shall be held at a maximum of 24 patients to ensure staff availability for increased monitoring of the unit and allowing for rotation of work to be completed in patient rooms. There was no documented evidence of the responsible party and the date to be completed.

2) Oncoming staff shall be educated at each shift on the changes to to the policy "Suicidal Risk/Protective Factors Assessment And Precautions" and the new Suicide Risk Assessment form use. A mandatory staff meeting will be held on 02/02/17 to review all findings and changes to policies and procedures and to educate on expectations. An emergency Medical Executive Committee meeting is being held on 02/02/17 to review the findings and approve the corrective actions and policies and procedures. There was no documented evidence of the plan to ensure that all staff will receive education prior to working their shift. The revised policies and procedures and new assessment tool was not approved by the governing body as of the date and time that the plan of removal was submitted to survey team. Review of the revised policy revealed the following areas that were not addressed: verbiage regarding what the nurse would do if a patient was actively suicidal was vague; the numerical scoring system was not based on any standard and had been determined by the administrative team based on review of some of their patients' assessments; the high risk score was determined to be 30, and if 9 of the 33 in the high-risk column were selected, the patient would be scored at moderate risk; the nurse had 8 hours to complete the initial assessment, and there was no documented evidence that the policy addressed how the patient would be monitored if the patient was not assessed for up to 8 hours.

3) A new Suicide Risk Assessment Tool was created to be used immediately by all disciplines on paper until it can be integrated into the electronic medical record. There was no documented evidence that the tool had been approved by the governing body.

4) An audit tool was created to monitor 100% of charts daily by S2DON for nursing, the Social Services Director for social services, and S1ADM for physicians. There was no documented evidence of the length of time that the 100% daily audits would be conducted and actions to be taken for non-compliance with policies and procedures.

5) The 24 hour chart check was modified to include that the risk assessment is complete and appropriate precautions/levels of observation have been assigned.

6) An Interim Life safety Measures Plan to mitigate safety risks identified by Joint Commission was created, and the plan failed. The hospital administration met with the licensed contractor on 01/31/17 regarding an action plan necessary to correct identified risks. The contractor will provide a work plan schedule with a proposed date of completion by 02/01/17. A new mitigation plan was implemented immediately on 01/31/17 at 5:30 p.m. that included increased monitoring of patient areas posing risks by assigning a staff member on each shift to conduct observation utilizing the Patient Room Monitoring Tool. Staff performing monitoring was educated on 01/31/17 at 6:00 p.m., and each oncoming shift staff will be educated prior to engaging in the special monitoring. All staff will be educated in the mandatory staff meeting on 02/02/17. S1ADM will review cameras daily as of 02/01/17 to ensure proper monitoring is being conducted. Documentation of camera review along with correction action necessary will be conducted by S1ADM on the newly created Camera Review Log. The camera access will be available to S1ADM and S2DON remotely effective 02/01/17. There was no documented evidence of the length of time that the camera monitoring would be conducted.

7) Piano hinges were ordered and delivered, and one-to-one (1:1) supervision of patients in seclusion will be done until the hinges can be replaced.

8) Install schedule by the contractor for completing the covering of plumbing fixtures in the time-out and seclusion rooms will be received by 02/01/17. The completion date was documented as 02/03/17.

9) New anti-ligature faucets were ordered. To mitigate risk until the faucets can be installed, increased monitoring will be done by assigning a staff member on each shift to conduct observations utilizing the Patient Room Monitoring Tool. The tool provided for every 30 minutes room checks. S5COO indicated it takes approximately 30 minutes to complete the assigned rounds of all patient rooms. When informed that if this observation takes 30 minutes for the staff to complete the entire hospital rooms, the patient's observation remains at every 15 minutes as was previously being done. S5COO indicated they would have to re-look at possibly assigning a staff member to do the observations on each hall (3 halls) rather than one staff member to do the entire hospital rooms.

10) All bed side rails will be removed as of 02/01/17. Each bed posing ligature risks will be replaced with box beds. Confirmation of delivery date with the contractor will be received on 02/01/17. Increased monitoring as stated in number 9 above will be implemented, along with camera reviews by S1ADM, will be done to mitigate the risk.

11) Met with contractor to plan for removal of the current door handles on patient room doors and secure the holes. The same plan for mitigating risk as stated in number 9 and 10 above will be implemented until this is completed.

12) The loose wires were secured and the multi-plug surge protector and television box were removed in the day room. Unsupervised access to the day room will restricted until wires can be permanently secured by the contractor with a completion date of 02/04/17.

13) Met with contractor to smooth the edges of the plexi-glass. Plan for mitigation is the same as stated in numbers 9 and 10 above. There is no documented evidence of the responsible party and date of completion for this plan.

14) Rooms "o" and "q" will be blocked from use until the holes in the walls can be repaired. There is no documented evidence of the responsible party and date of completion for this plan.

15) Room "x" will be blocked from use until the door is repaired and the mattress can be replaced. There is no documented evidence of the responsible party and date of completion for this plan.

16) The Seclusion Room on Hall C will be blocked until repairs can be made to the plumbing, the mattress replaced, and the lock repaired. Census will be limited to 24 as per regulations until the room is fully functional. There is no documented evidence of the responsible party and date of completion for this plan.

17) All electrical sockets in patient rooms will be covered with solid plate covers. There is no documented evidence of the responsible party, and the date of completion is 02/02/17.

18) All staff who failed to perform observations as ordered will receive formal written disciplinary action within 24 hours with a final warning of termination of any future occurrences. All direct care staff will be educated on observations prior to providing patient care and again at the mandatory staff meeting on 02/02/17. No staff shall be allowed to work without evidence of of re-education. S1ADM will review cameras on every hall daily as of 02/01/17 to ensure proper monitoring and will complete the Camera Review Log.

In an interview on 02/01/17 at 9:40 a.m. with S1ADM, S2DON, S4DQC, and S5COO present, S4DQC indicated they took a few of their patients' records and looked at how the patient would have scored with the scoring system they developed for suicide risk assessments. S5COO indicated they need to take their suicide risk assessment policy "back to the table" for discussion, because they need to include a homicide risk assessment. S1ADM confirmed that the plan of removal, the revised policies and procedures, and the newly-developed suicide risk assessment tool had not been presented to the governing body for approval.

The hospital's plan of removal was not fully implemented at the time of the survey, therefore, the Immediate Jeopardy situation remained in place as of the time of exit on 02/01/17 at 3:35 p.m.

See findings in Tag 0144.

Based on observations, record reviews, and interviews, the hospital failed to ensure each patient had the right to receive care in a safe setting as evidenced by:

1) Failing to ensure patient observations by staff were conducted as ordered by the physician for 6 (#4, #5, #6, #R4, #R5, #R3) of 6 patients observed on the hospital-provided video recording;

2) Failing to ensure identified safety risks that were identified by CMS recognized accrediting organization Survey Team on 01/26/17 had been mitigated; and

3) Having patients at risk for danger to self and others with inconsistent and inconclusive suicide risk assessments.

Findings:

1) Failing to ensure patient observations by staff were conducted as ordered by the physician:
Video footage from the morning of 01/31/17 of Hall A and Hall C was reviewed on 01/31/17 at 1:00 p.m. with S1ADM.

Video footage from Hall A revealed Patient #4 (ordered to be on suicide precautions) was in his room with the door closed, and no staff members entered the patient's room for a period of 1 hour and 8 minutes (from 2:23 a.m. until 3:31 a.m.). Review of Patient #4's "Close Observation Form" revealed S10MHT documented that she had observed Patient #4 in his room every 15 minutes during the time frame referenced above while the video footage showed no staff member had entered the patient's room.

Video footage from Hall C revealed Patient #5 (ordered to be on suicide precautions) was in his room with the door closed, and no staff members had entered the room for a period of 4 hours and 2 minutes (from 2:49 a.m. until 6:51 a.m.). Review of Patient #5's "Close Observation Form" revealed S11MHT documented that he had observed Patient #5 in his room every 15 minutes during the time frame referenced above while the video footage showed no staff member had entered the patient's room.

Video footage from Hall C revealed Patient #6 (ordered to be on suicide precautions) was in his room with the door closed, and no staff members had entered the room for a period of 43 minutes (from 2:49 a.m. until 3:32 a.m. when S16RN entered the room). Further review revealed no staff member entered the room for a period of 2 hours and 19 minutes (from 3:32 a.m. until 5:51 a.m.). Review of Patient #5's "Close Observation Form" revealed S11MHT documented that he had observed Patient #6 in his room every 15 minutes during the time frame referenced above while the video footage showed no staff member had entered the patient's room.

Video footage from Hall C revealed Patient #R4 was in her room with the door closed and no staff members had entered the room for a period of 43 minutes (from 2:49 a.m. until 3:32 a.m. when S16RN entered the room). Further review revealed no staff member entered the room for a period of 2 hours and 14 minutes (from 3:32 a.m. until 5:46 a.m.). Review of Patient #R4's "Close Observation Form" revealed S11MHT documented that he had observed Patient #R4 in her room every 15 minutes during the time frame referenced above while the video footage showed no staff member had entered the patient's room.

Video footage from Hall C revealed Patient #R5 was in her room with the door closed and no staff members had entered the room for a period of 43 minutes (from 2:49 a.m. until 3:32 a.m. when S16RN entered the room). Further review revealed no staff member entered the room for a period of 3 hours and 19 minutes (from 3:32 a.m. until 6:51 a.m.). Review of Patient #R5's "Close Observation Form" revealed S11MHT documented that he had observed Patient #R5 in his room every 15 minutes during the time frame referenced above while the video footage showed no staff member had entered the patient's room.

Video footage from Hall C revealed Patient #R3 was in her room with the door closed and no staff members had entered the room for a period of 43 minutes (from 2:49 a.m. until 3:32 a.m. when S16RN entered the room). Further review revealed no staff member entered the room for a period of 2 hours and 14 minutes (from 3:32 a.m. until 5:46 a.m.). Review of Patient # R3's "Close Observation Form" revealed S11MHT documented that he had observed Patient #R3 in her room every 15 minutes during the time frame referenced above while the video footage showed no staff member had entered the patient's room.

In an interview on 01/31/17 at 2:00 p.m. with S1ADM, he said the MHT's were supposed to observe the patients every 15 minutes to ensure their safety. He said S10MHT and S11MHT did not observe all of their patients every 15 minutes, although they documented that they had. He said the lack of observations was inexcusable, and he had no idea the patients were not being observed as ordered.

In an interview on 02/1/17 at 8:45 a.m. with S11MHT, he said he was working on the night of 01/30/17 and the morning of 01/31/17. S11MHT said the 15 minute rounds were done to make sure the patients were safe and not harming themselves or other patients. S11MHT said he was supposed to lay eyes on (visualize) the patients every 15 minutes. S11MHT said on the morning of 1/31/17 he did document on the patients every 15 minutes but did not actually observe them.

In an interview on 02/1/17 at 8:57 a.m. with S10MHT, she said she worked on the night of 01/30/17 and 01/31/17. She said 15 minute rounds meant she had to see the patients every 15 minutes to make sure they were alright. S10MHT said she was not aware Patient #6 did not get checked on every 15 minutes, although he was assigned to her, and she had documented that she had observed him every 15 minutes. S10MHT said they work as a team, and someone else was checking on Patient #6 for her. When asked who had checked on him, she could not recall.


2) Failing to ensure identified safety risks that were identified by CMS recognized accrediting organization Survey Team on 01/26/17 had been mitigated:

Observations during the tour of the hospital on 01/30/17 at 11:25 a.m. with S4DQC present revealed the following safety risks were identified:

a) All patient room entrance doors have the handle on the outside facing down which provides a ligature risk. There are 33 patient rooms.

b) All patient bathrooms have gooseneck faucets which provide a ligature risk.

c) The plexi-glass covering on the windows in the following patient rooms and/or bathrooms have sharp edges which provide a safety risk for cutting: Rooms " a " , " b " , " c " , " e " , " f " , " g " , " i " , " j " , " k " , " l " , " m " , " n " , " o " , " p " , " r " , " s " , " v " , " y " , " z " , " bb " , " dd " .

d) Beds in Rooms " a " , " b " , " c " , " d " , " e " , " f " , " g " , " h " , " i " , " j " , " m " , " n " , " o " , " p " , " q " , " r " , " s " , " t " , " u " , " v " , and " w " have ligature points that include side rails, hand cranks at the foot of the bed, and/or metal springs with an opening between each on the base where the mattress lies. All of these beds have a mattress with a zipper that can be unzipped that provides a means of suffocation or a place where contraband can be hidden.

e) Rooms " a " , " b " , " c " , " d " , " e " , " f " , " g " , " h " , " i " , " j " , " k " , " l " , " p " , " q " , " r " , " s " , " t " , " u " and " v " have exposed electrical outlets in the bedroom that provides a means for electrocution.

f) The mattress in Room " cc " had an opening on the side approximately 2 feet wide that presented a risk for suffocation or a means of hiding contraband. There was a hole in the bathroom wall behind the toilet that was large enough to provide a means of hiding contraband.

g) The Shower Room on Hall C had hinges on the door that were not continuous that presented a ligature risk. The door handle was facing sideways and presented a ligature risk. The sink faucets could be used as ligatures.

h) Room " dd " had 4 open holes in the wall behind the toilet that could be used to hide contraband.

i) The Seclusion Room on Hall B and C had the door with hinges that were not continuous. The hand rails in the bathroom have approximately 1.5 to 2 inch opening between the rail and the wall that presented a ligature risk. The plumbing for the sink and toilet were not contained. The door lock on the Seclusion Room on Hall C had been removed leaving exposed sharp wooden edges that could be a risk for cutting or injury. The bed frame in this seclusion room had 10 metal hand-like grips that could be lifted and used as a ligature.

j) Windows in the bathroom of Rooms " b " , " k " , and " ff " had an opening in the plex-glass that allowed contact with the window lock that when pulled outward provided a ligature risk. The bathroom in Room " ff " had the mirror removed with the remaining glue having sharp edges.

k) The entrance door to Room " x " had chipped wood on the inside of the door that left sharp edges that could be a risk for cutting or splinters.

l) The Group Therapy Room/Quiet Space on Hall C had a radio with long wires that provided a ligature risk. The door hinge was not continuous and left an opening between each hinge that could be a ligature risk.

m) The Occupational/Group Room on Hall C door did not have a continuous hinge that left an opening between each hinge that could be a ligature risk. In the room there was an area where a washer and dryer had been but had been removed. This area had the vent opening exposed and an unprotected electrical outlet on the wall. The window covering of the six windows in the room had an opening in the plex-glass that allowed contact with the window lock that when pulled outward provided a ligature risk.

n) Rooms " gg " and " hh " had the toilet plumbing not contained. The hinge on the entrance doors were not continuous leaving spaces between the hinges that could be a ligature risk.

o) The outdoor area used by patients had a wooden fence that separated the hospital ' s outdoor area from an adjacent separate facility ' s outdoor space. The fence had a wooden know protruding with a sharp edge on the gate, a slat to the right of the gate that was cracked and had a sharp edge, and 2 slats on the left side of the fence that had sharp protruding edges of wood.

p) The Group Room on Hall A had 14 windows that had an opening in the plex-glass that allowed contact with the window lock that when pulled outward provided a ligature risk. There was an outlet strip with a long cord that was a ligature risk, as well as a long cord from the television box to the outlet.

Review of the manufacturing literature, titled "Leviton Installing and Testing a GFCI Receptacle", presented by S1ADM on 01/30/17 at 2:15 p.m., revealed that "a GFCI receptacle does not protect against circuit overloads, short circuits, or shocks. For example, you can still be shocked if you touch bare wires while standing on a non-conducting surface..."

In an interview during the above observations, S4DQC confirmed the above findings. She indicated these were the same findings identified during the recently completed Joint Commission survey that was conducted on 01/26/17.


3) Having patients at risk for danger to self and others with inconsistent and inconclusive suicide risk assessments:

Review of the document titled Risk Assessment revealed it was a tool the nursing staff and social workers used to determine if a patient was no risk, a low risk, a moderate risk, or a high risk to themselves or others. Further review revealed a list of risk factors was rated from no risk to high risk based on the patient's history and current status. Once the form was completed, the staff completing the form would subjectively determine at what level of observation the patient needed to be monitored for safety.

Patient #2
Review of Patient #2's medical record revealed he was admitted to the hospital on 01/30/17. His presenting problem was listed as having presented to the emergency room for suicide attempt after verbal altercation with his girlfriend. He stated, "I would be better off dead". He had placed a firearm in his mouth, but the girlfriend pulled it away from him, and it discharged into the ground.

Review of Patient #2's Risk Assessment dated 01/30/17 at 5:41 a.m. revealed it had been completed by S17RN. Further observation revealed she had determined Patient #2 to be a moderate risk to himself which would have required him to be constantly observed by staff members.

Review of Patient #2's physician's orders dated 01/30/17 at 6:22 a.m. revealed S3MD ordered him to be observed every 15 minutes instead of constantly (41 minutes after the nurse had determined Patient #2 to be a risk to himself). Further review revealed S3MD did not assess Patient #2 until 5:30 p.m. on 01/30/17.

In an interview on 02/1/17 at 1:13 p.m. with S3MD, he said the orders for observation were based on what the patients said in the emergency department and what they said to the nurse. S3MD said the risk assessment should have been utilized to determine what observation level they were going to place the patient on at admission. S3MD said the risk assessments were not done consistently by the nurses. After reviewing Patient #2's risk assessment being scored as a moderate risk to self, he said during his assessment Patient #2 had said he was drunk and didn't mean to say he was going to kill himself. S3MD verified he had not yet assessed the patient when he had ordered the observation level, and it (the ordered observation level) would have been based off of the nurse's assessment.

In an interview on 01/31/17 at 10:40 a.m. with S18PIA, she said the nursing risk assessment had to be completed within 8 hours of admission. S18PIA said the nurses would call the doctor, and he would order an observation level based on the nurses' assessment. She said there was no policy on what observation level the patient was to be monitored until the risk assessment had been completed. S18PIA said the risk assessment tool was being redone because it was being scored differently by staff depending on who completed the form. S18PIA said the risk assessment tool was based on interpretation, not a standardized system. S18PIA said the hospital was making a new risk tool that was more specific and detailed, instead of vague. She said the physician made his order for assessment frequency based off what the nurses were telling him on the phone. For Patient #2, she said S2MD made the determination for the observation level to be every 15 minutes, although the tool ranked him to be direct observation. S18PIA said the current tool was too broad.

In an interview on 02/1/17 at 9:33 a.m. with S2DON, she said the suicide risk assessment needed to be something more distinctive and was too vague. S2DON said if someone came in suicidal, the staff needed to be more consistent when filling out the risk assessment, but they had not been. S2DON said the tool needed to be more specific of how to identify a high, medium, or low risk patient. S2DON said there was some ambiguity with the tool, and it was a little too subjective. S2DON verified the staff had 8 hours to complete the risk assessment, and the hospital did not have guidelines or policies on what level the patients would be observed until the initial risk assessment was completed.


30364

Based on record reviews and interview, the medical staff failed to ensure all required information was present at the time of appointment/reappointment of the medical staff prior to making a recommendation to the governing body as evidenced by failure to have queries, references, and/or request for privileges for 2 (S3MD, S8Psychiatrist) of 2 physician credentialing files reviewed from a total of 11 physicians credentialed by the hospital.

Findings:

Review of the "Medical and Professional Staff Organization Bylaws", presented as the current bylaws by S5COO, revealed that information required included recommendations from three persons other than family or affiliated by marriage for initial appointments and one for reappointment. Further review revealed evidence of a query sent to the NPDB and is also required. There was no documented evidence that the by-laws addressed whether a request for privileges had to be completed and returned with each reappointment application.


S3MD
Review of S3MD's credentialing file revealed his reappointment and medical privileges were approved and appointment recommended by the Medical Executive Committee and the governing body on 06/07/16 with an effective date from 06/07/16 to 06/07/18. Further review revealed the exclusions search was conducted on 10/04/16, after he had been appointed. Further review revealed his request for privileges was dated 05/27/14 with no documented evidence of a current request prior to his appointment. The NPDB query was conducted on 06/08/16, the day after he was appointed. Review of S3MD's file revealed no documented evidence of a peer recommendation as required by the by-laws.

S8Psychiatrist
Review of S8Psychiatrist's credentialing file revealed his appointment and medical privileges were approved and appointment recommended by the Medical Executive Committee and the governing body on 01/27/16 with an effective date from 01/27/16 to 01/27/18. Further review revealed no documented evidence of a third peer recommendation as required by the by-laws.


In a telephone interview on 02/01/17 at 2:12 p.m., S12HRG indicated she was responsible for credentialing corporate-wide. She further indicated previously each hospital in the group was responsible for their own credentialing, but the process was changed, because the facilities weren't doing their own credentialing. S12HRG indicated a request for privileges was supposed to submitted at the time of reappointment. When informed that S3MD didn't have a peer reference, she indicated she didn't know that this was needed. She confirmed that only two references were present for S8Psychiatrist, and she was aware that 3 references were required for initial appointments. S12HRG indicated she found some these findings when she took over the responsibility corporate-wide, but she didn't know how to correct what had been done previously.

Based on record reviews and interviews, the hospital failed to ensure the RN supervised and evaluated the nursing care of each patient as evidenced by:

1) Failure of the nursing staff to clarify physician orders that had no route of administration and/or indication for use for PRN medications ordered for 2 (#1, #3) of 6 patient records reviewed for indication for use of PRN medications.

2) Failing to ensure a RN assessed each patient at the time of admission as required by the LSBN's practice act for 1 (#6) of 6 sampled patients and 2 (#R1, #R2) of 2 random patients' records reviewed for RN assessment

Findings:

1) Failure of the nursing staff to clarify physician orders that had no route of administration and/or indication for use for PRN medications ordered:
Review of the policy titled "Medication Administration", presented as a current policy by S2DON, revealed that up-to-date medication information is available through the contracted pharmacy and includes information on indications for use. "PRN" medications administered are qualified by designating the times of administration and parameters, such as patient's blood sugar and blood pressure. There was no documented evidence that the policy required each physician order for PRN medications to include the indication for use and that a clarification order be obtained by the nurse if the indication for use was not documented by the physician's order.


Patient #1
Review of Patient #1's physician orders revealed the following medication orders with no documented evidence of the indication for use and/or route of administration:

Lorazepam 1 mg by mouth every 6 hours as needed;

Ativan 2 mg/ml, inject 0.5 ml every 6 hours as needed, give if refuses by mouth;

Clonidine 0.1 mg tablet by mouth twice a day as needed;

Milk of Magnesia 1200 mg/15 ml suspension, take 30 ml by mouth every 6 hours as needed;

Maalox Advanced 200 mg/5 ml suspension, take 20 ml by mouth every 4 hours as needed;

Acetaminophen 325 mg tablet, take 2 tablets by mouth every 8 hours as needed;

Haloperidol 5 mg tablet, take one by mouth every 6 hours as needed;

Haloperidol 5 mg/ml solution, inject 1 ml into muscle every 6 hours as needed, give if refuses by mouth administration.

In an interview on 01/31/17 at 10:15 a.m., S6PIA confirmed the medications ordered PRN or as needed did not have the indication for use, and the route of administration for Ativan was not documented. She confirmed there was no clarification order obtained by the nurse.


Patient #3
Review of Patient #3's physician orders revealed the following medication orders with no documented evidence of the indication for use and/or route of administration:

Zyprexa 10 mg one tablet by mouth every 6 hours as needed;

Milk of Magnesia 1200 mg/15 ml suspension, take 30 ml by mouth every 6 hours as needed;

Maalox Advanced 200 mg/5 ml suspension, take 20 ml by mouth every 4 hours as needed;

Acetaminophen 325 mg tablet, take 2 tablets by mouth every 8 hours as needed;

Phenergan 25 mg/1 ml solution inject 1 ml every 6 hours as needed.

In an interview on 02/01/17 at 12:15 p.m., S2DON confirmed the above findings. She confirmed there was no clarification order obtained by the nurse.


2) Failing to ensure a RN assessed each patient at the time of admission as required by the LSBN's practice act:

Review of LSBN's "Chapter 39. Legal Standards of Nursing Practice 3901. Legal Standards" revealed that the Louisiana State Board of Nursing recognizes that assessment, planning, intervention, evaluation, teaching, and supervision are the major responsibilities of the RN in the practice of nursing. The standards of nursing practice provides a means of determining the quality of care which an individual receives regardless of whether the intervention is provided solely by a RN or by a RN in conjunction with other licensed or unlicensed personnel.

Review of LSBN's "Chapter 37. Nursing Practice 3701. Duties of the Board Directly Related to Nursing Practice as cited in R.S. (revised statute) 37:918" revealed that assessing health status was defined as gathering information relative to physiologic, behavioral, sociologic, spiritual, and environmental impairments and strengths of an individual by means of the nursing history, physical examination, and observation, in accordance with the board's Legal Standards of Nursing Practice. Delegating nursing interventions was defined as entrusting the performance of selected nursing tasks by the RN to other competent nursing personnel in selected situations. The RN shall assess the patient care situation which encompasses the stability of the clinical environment and the clinical acuity of the patient, including the overall complexity of the patient's health care problems. The assessment shall be utilized to assist in determining which tasks may be delegated and the amount of supervision which will be required.


Review of the hospital's policy titled "Patient Assessment and Reassessment" revealed in part:
4. A registered nurse initiates the nursing assessment within 8 hours of the patient's admission.


Patient #6
Review of Patient #6's medical record revealed he had been admitted on 01/26/17 with the chief complaint of feeling very frustrated.

Review of Patient #6's initial nursing assessment dated 01/26/17 had been completed by S13LPN.


Patient #R1
Review of Patient #R1's medical record revealed she had been admitted to the hospital on 01/26/17 with the chief complaint of being depressed and frustrated.

Review of Patient # R1's initial nursing assessment dated 01/26/17 revealed it had been completed by S9LPN.


Patient #R2
Review of Patient #R2's medical record revealed she had been admitted to the hospital on 01/26/17 with the chief complaint of having severe depression.

Review of Patient # R2's initial nursing assessment dated 01/26/17 revealed it had been completed by S9LPN.

In an interview on 02/1/17 at 1:30 p.m. with S2DON, she verified the initial nursing assessment of the psychiatric patients should have been performed by a registered nurse.



30364

Based on record reviews and interviews, the hospital failed to ensure the nursing staff developed and kept current an individualized nursing care plan for each patient as evidenced by failure to have a comprehensive nursing care plan that included a plan for all medical problems for which a patient was being treated and goals that were measurable for 3 (#1, #3, #5) of 6 patient records reviewed for nursing care plans from a total sample of 6 patient records.

Findings:

Review of the policy titled "Plan of Care", presented as a current policy by S2DON, revealed that every patient shall have an individualized comprehensive plan of care that includes goals expressed in a manner that captures the patient's words or ideas. If a goal or objective must be deferred, the reason for the deferment is documented in the patient's medical record. Deferment of care, treatment, or services must be approved by the patient's attending licensed independent practitioner with the rationale for deferment documented. Measurable goals and objectives must be based on the assessed needs, strengths, and the patient's limitations.


Patient #1
Review of Patient #1's "Initial Psychiatric Evaluation" revealed her medical problems included Irritable Bowel Syndrome, Asthma, Type II Diabetes Mellitus, GERD, Anemia, and Fibromyalgia.

Review of Patient #1's "Core Problems" documented by S7RN revealed Asthma, Fibromyalgia, and Irritable Bowel Syndrome was deferred and not included in her nursing care plan with no documented evidence of the reason for these conditions being deferred and no approval for them being deferred by her physician.

Review of Patient #1's ordered medications revealed she had medications ordered to treat Asthma and Fibromyalgia.

In an interview on 02/01/17 at 8:40 a.m., S18PIA indicated the problems that were deferred were deferred, because Patient #1 was not receiving treatment for those problems while she was hospitalized. When informed that medications were ordered to treat Asthma and Fibromyalgia, S18PIA had no comment.


Patient #3
Review of Patient #3's Psychiatric Evaluation revealed she had medical problems of Hyperglycemia and Hypokalemia. Review of her medications ordered revealed an order for Potassium Chloride.

Review of Patient #3's Treatment Plan revealed a plan was implemented for risk for suicide and risk for decreased cardiac output related to Hypertension. There was no documented evidence that a plan was developed for Hyperkalemia and Hyperglycemia. Further review revealed the following goals that were not stated in measurable terms:
Patient will maintain a healthy lifestyle contributing to better management of Hypertension;
Patient will display improvement in blood pressure within 1 week;
Maintain blood pressure within individually acceptable range.

There was no documented evidence of the acceptable range for the blood pressure or how improvement in blood pressure would be measured.

In an interview on 02/01/17 at 12:15 p.m., S2DON confirmed the above findings.


Patient #5
Review of Patient #5's History and Physical revealed his medical problems included Hypertension, Hepatitis B and C, Epilepsy, and Nicotine Abuse.

Review of Patient #5's treatment plan revealed a plan was developed for suicidal ideations and brief psychotic disorder. Further review revealed the following goals that were not stated in measurable terms:
Alleviate depressed mood and return to previous level of functioning within 7 days;
Exhibit decreased frequency and intensity of psychotic and other severe mental illness symptoms.
Further review revealed no documented evidence that a care plan had been developed for his medical conditions of Hypertension, Hepatitis B and C, Epilepsy, and Nicotine Abuse.

In an interview on 02/01/17 at 12:36 p.m., S2DON confirmed the above findings.

Based on record reviews and interview, the hospital failed to ensure a RN assigned the nursing care of each patient to other nursing personnel in accordance with the patient's needs as evidenced by having the MHT who was assigned the observation of a patient on one-to-one (1:1) observation to also be assigned the observation of other patients in separate rooms or on a different hall of the hospital on 4 of 14 days reviewed for staffing assignments.

Findings:

Review of the nurse staffing pattern completed by S2DON from 01/16/17 through 01/29/17 revealed there were 8 days that Patient R6 was ordered to be on 1:1 observation. Review of the staffing assignments presented by S2DON for 01/21/17, 01/22/17, 01/23/17, and 01/26/17 and patients' "Close Observation Form" revealed the following shifts with the MHT assigned to observe Patient R6, who was ordered to be on 1:1 observation, also assigned to observe other patients:

01/21/17 Night Shift (7:00 p.m. to 7:00 a.m.) - S11MHT observed Patient R6, Patient R7, and Patient R8 the entire shift;

01/22/17 Night Shift - S11MHT observed Patient R6 and Patient R8 the entire shift;

01/23/17 Day Shift (7:00 a.m. to 7:00 p.m.) - S19MHT observed Patient R6, Patient R9, and Patient R5 simultaneously from 7:00 a.m. to 8:15 a.m., from 1:30 p.m. to 2:15 p.m., from 2:45 p.m. to 3:00 p.m., and from 4:15 p.m. to 4:45 p.m.;

01/26/17 Night Shift - S10MHT observed Patient R6 and Patient #4 the entire shift.

In an interview on 02/01/17 at 2:24 p.m., S2DON indicated the nurses are supposed to make the MHT assignments with the lead MHT each shift. She further indicated she was not aware that MHTs assigned to observe patients 1:1 were being assigned to observe other patients at the same time. She indicated she had done chart audits to check that the RN was signing the MHT observation records but had not reviewed for observation of 1:1 patients by one MHT with no other assignment. When asked if a MHT is able to observe a patient ordered to be 1:1 or at arm's length and also observe other patients, S2DON answered, "absolutely not." S2DON confirmed the above findings during the interview.

Based on record reviews and interviews, the hospital failed to meet the requirements of:

1) The Condition of Participation for Patient Rights (see findings in Tag 0115).

2) The Condition of Participation of Governing Body (see findings in Tag A0043).

Based on record review and interview, the hospital failed to ensure each patient received a psychiatric evaluation that included an inventory of the patient's assets in a descriptive, not interpretive, fashion as evidenced by failure to have documentation of the patient's assets for 1 (#5) of 6 patient records reviewed for psychiatric evaluations.

Findings:

Review of the policy titled "Psychiatric Evaluation", presented as a current policy by S2DON, revealed that the psychiatric evaluation includes an inventory of the patient's assets in descriptive, not interpretive fashion.

Review of Patient #5's "Initial Psychiatric Evaluation", documented by S3MD on 01/28/17 at 10:11 a.m. revealed no documented evidence that the patient's assets were included in the evaluation.

In an interview on 02/01/17 at 1:12 p.m., S3MD indicated he "must have mistakenly missed" assessing Patient #5's strengths.

Based on record reviews and interviews, the hospital failed to ensure each patient's written treatment plan included short-term and long range goals that were written as observable, measurable patient behaviors to be achieved as evidenced by having treatment plans that did not include all medical problems for which the patient was being treated and goals were not written as observable, measurable patient behaviors for 2 (#3, #5) of 6 patient records reviewed for treatment plans from a total sample of 6 patient records.

Findings:

Review of the policy titled "Plan of Care", presented as a current policy by S2DON, revealed that every patient shall have an individualized comprehensive plan of care that includes goals expressed in a manner that captures the patient's words or ideas. If a goal or objective must be deferred, the reason for the deferment is documented in the patient's medical record. Deferment of care, treatment, or services must be approved by the patient's attending licensed independent practitioner with the rationale for deferment documented. Measurable goals and objectives must be based on the assessed needs, strengths, and the patient's limitations. The policy did not require goals to be written as observable, measurable patient behaviors.


Patient #3
Review of Patient #3's Psychiatric Evaluation revealed she had medical problems of Hyperglycemia and Hypokalemia. Review of her medications ordered revealed an order for Potassium Chloride.

Review of Patient #3's Treatment Plan revealed a plan was implemented for risk for suicide and risk for decreased cardiac output related to Hypertension. There was no documented evidence that a plan was developed for Hyperkalemia and Hyperglycemia. Further review revealed the following goals that were not written as observable, measurable patient behaviors:

Patient will maintain a healthy lifestyle contributing to better management of Hypertension;

Patient will display improvement in blood pressure within 1 week;

Maintain blood pressure within individually acceptable range.

There was no documented evidence of the acceptable range for the blood pressure or how improvement in blood pressure would be measured.

In an interview on 02/01/17 at 12:15 p.m., S2DON confirmed the above findings.


Patient #5
Review of Patient #5's History and Physical revealed his medical problems included Hypertension, Hepatitis B and C, Epilepsy, and Nicotine Abuse.

Review of Patient #5's treatment plan revealed a plan was developed for suicidal ideations and brief psychotic disorder. Further review revealed the following goals were not written as observable, measurable patient behaviors:

Alleviate depressed mood and return to previous level of functioning within 7 days;

Exhibit decreased frequency and intensity of psychotic and other severe mental illness symptoms.

Further review revealed no documented evidence that a care plan had been developed for his medical conditions of Hypertension, Hepatitis B and C, Epilepsy, and Nicotine Abuse.

In an interview on 02/01/17 at 12:36 p.m., S2DON confirmed the above findings.