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Based on personnel file review and interview, the facility failed to ensure two (#2, #3) of three (#1, #2, #3) Contracted Rehabilitation Staff had current training in cardiopulmonary resuscitation as required by standard of practice according to the Rules and Regulations for Hospitals and Related Institutions in Arkansas 2016. The deficient practice had the potential to affect all patients receiving services from the two Contracted Rehabilitation Staff. Findings follow:


A. Personnel files for the Contracted Rehabilitation Staff were reviewed on 03/23/17 at 1230. Two (#2-Occupational Therapist, #3-Speech Language Pathologist) lacked evidence of training in cardiopulmonary resuscitation


B. An interview was conducted with the Administrator at 1410 on 03/23/17. The Administrator verified through interview Contracted Rehabilitation Staff #2 and #3 did not have training in cardiopulmonary resuscitation.

Based on observation, clinical record review, policy and procedure review, and interview, it was determined that the Governing Body failed to effectively discharge it's oversight responsibilities based on the deficiencies cited as follows:


1. Nursing Service staff failed to:


A. Provide evidence of staffing to assure the immediate availability of a Registered Nurse (RN) and other clinical staff for the bedside care of any patient. See A392

B. Ensure a RN evaluated the care of 10 (#17-#19, #21-#23 and #26-#29) of 30 (#1-#30) patients in that there was no evidence a RN assessed each patient each shift; ensure a RN supervised and evaluated the care of eight (#17, 18, 20, 22, #23, #27-#29) of ten (#17-#23, #27-#29) patients in that vital signs were not documented as performed as ordered by the physician; document a bath or shower daily on 22 (#1-#8, #10, #11, #15, #17, #19-#26, #28, and #29) of 30 (#1-#30) patients. See A395

C. Provide evidence of staffing assignments made by a RN for 4 of 4 patient care units (Unit #1-#4). See A397

D. Failed to assure the accurate maintenance of the clinical records in that seven (#17-#23) of eight (#17-#23 and #30) clinical records did not have accurate documentation of the percentage (%) of meal intake. See A438


The failed practices did not assure the immediate availability of a Registered Nurse for the bedside care of any patient; a Registered Nurse supervised and evaluated each patient's care, that vital signs were obtained and documented and that each patient was provided a shower or bath daily. The failed practice affected Patient #1-#8, #10, #11, #15, #17-#19, #20-#23 and #26-#29 and had the likelihood to affect all patients admitted to the facility.


2. The Infection Control Officer failed to have an active Infection Control Program to identify, report and control infections as follows:


A. Infection Control Officer failed to identify, report and control infections in that clothes were stored in which it could be determined if they were clean or dirty; the surface integrity of furniture was compromised due to rips, tears and rust which cannot be cleaned or disinfected; floors had a sticky residue; dust, dirt stains and trash on floors in five of five (Units 1-4 and Gym) areas observed. See A749

B. Infection Control Officer failed to ensure only currently dated supplies were available for patient and staff use in one of one Exam Room. See A749

C. Infection Control Officer failed to assure FIT testing was performed for new hires in two years (2015 -2017). See A749

D. Infection Control Officer failed to assure staff was knowledgeable of what constituted Personal Protective Equipment (PPE) and there was no evidence PPE was available in the Facility for four of four Nursing Units. See A749.

E. Infection Control Nurse failed to assure the nursing staff was knowledgeable in the process for cleaning and disinfection of shared patient equipment/toys and the recording of disinfection for four of four Nursing Units. See A749.

F. Infection Control Officer failed to control infections and provide a safe work environment in that expired Body Fluid Clean-up Kits were available for use in three of three (Unit One and Two Nursing Station, Unit Three and Four Nursing Station and the Dirty Laundry Room) areas. See A749


The cumulative effects of the failed practices placed each patient on census and staff at risk for infections.

Based on review of the Performance Improvement Plan, QA (Quality Assurance) Meeting Minutes, Governing Board Meeting Minutes, Medical Executive Committee Meeting Minutes for March 2016 through February 2017, and interview, it was determined the Facility failed to ensure Environmental Services and Rehabilitation Services were included in the Facility's QA Program. The failed practice did not ensure the Governing Body was responsible for all aspects of the Facility and created the potential to affect those departments. Findings follow.


A. Review of the Quality Assessment Plan revealed "Each committee/department/service shall report on a quarterly basis to the Quality Assessment Performance Improvement."

B. Review of QA Meeting Minutes, Governing Board Meeting Minutes and Medical Executive Committee Meeting Minutes for March 2016 through February 2017 revealed Rehabilitation Services had not reported during the first three quarters of 2016 and Environmental Services had not reported for the past four quarters.

C. During an interview on 03/22/17 at 1600, the Administrator confirmed the lack of Rehabilitation Services and Environmental Services QA.

Based on observation, review of clinical records, and interview, it was determined the Nursing Services staff failed to:

1. Provide evidence of staffing to assure the immediate availability of a Registered Nurse (RN) and other clinical staff for the bedside care of any patient. See A392

2. Ensure a RN evaluated the care of 10 (#17-#19, #21-#23 and #26-#29) of 30 (#1-#30) patients in that there was no evidence a RN assessed each patient each shift; ensure a Registered Nurse supervised and evaluated the care of eight (#17, 18, 20, 22, #23, #27-#29) of ten (#17-#23, #27-#29) patients in that vital signs were not documented as performed as ordered by the physician; document a bath or shower daily on 22 (#1-#8, #10, #11, #15, #17, #19-#26, #28, and #29) of 30 (#1-#30) patients. See A395

3. Provide evidence of staffing assignments made by a RN for 4 of 4 patient care units (Unit #1-#4). See A397

4. Failed to assure the accurate maintenance of the clinical records in that seven (#17-#23) of eight (#17-#23 and #30) clinical records did not have accurate documentation of the percentage (%) of meal intake. See A438


The failed practices did not assure the immediate availability of a Registered Nurse for the bedside care of any patient; a RN supervised and evaluated each patient's care, that vital signs were obtained and documented and that each patient was provided a shower or bath daily. The failed practice affected Patient #1-#8, #10, #11, #15, #17-#19, #20-#23 and #26-#29 and had the likelihood to affect all patients admitted to the facility.

Based on interview, review of the Director of Nursing Job Description, and documents provided during the survey, it was determined the facility failed to assure the immediate availability of a Registered Nurse and other clinical staff for the bedside care of any patient. Failure to maintain, review, and revise staffing schedules did not assure adjustments would be made based on the number and acuity of patients and that patient care needs would be met. The failed practice likely affected all patients admitted to the facility. The findings were:


A. Staffing assignments were requested from the Director of Nursing on 03/21/17 at 0848 during the entrance conference. On 03/22/17 at 1009, copies of the "Nursing Daily Report" for Units #1 and #2 for the period 02/01/17-03/21/17 were provided by the Director of Nursing. The Nursing Daily Report, a form that listed by shift the Registered Nurse and Behavioral Instructor staff assigned to each Unit, was incomplete in that 78 of 133 shift assignments for Unit 1 and Unit 2 from 02/01/17-03/21/17 were not documented.


B. On 03/22/17 at 1420, the Director of Nursing was interviewed and confirmed the incomplete Nursing Daily Reports for Unit 1 and Unit 2. Staffing assignments for Unit #3 and Unit 4 were requested and the Director of Nursing stated she did not have them because they were incomplete. The Director of Nursing stated she could provide a copy of the schedule of who worked for each shift.


C. On 03/22/17 at 1515, a copy of the schedule for Units #1-4 was received from the Director of Nursing. Review of the licensed nurse staffing schedule revealed no documentation of Registered Nurse coverage for Unit 3 from 02/01/17-03/21/17 for 35 shifts on nights (2300-0700) and 15 shifts on nights for the weekend (1900 - 0700). On 03/24/17 at 1047, the Director of Nursing confirmed 4 shifts on 03/20/17-03/23/17 on days (0700-1500), that the Registered Nurse listed on the schedule for day shift was in fact not working. The Director of Nursing stated she was the RN that covered the day shifts on 03/20/17-03/23/17.


D. On 03/24/17 at 1015, the Administrator was interviewed regarding staffing assignments. On 03/24/17 at 1040 a print out of the Behavioral Instructor (BI) staff Time Log for 02/01/17-03/23/17 was provided by the Administrator. Staff listed on the schedule and/or "Nursing Daily Report" was compared to actual punches for the BI with the Director of Nursing. Discrepancies were noted, including 03/21/17 on 2300-0700 shifts because the BI's listed on the Nursing Daily Report were not the same as on the Time Log. To determine who worked as a BI on 03/21/17, the Director of Nursing and Surveyor #1 went to Unit #1-4 and reviewed BI documentation on the Observation Forms in individual patient records. The Director of Nursing confirmed on 03/24/17 at 1116 the lack of documentation of staff assignments on the Nursing Daily Report and schedule.


E. Review of the job description for the Director of Nursing on 03/23/17 revealed "Responsibilities: Orienting and maintaining adequate numbers of qualified staff to perform safe and effective patient care." Based on the review of the schedule and Nursing Daily Reports provided during the survey, an accurate determination of bedside staff for Unit #1-4 could not be established.


Based on review of personnel files, census data, and interview, it was determined the facility failed to assure two (#1 and #2) of seven (#1-#7) Registered Nurses (RN) reviewed had evidence of training in Cardiopulmonary Resuscitation (CPR) for children. Without evidence of training that included child CPR, the facility could not assure Registered Nurses #1 and #2 would be knowledgeable in Cardiopulmonary Resuscitation for the population of children in the facility. The failed practice affected all children admitted to the facility. The findings were:


A. Review of personnel files on 03/22/17 and 03/23/17 revealed two (#1 and #2) of seven (#1-#7) RNs reviewed had American Heart Association cards that reflected optional modules of Child CPR (Cardiopulmonary Resuscitation) and AED (Automatic External Defibrillator) were not completed. The patient age range as listed on the facility census provided 03/21/17 was 5-17 years.


B. Personnel file for RN #1 included a copy of the "Heartsaver CPR AED" issued 01/08/16. The card included the statement, "This card certifies that the above individual has successfully completed the objectives and skills evaluations in accordance with the curriculum of the AHA Heartsaver CPR AED Program. Optional completed modules are those NOT marked out:" Additional instructions on the card included "Strike through the modules NOT completed." The card for RN #1 had a line through "Child CPR AED, Infant CPR and Written test."


C. Personnel file for RN #2 included a copy of the "Heartsaver First Aide CPR AED" issued 04/15/16. This card included the statement, "This card certifies that the above individual has successfully completed the objectives and skills evaluations in accordance with the curriculum of the AHA Heartsaver First Aid CPR AED Program. Optional completed modules are those NOT marked out:" Additional instructions on the card included "Strike through the modules NOT completed." The card for RN #2 had a line through "Child CPR AED, Infant CPR and Written Test."


D. On 03/24/17 at 1506 the Director of Nursing confirmed the CPR cards in the personnel files, but stated "We took all of the CPR. We all do." On 03/27/17 at 1520, the Administrator stated the wrong cards for CPR must have been sent because they all take all the modules." No other evidence was provided.

Based on clinical record review and interview, it was determined the facility failed to ensure a Registered Nurse (RN) evaluated the care of 10 (#17-#19, #21-#23 and #26-#29) of 30 (#1-#30) patients in that there was no evidence a RN assessed each patient each shift. Failure to have a RN assessment each shift did not assure patient care needs, health status and response to care provided would be identified. The failed practice affected Patient #17-#19, #21-#23 and #26-#29 and was likely to affect all patients admitted to the facility. The findings were:


A. In an interview on 03/22/17 at 1420, the Director of Nursing stated the staff worked 8 hour shifts Monday through Friday, then 12 hour shifts on Saturday and Sunday. Registered Nurses document on each patient one time per shift. Clinical record review 03/22/17-03/27/17 revealed the following:


1) Patient #17 was admitted on 03/14/17 and discharged on 03/23/17. There was no evidence of RN assessment on 03/15/17 (1500-2300). The finding was verified by the Director of Corporate Compliance on 03/24/17 at 1444.


2) Pt #18 was admitted on 03/17/17 and discharged on 03/22/17. There was no evidence of RN assessment on 03/18/17 (0700-1900). The finding was verified by the Director of Corporate Compliance on 03/24/17 at 1107.


3) Patient #19 was admitted on 03/15/17 and discharged on 03/22/17. There was no evidence of RN assessment on 03/16/17 (1500-2300). The finding was verified by the Director of Corporate Compliance on 03/24/17 at 1307.


4) Patient #21 was admitted on 03/15/17 and was inpatient on 03/27/17. There was no evidence of RN assessment on 03/15/17 (1500-2300). The finding was verified by the Director of Corporate Compliance on 03/27/17 at 1122.


5) Patient #22 was admitted on 03/15/17 and discharged on 03/22/17. There was no evidence of RN assessment on 03/16/17 (1500-2300). The finding was verified by the Director of Corporate Compliance on 03/27/17 at 1333.


6) Patient #23 was admitted on 03/14/17 and discharged on 03/21/17. There was no evidence of RN assessment on 03/15/17 and 03/16/17 (1500-2300). The findings were verified by the Director of Corporate Compliance on 03/27/17 at 1405.


7) Patient #26 was admitted on 12/21/16 and was inpatient 03/27/17. There was no evidence of RN assessment from 03/01/19 - 03/23/17 as follows: 03/02/17 (2300-0700); 3/03/17 (1500-2300); 03/07/17 (2300-0700); 03/16/17 (2300-0700); 03/20/17 (0700-1500). The findings were verified by the Director of Health Information Management (HIM) on 03/27/17 at 1050.


8) Patient #27 was admitted on 11/30/16 and was inpatient on 03/27/17. There was no evidence of RN assessment for each shift from 03/01/17 -03/26/17 as follows: 03/01/17 (0700-1500); 03/03/17 (1500-2300); 03/03/17 (2300-0700); 03/18/17 (1900 - 0700); 03/20/17 (0700-1500); 03/22/17 (2300-0700). The findings were verified by the Administrator on 03/27/17 at 1426.


9) Patient #28 was admitted on 10/17/16 and was inpatient on 03/27/17. There was no evidence of RN assessment for each shift from 03/01/17 - 03/26/17 as follows: 03/01/17 (0700-1500); 03/03/17 (1500-2300); 03/04/17 (1500-2300); 03/09/17 (2300-0700); 03/20/17 0700-1500; 03/22/17 (2300-0700); 03/23/17 (2300-0700); 03/24/17 (1500-2300). The findings were verified by the HIM Director on 03/27/17 at 1407.


10) Patient #29 was admitted on 11/10/16 and was inpatient on 03/27/17. There was no evidence of RN assessment for each shift from 03/01/17 - 03/26/17 as follows: 03/01/17 (1500-2300); 03/03/17 (1500-2300); 3/07/17 (2300-0700); 03/14/17 (1500-2300); 0/3/20/17 (0700-1500); 03/22/17 (2300-0700); 03/23/17 (2300-0700). The findings were verified by HIM at 03/27/17 at 1450.


B. Review of the Registered Nurse Job Description on 03/22/17 revealed the statement, "Responsibilities: Documents assessments, interventions and responses to care."


C. Review of the policy "Assessment Procedures" on 03/23/17 revealed "The goal of assessment is to determine the need for treatment, care and services; the type of treatment, care and services to be provided and the need for any further assessments." "Procedure: Assessment begins at A & R, is ongoing throughout the patient's stay and ends at the point of the patients' discharge. Patients are assessed at the following points: admission, every shift, clinical or other crisis events, admission/discharge meetings, treatment plan reviews and discharge."




29485



Based on clinical record review and interview, it was determined the facility failed to ensure a Registered Nurse supervised and evaluated the care of 8 (#17, #18, #20, #22, #23, #27-#29) of 10 (#17-23, #27-29) patients in that vital signs were not documented as performed as ordered by the physician. Failure to obtain vital signs as ordered by the physician did not ensure the physician had the necessary information to make informed decisions regarding patient care. The failed practice affected Patients #17, #18, #20, #22, #23, #27 - #29. Findings follow:


A. Review of Patient #17's clinical record revealed an admission date of 03/14/17 and discharge date of 03/23/17. Review of the admission orders revealed orders for admission and daily vital signs. Review of the clinical record revealed vital signs were not documented as performed 7 (3/15-17, 3/20-23) of 10 (3/14/17-03/23/17) days. The above was verified by the Director of Corporate Compliance at 1444 on 03/24/17.


B. Review of Patient #18's clinical record revealed an admission date of 03/17/17 and discharge date of 03/22/17. Review of the admission orders revealed orders for admission and daily vital signs. Review of the clinical record revealed vital signs were not documented as performed 3 (03/20-03/22/17) of 6 (03/17/17-03/22/17) days. The above was verified by the Director of Corporate Compliance at 1107 on 03/24/17.


C. Review of Patient #20's clinical record revealed an admission date of 03/13/17 and discharge date of 03/22/17. Review of the admission orders revealed orders for admission and daily vital signs. Review of the clinical record revealed vital signs were not documented as performed 5 (03/14-15, 03/20-03/22/17) of 10 (03/17-03/22/17) days. The above was verified by the Director of Corporate Compliance at 0923 on 03/27/17.


D. Review of Patient #22's clinical record revealed an admission date of 03/15/17 and discharge date of 03/22/17. Review of the admission orders revealed orders for admission and daily vital signs. Review of the clinical record revealed vital signs were not documented as performed for 6 (03/15/17, 03/17/17 and 03/19 - 03/22/17) of 8 (03/15 - 03/22/17) days. The above was verified by the Director of Corporate Compliance at 1333 on 03/27/17.


E. Review of Patient #23's clinical record revealed an admission date of 03/14/17 and discharge date of 03/21/17. Review of the admission orders revealed orders for admission and daily vital signs. Review of the clinical record revealed vital signs were not documented as performed for 6 (03/15-18, 03/20-21/17) of 8 (03/14-03/21/17) days. The above was verified by the Director of Corporate Compliance at 1405 on 03/27/17.


F. Review of Patient #27's clinical record revealed an admission date of 11/30/16. Review of the admission orders revealed orders for weekly vital signs. Review of the clinical record revealed vital signs were not documented as performed for the weeks of 12/15/16, 12/22/16, 12/29/16, 01/22/17, 02/05/17, 02/12/17, 02/19/17, 02/26/17 and 03/18/17. The above was verified by the Administrator at 1426 on 03/27/17.


G. Review of Patient #28's clinical record revealed an admission date of 10/17/16. Review of the admission orders revealed orders for weekly vital signs. Review of the clinical record revealed vital signs were not documented as performed for the week of 02/26/17. The above was verified by the HIM (Health Information Management) Director at 1407 on 03/27/17.


H. Review of Patient #29's clinical record revealed an admission date of 11/10/16. Review of the admission orders revealed orders for weekly vital signs. Review of the clinical record revealed vital signs were not documented as performed for the week of 02/26/17. The above was verified by the HIM Director at 1450 on 03//27/17.


30634



Based on clinical record review and interview, it was determined the facility failed to document a bath or shower daily on 22 (#1-#8, #10, #11, #15, #17, #19-#26, #28 and #29) out of 30 (#1-#30) patients. The failed practice did not ensure patient's hygiene status was maintained at optimum levels and created the potential to affect any patient in the facility. Findings follow.


A. Review of clinical records revealed the following:


1) Patient #1 was admitted on 03/20/17. No bath/shower was documented for 3 of 3 days (03/20/17 - 03/22/17).


2) Patient #2 was admitted on 03/20/17. No bath/shower was documented for 3 of 3 days (03/20/17 - 03/22/17).


3) Patient #3 was admitted on 03/13/17. No bath/shower was documented for 9 of 10 days (03/13/17 - 03/20/17 and 03/22/17).


4) Patient #4 was admitted on 03/17/17. No bath/shower was documented for 6 of 6 days (03/17/17 - 03/22/17).


5) Patient #5 was admitted on 03/10/17. No bath/shower was documented for 13 of 13 days (03/10/17 - 03/22/17).


6) Patient #6 was admitted on 03/18/17. No bath/shower was documented for 5 of 5 days (03/18/17 - 03/22/17).


7) Patient #7 was admitted on 03/16/17. No bath/shower was documented for 6 of 7 days (03/16/17 - 03/17/17 and 03/19/17 - 03/22/17).


8) Patient #8 was admitted on 01/09/17. No bath/shower was documented for 65 of 72 days (01/09/17, 01/14/17, 01/16/17 - 02/04/17, 02/06/17 - 02/17/17, 02/19/17 - 03/04/17, 03/07/17 - 03/10/17 and 03/12/17 - 03/23/17).


9) Patient #10 was admitted on 03/17/17. No bath/shower was documented for 3 of 6 days (03/18/17, 03/21/17 and 03/22/17).


10) Patient #11 was admitted on 03/20/17. No bath/shower was documented for 2 of 2 days (03/20/17 and 03/21/17).


11) Patient #15 was admitted on 03/16/17. No bath/shower was documented for 4 of 6 days (03/16/17, 03/18/17, 03/19/17 and 03/21/17).


12) Patient #17 was admitted on 03/14/17. No bath/shower was documented for 2 of 8 days (03/17/17 and 03/19/17). The above findings were verified by the Corporate Compliance Officer at 1444 on 03/24/17.


13) Patient #19 was admitted on 03/16/17. No bath/shower was documented for 1 of 6 days (03/19/17). The above findings were verified by the Corporate Compliance Officer at 1307 on 03/24/17.


14) Patient #20 was admitted on 03/13/17. No bath/shower was documented for 7 of 9 days (03/13/17 - 03/18/17 and 03/21/17). The above findings were verified by the Corporate Compliance Officer at 0923 on 03/27/17.


15) Patient #21 was admitted on 03/15/17. No bath/shower was documented for 2 of 11 days (03/16/17 and 03/19/17). The above findings were verified by the Corporate Compliance Officer at 1122 on 03/27/17.


16) Patient #22 was admitted on 03/15/17. No bath/shower was documented for 1 of 6 days (03/19/17). The above findings were verified by the Corporate Compliance Officer at 1333 on 03/27/17.


17) Patient #23 was admitted on 03/14/17. No bath/shower was documented for 3 of 7 days (03/14/17, 03/17/17 and 03/18/17). The above findings were verified by the Corporate Compliance Officer at 1405 on 03/27/17.


18) Patient #24 was admitted on 01/19/17. No bath/shower was documented for 59 days (01/26/17 - 03/26/17). Findings were verified by Director of Health Information Management (HIM) on 03/24/17 at 1250.


19) Patient #25 was admitted on 03/11/17. No bath/shower was documented for 15 of 16 days (03/12/17 - 03/26/17). Findings were verified by the Corporate Compliance Director on 03/27/17 at 1000.


20) Patient #26 was admitted on 12/21/16. No bath/shower was documented for 24 of 26 days (03/01/17 -03/26/17). Findings were verified by the Director of Health Information Management (HIM) on 03/27/17 at 1050.


21) Patient #28 was admitted on 10/17/16. No bath/shower was documented for 24 of 26 days (03/01/17 - 03/26/17). Findings were verified by the Corporate Compliance Director on 03/27/17 at 1435.


22) Patient #29 was admitted on 03/01/17. No bath/shower was documented for 24 of 26 days (03/01/17 -03/26/17). Findings were verified by the Director of Health Information Management (HIM) on 03/27/17 at 1450.


B. Findings for Patients #1 through #16 were verified by the Administrator on 03/23/17 at 1356.


C. During an interview on 03/24/17 at 1430, the Administrator stated he expected every patient to get a bath or shower every day.

Based on interview, review of Director of Nursing Job Description, and documents provided during the survey, it was determined the facility failed to provide evidence of staffing assignments made by a Registered Nurse for four of four patient care Units (#1-#4). Failure to document nursing personnel assignments did not allow nursing administration to assure nursing staff with the appropriate qualifications and experience would be distributed throughout the facility to meet daily patient care needs, considering special needs of individual patients on each Unit. The failed practice likely affected all patients treated at the facility. The findings were:


A. Staffing assignments were requested from the Director of Nursing on 03/21/17 at 0848, during the entrance conference. On 03/22/17 at 1009, copies of the "Nursing Daily Report" for Units #1 and #2 for the period 02/01/17 - 03/21/17 was provided by the Director of Nursing. The Nursing Daily Report, a form that listed, by shift, the Registered Nurse and Behavioral Instructor staff assigned to each Unit, was incomplete in that 78 of 133 shift assignments for Unit 1 and Unit 2 from 02/01/17 - 03/21/17 were not documented.


B. On 03/22/17 at 1420, the Director of Nursing was interviewed and confirmed the incomplete Nursing Daily Reports for Unit 1 and Unit 2. Staffing assignments for Unit 3 and Unit 4 were requested and the Director of Nursing stated she did not have them because they were incomplete. The Director of Nursing stated she could provide a copy of the schedule of who worked for each shift.


C. On 03/22/17 at 1515, a copy of the schedule for Units 1-4 was received from the Director of Nursing. Review of the licensed nurse staffing schedule revealed no documentation of Registered Nurse coverage for Unit 3 from 02/01/17-03/21/17 for 35 shifts on nights (2300-0700) and 15 shifts on nights for the weekend (1900-0700). On 03/24/17 at 1047, the Director of Nursing confirmed 4 shifts (03/20/17-03/23/17) on days (0700-1500) the Registered Nurse listed on the schedule for day shift was in fact not working. The Director of Nursing stated she was the RN that covered the day shifts on 03/20/17-03/23/17.


D. On 03/24/17 at 1015, the Administrator was interviewed regarding staffing assignments. On 03/24/17 at 1040 a print out of the BI staff Time Log for 02/01/17 - 03/23/17 was provided by the Administrator. Staff listed on the schedule and/or "Nursing Daily Report" was compared to actual punches for the BI with the Director of Nursing. Discrepancies were noted, including 03/21/17 on 2300-0700 shifts because the BI's listed on the Nursing Daily Report were not the same as on the Time Log. To determine who worked as a BI on 03/21/17, the Director of Nursing and Surveyor #1 went to Unit 1-4 and reviewed BI documentation on the Observation Forms in individual patient records. The Director of Nursing confirmed on 03/24/17 at 1116 the lack of documentation of staff assignments on the Nursing Daily Report and schedule.


E. Review of the job description for the Director of Nursing on 03/23/17 revealed "Responsibilities: Orienting and maintaining adequate numbers of qualified staff to perform safe and effective patient care." The Director of Nursing was not able to determine by review of the schedule the Registered Nurse assigned patient care.

Based on clinical record review and interview, it was determined that the Facility failed to assure the accurate maintenance of the clinical records in that 7 (#17-23) of 8 (#17-23 and #30) clinical records did not have accurate documentation of the percentage (%) of meal intake. Failure to document the amount of meal intake did not allow practitioners access to information that could impact treatment decisions regarding medications, meals and therapy. The failed practice affected Patients #17- #23. Findings follow:


Review of the clinical records for Patients #17- #23 revealed mismatched and missing documentation of percentages of meal intake. Examples include:


A. Patient #17:

1) 03/16/17 Behavioral Instructor (BI) documented breakfast as 100% and Registered Nurse (RN) documented 75%; No documentation of dinner intake.

2) 03/17/17 BI documented breakfast and lunch each as 100%; RN documented breakfast and lunch each as 75%.

3) 03/19/17 No documentation of breakfast, lunch or dinner.

During an interview with the Corporate Compliance Director at 1444 on 03/24/17 she verified the above.


B. Patient #19:

1) 03/15/17 BI documented breakfast as 0% and Registered Nurse RN documented breakfast as 75%,

2) 03/16/17 BI documented breakfast 100% and RN documented breakfast as 75%.

3) 03/19/17 No documentation of dinner intake.

4) During an interview with the Corporate Compliance Director at 1307 on 03/24/17 she verified the above.


C. Patient #21:

1) 03/15/17 BI documented breakfast and lunch each as 100%; RN documented breakfast and lunch each as 25% and 75%.

2) 03/16/17 BI documented breakfast and lunch each as 100%; RN documented breakfast and lunch each as 75% and 75%.

3) 03/17/17 BI documented lunch as 100%; RN documented lunch as 75%.

4) 03/18/17 No documentation of dinner intake.

5) 03/19/17 No documentation of dinner intake.

6) 03/20/17 BI documented breakfast and lunch each as 100% and dinner as 75%; RN documented breakfast and lunch each as 75% and dinner as 100%.

7) 03/21/17 BI documented dinner as 75% and RN documented dinner as 100%.

8) 03/22/17 BI documented dinner as 75% and RN documented dinner as 100%.

9) 03/23/17 BI documented dinner as 75% and RN documented dinner as 100%.

10) 03/24/17 BI documented breakfast as 100% and RN documented breakfast as 75%.

11) During an interview with the Corporate Compliance Director at 1122 on 03/27/17 she verified the above.


D. Patient #22:

1) 03/16/17 BI documented 75% breakfast and RN documented breakfast as 100%.

2) 03/17/17 BI documented 75% breakfast and RN documented breakfast as 100%; BI documented dinner intake as 75% and RN documented dinner intake as 100%.

3) 03/19/17 No documentation of lunch and dinner intake.

4) 03/20/17 BI documented lunch as 25% and supper as 75%; RN documented lunch and supper each as 100%.

5) 03/21/17 BI documented breakfast as 100% and RN documented breakfast as 75%.

6) 03/22/17 BI documented lunch as 75% and RN documented lunch as 50%.

7) During an interview with the Corporate Compliance Director at 1333 on 03/17/17 she verified the above.

Based on review of Health Information Management (HIM) policies and procedures, and interview, it was determined that the facility failed to follow policy to monitor access to Protected Health Information (PHI) in that logs of electronic access to patient records were not periodically reviewed. The confidentiality of PHI could not be assured and affected all patients admitted to the Facility. The findings were:


A. Review of the policy "Data Integrity and Security of Protected Health Information" provided by the Director of HIM on 03/23/17 at 1236, revealed "All information systems that create, receive, store or transmit data classified as Protected Health Information (PHI) must adhere to the integrity of this policy." "All access to Confidential Systems must be logged. Logs must be audited on a predetermined, periodic basis. Documented procedures must be in place for the regular review of the audited activity. Discrepancies or access violations found through audits must be documented and, when appropriate, reported to supervisors."


B. The Director of Health Information Management was interviewed on 03/23/17 at 1330, and the policy requirements for "Data Integrity and Security of PHI" were reviewed at that time. The Director of HIM stated electronic access to patient records was limited by physical location and to categories of staff such as nurses, therapy staff and administrative staff. Log in attempts are recorded with staff identifying information. The Director of HIM stated she did not perform a regular or periodic review of electronic patient record log in attempts by Facility staff to determine if unauthorized use of PHI had occurred.

Based on observations, interviews, and policy and procedure review, it was determined that the Infection Control Officer failed to have an active Infection Control Program to identify, report and control infections and assure the physical environment was monitored for cleanliness to maintain a sanitary environment for four of four Nursing Units as evidenced by:


1. Infection Control Officer failed to identify, report and control infections in that clothes were stored in a manner that will not allow s determination whether those were clean or dirty; the surface integrity of furniture was compromised due to rips, tears and rust which cannot be effectively cleaned or disinfected; floors had a sticky residue; dust, dirt stains, and trash were found on floors in five of five (Units 1-4 and Gym) areas observed. See A749


2. Infection Control Officer failed to ensure only currently dated supplies were available for patient and staff use in one of one Exam Room. See A749


3. Infection Control Officer failed to assure FIT testing was performed for new hires in two years (2015 -2017). See A749


4. Infection Control Officer failed to assure staff was knowledgeable of what constituted Personal Protective Equipment (PPE) and there was no evidence PPE was available in the Facility for four of four Nursing Units. See A749.


5. Infection Control Nurse failed to assure that the nursing staff was knowledgeable in the process for cleaning and disinfection of shared patient equipment/toys and the recording of disinfection for four of four Nursing Units. See A749.


6. Infection Control Officer failed to control infections and provide a safe work environment in that expired Body Fluid Clean-up Kits were available for use in three of three (Unit One and Two Nursing Station, Unit Three and Four Nursing Station and the Dirty Laundry Room) areas. See A749


The cummulative effects of the failed practices placed each patient on census and staff at risk for infections.

Based on observation and interview, it was determined that the Infection Control Officer failed to identify, report, and control infections in that clothes were stored in a manner in which it could not be determined if they were clean or dirty; the surface integrity of furniture was compromised due to rips, tears, and rust which cannot be effectively cleaned or disinfected; floors had a sticky residue; dust, dirt stains, and trash were found on floors in five of five (Units 1-4 and Gym) areas observed. The failed practice had the potential to affect all patients in the Facility. Findings follow:


A. A tour of the Facility was conducted with the Administrator at 1005 on 03/21/17. The following was observed and confirmed with the Administrator at the time of observation:


1) Zone 3 Room 116 - Clothes belonging to patients and the Facility were mixed together, nine bags and multiple pairs of shoes and outer garments stored on metal shelving units. During an interview with the Administrator at 1015 he stated the clothing was not routinely washed prior to storage so it was unknown if the clothing was clean or dirty.


2) Zone 3 Room 115 - Clothes, bags, and outer garments belonging to discharged patients were stored on metal shelving units. During an interview with the Administrator at 1017 he stated the clothing was not routinely washed prior to storage so it was unknown if clothing was clean or dirty.


3) Zone 3 Exam Room - One walker with dust on hand supports, rusty hinges and bars was observed; trash (multiple clear butterfly needle covers, empty alcohol swab packets, pieces of paper and dust) were observed underneath the exam table; the floor was dirty and had multiple sticky spots in which shoe soles stuck to the floor; the red cart holding EKG (electrocardiogram) machine had multiple rusted areas on the top which were not able to be cleaned; exam table with a rip in vinyl covering which was not able to be cleaned; privacy screen was dusty; goose neck lamp and weight scale were dusty. During an interview with the Administrator at 1035 he verified the above.


4) Unit One Day Area - the vinyl for four chairs had holes and the foam was exposed. During an interview with the Administrator at 1040 he verified the above.


5) Unit One Laundry Area - Trash (Ritz Bits bag, pieces of paper, and dust) were observed between the washer and dryer,and there were trash in the floor next to the locker. During an interview with the Administrator at 1045 he verified the above.


6) Unit One and Two Seclusion Room #2 - the floor was dirty and had multiple sticky spots in which the shoe soles stuck to the floor and dust in the corners. During an interview with the Administrator at 1106 he verified the above.


7) Unit One and Two Seclusion Room #1 - Large cobweb on bottom left corner of window was observed, also, trash in all corners of the room. During an interview with the Administrator at 1108 he verified the above.


8) Unit One and Two Medication Room Window ledge - 8 inch strip of rusted area was observed. During an interview with the Administrator at 1110 he verified the above.


9) Unit Two Multipurpose Room 205 - couch on the left wall was found with rips in the back of the middle cushion, and small tears and rips in first seat cushion. During an interview with the Administrator at 1112 he verified the above.


10) Unit Two Room 209 - A bed mattress with small rips at right corner of the head of the bed was observed. During an interview with the Administrator at 1115 he verified the above.


11) Unit Three Multipurpose Room - multiple couches and chairs in room with rips in cushion seats and backs exposing the foam underneath were observed; there were dust and trash under couches. During an interview with the Administrator at 1250 he verified the above.


12) Unit Three and Four Seclusion Room - 1 by 1.5 inch piece of floor tile was missing; the floor was dirty and had multiple sticky spots in which shoe soles stuck to the floor, there were multiple small bits of white paper and crumbs in the floor. During an interview with the Administrator at 1255 he verified the above.


13) Unit Four Storage Room 419 - multiple jackets belonging to patients and two blankets were piled in a blue tub in the room. It could not be determined if the clothing items and blankets were clean or dirty. During an interview with the Administrator at 1300 he verified the above.


14) Unit Four Day Area - there were couches on three sides of the room with multiple rips, holes, and pinpricks on the seat and back cushions; also, chair with holes in the seat and back cushions. During an interview with the Administrator at 1305 he verified the above.


15) Observations by Surveyor #1: Gym - bathroom sink was soiled; popcorn popper in first closet was dirty; Room C1 there was trash on the floor. During an interview with the Administrator at 1011 he verified the above.


B. During an interview with the Infection Control Officer at 1045 on 03/23/17, she was asked how often she rounded in the Facility. The Infection Control Officer stated she was responsible for this Facility, the Little Rock and Jonesboro Facilities and usually came to this Facility about three times per month. The Infection Control Officer stated she performed hand hygiene observations and would watch housekeeping clean a room if they were available.




Based on observation and interview it was determined the Infection Control Officer failed to ensure that only currently dated supplies were available for patient and staff use in the Exam Room. Failure to ensure currently dated supplies were available for patient use had the potential to affect the accuracy of patients suspected of having Strep A. The failed practice had the potential to affect any patient screened for Strep A since 08/31/16. Findings follow:


Observation in the Zone 3 Exam Room at 1015 on 03/21/17, revealed the following: Bio Strep A swabs 22 of 22 expired 08/31/16; Strep A Extraction Reagent, Strep B Extraction Reagent, Strep A Negative Control and Strep A Positive Control all expired 02/28/17. During an interview with the Administrator at 1025 on 03/21/17, he verified the above.




Based on policies and procedures review, and interviews, it was determined that the Facility had not performed FIT testing in two years (2015 -2017). Failure to perform FIT testing as mandated by the Centers for Disease Control in Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005 did not ensure the Facility was prepared, equipped, and its personnel trained in the proper use of respirators. Failure to perform FIT testing on hire and annually had the likelihood to allow the spread of communicable respiratory diseases to staff, patients, and visitors, and prevented staff from being knowledgeable in proper fitting, usage, standards and practices of respiratory protection. The failed practice had the potential to affect all patients, staff and visitors who were in the Facility. Findings follow:


A. Review of the policy and procedure titled "Tuberculosis (TB) Prevention and Control Plan" received from the Administrator at 1500 on 03/21/17 revealed the following: "Patient Admission/Screening Procedure, on admission, patients will be screened for TB. High risk patients/clients will be given per MD (Medical Doctor) order, a TB skin test by nursing staff. In the event of a PPD (purified protein derivative) shortage, the patient/client will be referred to the ADH. This will be documented in the patient's record..." "In the event a child is determined to have signs and symptoms of tuberculosis (positive acid-fast bacilli sputum smear result), the child will be placed on isolation precautions in a separate room with the door closed, away from others and not in a waiting area and arrangements will be made to transport the child to another Facility where appropriate accommodations and strict isolation and medical care may be provided."


B. Review of the policy and procedure titled "Airborne Precautions" received from the Administrator at 1500 on 03/21/17 revealed the following under "Policy: Airborne precautions will be used in addition to standard precautions for patients known or suspected to be infected with a disease spread by very small droplet nuclei. These particles may be spread through the air and may be carried on air currents or inhaled by another person. Special air handling/ventilation is needed."


Under "Procedure" the following was noted: "Barriers indicated for airborne precautions:

1. Patient Placement

a. if a patient is being admitted and is found to have an airborne transmittable disease (e.g. tuberculosis), the supervisor will make arrangements for immediate transfer to a Facility which can accommodate the patient and provide a negative-pressure isolation room.

b. While awaiting transfer, the patient must be isolated.

2. Masks

a. A mask should be worn at all times, when entering the room.

b. Susceptible persons entering the room of a patient with measles, chicken pox or disseminated zoster must wear a mask. Preferably, caregivers immune to these diseases should provide care and do not have to wear a mask.

c. A N-95 Mask is required to be worn for patients known or suspected of having TB or SARS (Severe Acute Respiratory Syndrome).

3. Transport

a. Patient must be masked when transported to other areas of the facility. Efforts should be made to keep patient within the room, when possible...".


C. Review of the policy and procedure titled "Transmission Based Precautions" received from the Administrator at 1040 on 03/22/17 revealed the following ...1. Personal Protective Equipment will be available to all employees and will be used according to the type and severity of the associated pathogen.... If a patient is determined to be highly contagious, the patient will be transported to an appropriate facility where necessary isolation can be provided. In the event it is not possible to transport at that time, a private room will be designated as an isolation room and appropriate isolation precautions will be put into effect until appropriate transfer is arranged."


D. During an interview with the Infection Control Officer at 1330 on 03/23/17 she stated the Facility followed CDC and APIC (Association for Professionals in Infection Control and Epidemiology) guidelines, the Facility had not performed FIT testing in two years (2015 - 2017) but did have the capability to perform FIT testing.


E. During an interview with Licensed Practical Nurse #1 at 0930 on 03/24/17 she stated a TB test was administered to all patients on admission.




Based on policies and procedures review, observations, and interviews, it was determined the Infection Control Nurse failed to educate and make available personal protective equipment (PPE) for staff on four of four Units. Failure to ensure PPE was available at point of use had the potential for staff and patient infection. The failed practice had the potential to affect all staff and patients. Findings follow:


A. Review of the policy and procedure titled "Transmission Based Precautions" received from the Administrator at 1040 on 03/22/17 revealed the following "...1. Personal Protective Equipment will be available to all employees and will be used according to the type and severity of the associated pathogen... If a patient is determined to be highly contagious, the patient will be transported to an appropriate facility where necessary isolation can be provided. In the event it is not possible to transport at that time, a private room will be designated as an isolation room and appropriate isolation precautions will be put into effect until appropriate transfer is arranged."


B. Review of the policy and procedure titled "Airborne Precautions" received from the Administrator at 1500 on 03/21/17 revealed the following under "Policy: Airborne precautions will be used in addition to standard precautions for patients known or suspected to be infected with a disease spread by very small droplet nuclei. These particles may be spread through the air and may be carried on air currents or inhaled by another person. Special air handling/ventilation is needed."

Under "Procedure" the following was noted: "Barriers indicated for airborne precautions:

1. Patient Placement

a. if a patient is being admitted and is found to have an airborne transmittable disease (e.g. tuberculosis), the supervisor will make arrangements for immediate transfer to a facility which can accommodate the patient and provide a negative-pressure isolation room.

b. While awaiting transfer, the patient must be isolated.

2. Masks

a. A mask should be worn at all times, when entering the room.

b. Susceptible persons entering the room of a patient with measles, chicken pox or disseminated zoster must wear a mask. Preferably, caregivers immune to these diseases should provide care and do not have to wear a mask.

c. A N-95 Mask is required to be worn for patients known or suspected of having TB or SARS (Severe Acute Respiratory Syndrome).

3. Transport

a. Patient must be masked when transported to other areas of the facility. Efforts should be made to keep patient within the room, when possible...".


C. Review of the policy and procedure titled "Standard - Universal Precautions" received from the Administrator at 1040 on 03/22/17 revealed the following under "Policy: Methodist Family health will instruct all employees in use of universal or standard precautions. All MFH employees will follow established guidelines and use standard precautions and consider all patient blood and body fluids as potentially infectious. Procedure: Barriers indicated in standard precautions:

1) Gloves: Gloves should be worn whenever exposure to the following is planned or anticipated:

Blood/body fluids with visible blood
Urine
Feces
Saliva
Mucous Membranes
Wound Drainage
Drainage tubes
Non-intact skin
Performing venipuncture or invasive procedures ..."


"Personal Protective Equipment (PPE)

1. PPE is available to all employees. Each employee is responsible for knowing where the equipment is kept within the department.

2. The type of protective barrier(s) should be appropriate for the procedure being performed and the type of exposure anticipated.

3. PPE available includes gloves, gowns, masks, eye protection, and resuscitation devices."


D. Observations of four of four Units from 0930 on 03/21/17 through 1000 on 03/24/17 revealed no gowns, masks, eye protection or PPE kits on the Units or the nursing stations.


E. The following interviews were conducted by Surveyor #2 with the following employees:

1) BI #3 at 0840 on 03/23/17 was asked where the PPE was located. BI #3 stated PPE was located in nursing station in a cabinet. Tour nursing station with BI #3; BI #3 opened cabinet and no PPE found. BI #3 took Surveyor #2 to Room 115 thinking PPE was located there; none found. BI #3 then passed Surveyor #2 off to Housekeeper #1.

2) Housekeeper #1 took Surveyor #2 to Room 2106 and no PPE found there; stated she did not know where gowns, PPE was located.

3) RN #4 at 0900 on 03/23/17 stated the gowns and PPE were in the exam room.

4) Pharmacy Technician at 0901 on 03/23/17 was asked if she knew where gowns or PPE was located. Pharmacy Technician stated she "had been at Facility for nine years and had never seen gowns here. Don't think they are readily available."

5) RN #8 at 0905 on 03/23/17 stated gowns and PPE in the exam room. RN #8 to exam room with Surveyor. RN #8 opened multiple cabinet doors and drawers before finding one blue sleeveless gown and one plastic wadded up gown in top corner cabinet. RN #8 then removed 5 bouffant hair covers from bottom drawer of red cart and stated those were shoe covers. RN #8 then opened middle drawer of exam table and pulled out a package of five yellow isolation gowns.

6) Housekeeper #2 at 0955 on 03/23/17 to Housekeeping Storage Room and no PPE located in there. Housekeeper #2 was asked if she carried PPE on her work cart and she stated no.

7) Facility Maintenance Supervisor at 0815 on 03/24/17 was asked if housekeeping staff had PPE on their carts. Facility Maintenance Supervisor stated "As of yesterday they do".


F. During an interview with the Infection Control Nurse at 1045 on 03/23/17 she stated there were no PPE cart/boxes for isolation precautions, no signage to put at entry points to isolation, staff were supposed to limit their patient contact and use good hand hygiene.



Based on policy and procedure review, observations, interview and Patient Care and Share Equipment Low Disinfection Cleaning Log review it was determined the Infection Control Nurse failed to educate and assure shared patient equipment was cleaned per policy and procedure. Failure to assure responsible staff was knowledgeable and compliant per policy and procedure had the potential for dirty shared patient equipment to be utilized in patient care. The failed practice had the potential to affect all patients and staff. Findings follow:


A. Review of the policy and procedure titled "Cleaning of Patient Care Equipment" received from the Administrator at 1020 on 03/22/17 revealed the following under Policy:

1) Methodist Family Health will provide procedures and guidelines to minimize the risk of healthcare acquired infections that may occur through the use of shared patient care equipment, shared patient care items and toys. ...

4) All shared patient care equipment will be cleaned/disinfected once a day. ...

5) Shared unit toys and shared items will be cleaned/disinfected once a day. ...

7) Hospital nursing staff will ensure that the cleaning/disinfecting of shared unit patient care equipment and items is completed and documented daily.


Procedure:

...7) Document completion of cleaning/disinfecting, using the Patient Care Equipment Cleaning Log. ...


Patient Care Equipment (List not to be considered all inclusive; use as a guide for items not listed.) All Patient Care Equipment shall be cleaned between patients and when visibly soiled...
Toys on the Units shared by patients are considered Patient Care Items:

1. All shared toys. ...


B. The following observations were made at 0950 on 03/23/17 in Unit 2 Day Area:

1) Patients #22 and #7 playing chess; Patient #22 quit the game and Patient #31 took that spot. Chess pieces were not cleaned between patients.

2) Patients #32 and #33 were playing dominoes; Patient #33 quit the game and Patient #34 took that spot. The dominoes were not cleaned between patients.


C. The following interviews were conducted with:

1) RN #8 and RN #4 were asked at 1008 on 03/23/17 for the log of when toys were cleaned. RN #8 and #4 both stated they were not aware of a log to document the cleaning of toys. RN #8 stated he thought it was Housekeeping's responsibility to clean the toys.

2) RN #3 was asked at 1015 on 03/23/17 for the log of when toys were cleaned. RN #3 stated he was not aware of a log to document the cleaning of toys. RN #3 stated he thought the BIs (Behavioral Instructors) and Housekeeping were responsible for cleaning the toys.

3) Director of Nursing was asked at 1020 on 03/23/17 who was responsible for cleaning the toys. The Director of Nursing stated Housekeeping was responsible for cleaning the toys.


D. A log titled Patient Care and Shared Equipment Low Disinfection Cleaning Log for December 2016, January 2017 and February 2017 was received from the Infection Control Officer at 1250 on 03/24/17. Review of the log revealed initials of either Housekeeper #2 or Lead Housekeeper Monday through Friday for three of three months indicating Patient Shared Equipment was cleaned. The log did not specify which unit, which toys, no cleaning between patients and there was no cleaning documented for any Saturday or Sunday for three of three months.



Based on policies and procedures review, observations, and interview, it was determined the Infection Control Officer failed to control infections and provide a safe work environment in that expired Body Fluid Clean-up Kits were available for use in three (Unit One and Two Nursing Station, Unit Three and Four Nursing Station and the Dirty Laundry Room) of three areas. Failure to ensure currently dated Body Fluid Clean-up Kits were available for use increased staff risk for exposure and infection in the event of a blood or bodily fluid spill. The failed practice had the potential to affect any staff member who used one of the expired kits. Findings follow:


A. Review of the policy and procedure titled "Infectious Waste Management" received from the Administrator at 1040 on 03/22/17 revealed the following under "Infectious Waste Spill;"

1) If there is an infectious waste spill that involves body fluids (e.g. blood, diarrhea, vomit) it will be cleaned up immediately.

2) MFH (Methodist Family Home) uses disposable spill kits. Spill kits are to be used according to the instructions on the package label. ...


B. Review of the policy and procedure titled "Orientation Training - Infection Control" revealed the following under "Environmental Sanitation Duties: When performing environmental sanitation duties (cleaning, disinfecting surfaces, and handling trash/waste) MFH will use appropriate personal protective equipment (e.g.gloves). If there is an infectious waste spill involving blood or body fluids, it will be cleaned up immediately. MFH uses disposable spill kits. Spill kits are to be used according to the instructions on the package."


C. Observations of Body Fluid Clean-up kits included:

1) Unit One and Two Nursing Station Body Fluid Clean-up kit expired 03/2013. During an interview with the Administrator at 1103 on 03/21/17 he verified the above.

2) Unit Three and Four Nursing Station Body Fluid Clean-up kit expired 03/2013. During an interview with the Administrator at 1310 on 03/21/17 he verified the above.

3) Dirty Laundry Room Body Fluid Clean-up kit expired 03/2013. During an interview with the Facility Maintanance Supervisor at 0815 on 03/24/17 he verified the above.


D. During an interview with the Infection Control Nurse at 1040 on 03/23/17 she was asked how body fluid spills were cleaned up. The Infection Control Nurse stated "Staff can call Housekeeping. If Housekeeping is not available they can use the Body Fluid kits hanging on the walls at the nursing station." The Infection Control Nurse was then asked if she checked for expiration of the Body Fluid Clean-up Kits and she stated "No I just check to see if the zip tie is still intact."

Based on observation, interview, record review, and document review, the facility failed to:


I. Ensure social work assessments met professional social work standards including conclusions and recommendations that described anticipated social work roles in treatment and discharge planning for eight (8) of eight (8) sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). This deficiency results in a lack of professional social work treatment services. (Refer to B108).


II. Ensure that Master Treatment Plans (MTPs) were comprehensive, individualized, and behaviorally descriptive with all necessary components to provide active treatment. Specifically, the MTPs were missing the following components:


A. Behaviorally descriptive psychiatric problem statements based on each patient's unique presenting symptoms of four (4) of eight (8) active sample patients. (A3, A5, A6, and A7). (Refer to B119).


B. Individualized, measurable, and behaviorally descriptive goals and objectives for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). (Refer to B121).


C. Individualized and specific active treatment interventions with the focus of treatment to address each patient's unique presenting psychiatric problems for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). (Refer to B122).


Failure to develop individualized MTPs with all the necessary components impedes the staff's ability to provide coordinated interdisciplinary care; potentially resulting in patient's active treatment needs not being met.


III. Ensure the provision of sufficient therapeutic scheduled programming (on unit) for weekdays and weekends for eight (8) of eight (8) sample patients (A1, A2, A3, A4, A5, A6, A7, and A8) and age appropriate programming for two (2) of eight (8) sample patients (A4 and A7). This lack of active treatment therapies results in these patients being hospitalized without all interventions for patient recovery being provided to them, potentially delaying their improvement. (Refer to B125).

Based on record review and interview, the facility failed to provide social work assessments that met professional social work standards including conclusions and recommendations that described anticipated social work roles in treatment and discharge planning for eight (8) of eight (8) sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). This deficiency results in an inability for the other members of the multidisciplinary treatment team knowing what anticipated efforts the social service staff propose for discharge planning.


Findings include:


A. Record Review


1. Patient A1: The (Biopsychosocial Assessment dated 3/16/17) had no focused recommendations for the anticipated social work role in treatment and discharge planning.


2. Patient A2: The (Biopsychosocial Assessment dated 2/15/17) had no focused recommendations for the anticipated social work role in treatment and discharge planning.


3. Patient A3: The (Biopsychosocial Assessment dated 2/7/17) had no focused recommendations for the anticipated social work role in treatment and discharge planning.


4. Patient A4: The (Biopsychosocial Assessment dated 3/13/17) had no focused recommendations for the anticipated social work role in treatment and discharge planning.


5. Patient A5: The (Biopsychosocial Assessment dated 3/12/17) had no focused recommendations for the anticipated social work role in treatment and discharge planning.


6. Patient A6: The (Biopsychosocial Assessment dated 3/17/17) had no focused recommendations for the anticipated social work role in treatment and discharge planning.


7. Patient A7: The (Biopsychosocial Assessment dated 2/8/17) had no focused recommendations for the anticipated social work role in treatment and discharge planning.


8. Patient A8: The (Biopsychosocial Assessment dated 11/10/16) had no focused recommendations for the anticipated social work role in treatment and discharge planning.


B. Interview


In an interview on 3/22/17 at 4:15 p.m., the Director of Social Work stated, "I see that the recommendations for social work treatment are not there."

Based on record review and staff interviews, the facility failed to ensure that each patient had individualized psychiatric problem statements written in behavioral and descriptive terms on Master Treatment Plans (MTPs) for four (4) of eight (8) active sample patients (A3, A5, A6, and A7). Instead, the problems on the treatment plans included generalized statements, diagnostic terms, or psychiatric jargon rather than behaviorally descriptive psychiatric problems based on clinical assessment data and how presenting problems were specifically manifested by each patient. This failure potentially hampers the treatment team's ability to determine patient response to treatment interventions, evaluate whether there are measurable changes in the patient's condition, and revise the treatment plan if/when needed.


Findings include:


A. Record review


1. Patient A3: The MTP, updated 3/1/17, included the following psychiatric problem statement: "Mood. Labile and psychosis with potential to harm self and others." The section of the MTP titled, "Presenting Problem" had the following statement from the psychiatric evaluation dated 2/7/17: " ... presents with increased mood instability, physical aggression and suicidal thoughts. Within 24 hrs. [hours] pt. [patient] assaulted a male and female peer unprovoked in the group home. Pt then ran away and was brought back by police ... pt. started expressing suicidal ideations stating, 'I don't want to be here' and 'I don't want to be alive anymore." The psychiatric evaluation had the following additional information: "Upon arrival pt. admits to assaulting peers and shows no remorse for [his/her] behavior putting [him/her] at risk of repeating [his/her] dangerous behaviors." There was no relevant descriptive information from the psychiatric evaluation or other clinical assessments. Additionally, there were no behavioral descriptors regarding the patient's symptoms of psychosis.


2. Patient A5: The MTP, dated 3/13/17, had the following psychiatric problem statement: "Depression w/SI - Suicidal thoughts and/or actions." The section of the MTP titled, "Presenting Problem" had a brief statement: "Pt [Patient] is a 16 y/o [year old] ... presented with suicidal ideation, self-harming behaviors, increased mood instability." The psychiatric evaluation dated 3/11/17 provided the following behaviorally descriptive information. " ...The client became upset/distraught, and began threatening to kill [himself/herself] ... Pt said had been feeling suicidal, 'me and my dad don't get along.' ... Said tried to hang self with cover and tried to hit my head on the concrete ..." A synopsis of relevant descriptive information from the psychiatric evaluation and other clinical assessments was not included on the MTP to provide a clear picture of the patient's psychiatric problems and level of functioning that led to hospitalization.


3. Patient A6: The MTP, dated 3/18/17, included the following psychiatric problem statement: "Mood. Labile mood w/potential to harm self and others." The section of the MTP titled, "Presenting Problem" noted, "Pt [Patient] is a [sic] 8 y/o [year old] ... came in due to increased physical aggression and homicidal threats." The psychiatric evaluation dated 3/17/17 provided the following behaviorally descriptive information. " ...Patient has been hitting, punching and kicking staff with the intentions of harming them. Patient has been attacking peers ...Patient's dad reported [him/her] having increased separation and anxiety since house fire ... Patient ... worried about dad and family safety ..." A synopsis of relevant behaviorally descriptive information from the psychiatric evaluation and other clinical assessments was not included on the MTP to provide a clear picture of the patient's psychiatric problems and level of functioning that led to hospitalization.


4. Patient A7: The MTP, dated 2/8/17, included the following psychiatric problem statement: "Mood. Labile and psychosis with potential to harm self and others." The psychiatric evaluation dated 3/17/17 provided the following behaviorally descriptive information. " ... Patient is unable to function on an outpatient level due to [his/her] current dangerous behaviors and unstable mood ... Client was acting out in class and physically had to be removed by the principal after attempts to redirect were unsuccessful ... 48 hrs. ago slapped [his/her] sister across the face. Client ... crying, with scratches ... saying [his/her] sister scratched [him/her] ... Client admitted [s/he] actually scratched [himself/herself] ... The previous night client's mother attempted to kill herself by overdose ... left note for both of her children." A synopsis of behavioral descriptive information the from psychiatric evaluation and other clinical assessments was not included on the MTP to provide a clear individualized picture of the patient's psychiatric problems and level of functioning that led to hospitalization. Additionally, there were no behavioral descriptors regarding the patient's symptoms of psychosis.


B. Policy Review


The facility's policy titled, "Treatment Plan Procedures" stipulated that, " ... The Master Treatment Plan is tailored to meet the individual needs of each patient. The treatment problems are individually specified based on a patient's psychiatric history, physical condition, and presenting problems at admission ..."


C. Interviews


1. In an interview on 3/22/17 at 12:25 p.m. with the Director of Nursing, MTPs were reviewed. She did not dispute the findings that the problem statements were not individualized and did not contain behavioral descriptions based on each patient's specific presenting problems or symptoms.


2. An interview was conducted with the Medical Director 3/22/17 at 2:05 p.m. He did not dispute the findings that problem statements were not individualized and did not include behavioral descriptors based on the patient's specific presenting problems or symptoms.

Based on record review and interview, the facility failed to document individualized long-term and short-term goals (called goal and objectives by the facility) on Master Treatment Plans (MTPs) for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). Specifically, MTPs included goals and objectives that were not written in measurable and behavioral terms and did not consistently relate to presenting psychiatric problems, symptoms, or needs identified in clinical assessments. This failure results in MTPs that failed to identify expected treatment outcomes in a manner that can be defined and understood by patients and treatment staff.


Findings include:


A. Record Review


1. Patient A1: The MTP, dated 3/17/17, had the following deficient goal/objective for the psychiatric problem of, "Depression with SI [Suicidal Ideation]. Suicidal thoughts and/or actions." Goal/Objective: "Reduce depressive symptoms and show evidence of usual energy levels, activities, and socialization levels." The goal and objective statement were identical, very broad, not measurable, or stated in behavioral terms. Objective Narrative: "Client will verbalize improved mood and effectively utilize 3 healthy coping skills." Since the problem statement failed to include behavioral descriptors regarding this patient's current and/or baseline level of energy, activities, and socialization, it would be difficult for staff to determine goal/objective achievement. In addition, the goal, objective, and objective narrative statements were not written in a manner that would be easily understood by this11 year-old patient.


2. Patient A2: The MTP, updated 3/15/17, had the following deficient goals/objectives for the psychiatric problem of "Behavior. Aggression. History of aggression and assaultive behavior. "Goal/Objective: "Demonstrate marked improvement in the ability to listen and respond empathetically and respectfully to thoughts, feelings, and wishes of others." Objective Narrative: "Learn and implement at least 3 problem solving and/or conflict resolution skills to manage interpersonal problems." The goal and objective narrative statements were not measurable and did not include behaviorally specific actions the patient would take to replace aggressive and assaultive behaviors. In addition, the objective narrative contained psychiatric jargon such as "conflict resolution" that would not be necessarily understood by this 15-year-old patient.


3. Patient A3: The MTP, updated 3/1/17, included the following deficient goals/objectives for the psychiatric problem of, "Mood. Labile and psychosis with potential to harm self and others." Goal/Objective: "Decrease irritability and impulsivity, improve social judgment, and develop sensitivity to the consequences of behavior while having more realistic expectation of self." This goal/objective was not individualized and the identical or similarly worded statement was also included on MTPs for active sample patients A4, A6, and A7. This occurred despite the fact that these patients have different presenting symptoms and needs. Objective Narrative: "Client will achieve mood stability, become slower to react with anger/impulsivity and more socially appropriate and sensitive. Client will effectively utilize 3 impulse control skills." The goal, objective, and objective narrative statements were very broad, not measurable, and did not include behavioral and specific actions the patient would take to replace mood instability, anger, and socially inappropriate behaviors. The goal, objective, and objective narrative statements were not written in a manner that would be easily understood by this 15-year-old patient.


4. Patient A4: The MTP, dated 3/12/17, had the following deficient goal/objectives for the psychiatric problem of, "Mood. Labile mood with potential to hurt self and others." Goal/Objective: Goal/Objective: "Decrease irritability and impulsivity, improve social judgment, and develop sensitivity to the consequences of behavior while having more realistic expectation of self." Objective Narrative: "Client will achieve mood stability, become slower to react with anger/impulsivity and more socially appropriate and sensitive. Client will effectively utilize 3 impulse control skills." The goal, objective, and objective narrative statements were very broad, not measurable, and did not include behavioral and specific actions the patient would take to replace mood instability, anger, and socially inappropriate behaviors. The goal, objective, and objective narrative statements were not written in a manner that would be easily understood by this 7-year-old patient.


5. Patient A5: The MTP, dated 3/13/17, included the following deficient goal/objective statements for the psychiatric problem of, "Depression w/SI - Suicidal thoughts and/or actions." Goal/Objective: "Develop healthy cognitive patterns and beliefs about self and the world that lead to alleviation and help prevent the relapse of depressive symptoms." The goal and objective statements were identical, very broad, not measurable, or not stated in behavioral terms. In addition, parts of the objective statement regarding "healthy cognitive patterns and belief" could not be realistically achieved during hospitalization. Objective Narrative: "Identify 3 healthy cognitive thinking patterns while also increasing social interaction and involvement in positive activities." The goal, objective, and narrative statements were not written in a manner that would be easily understood by this 16-year-old patient.


6. Patient A6's MTP, dated 3/18/17, included the following goal/objectives for the psychiatric problem of, "Mood. Labile mood w/potential to harm self and others." Goal/Objective: "Decrease irritability and impulsivity, improve social judgment, and develop sensitivity to the consequences of behavior while having more realistic expectation of self." Objective Narrative: "Client will achieve mood stability, become slower to react with anger/impulsivity and more socially appropriate and sensitive. Client will effectively utilize 3 impulse control skills." The goal, objective, and objective narrative statements were very broad, not individualized, not measurable, and did not include behavioral and specific actions the patient would take to replace mood instability, anger, and socially inappropriate behaviors. The goal, objective, or narrative statements were not written in a manner that would be easily understood by this 8-year-old patient.


7. Patient A7's MTP, dated 2/8/17, included the following goal/objectives for the psychiatric problem of, "Mood. Labile mood w/potential to harm self and others." Goal/Objective: "Decrease irritability and impulsivity, improve social judgment, and develop sensitivity to the consequences of behavior while having more realistic expectation of self." Objective Narrative: "Client will achieve mood stability, become slower to react with anger/impulsivity and more socially appropriate and sensitive. Client will effectively utilize 3 impulse control skills." The goal, objective, and objective narrative statements were very broad, not individualized, not measurable, and did not include behaviorally specific actions the patient would take to replace mood instability, anger, and socially inappropriate behaviors. The goal, objective, or narrative statements were not written in a manner that would be easily understood by this 7-year-old patient.


8. Patient A8: The MTP, updated 3/15/17, included the following goal/objectives for the psychiatric problem of, "Behavior. Defiance of Authority and Oppositionality." Goal/Objective: "Marked reduction in the intensity and frequency of hostile [sic] and defiant behaviors toward adults." Objective Narrative: "Identify at least 2 situations, thoughts, and feelings that trigger angry feelings, problem behaviors, and the targets of those actions." The goal and objective narrative statements were not measurable and did not include behavioral and specific actions the patient would do and/or say to replace hostile and defiant behaviors toward adults.


B. Interviews


1. In an interview on 3/22/17 at 12:25 p.m. with the Director of Nursing, MTPs were reviewed. She did not dispute the findings that goal and objective statements were not individualized, not measurable or written in behavioral terms.


2. An interview was conducted with the Medical Director 3/22/17 at 2:05 p.m. He did not dispute the findings that problem statements on MTPs were not individualized and did not contain behavioral descriptions based on the patient's specific presenting problems or symptoms.

Based on record review, document review, and interviews, the facility failed to ensure that Master Treatment Plans (MTPs) for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8) included individualized and specific active treatment interventions based on the unique psychiatric symptoms of each patient. Specifically, intervention statements were generic or routine discipline functions. MTPs also included several intervention statements that failed to identify a focus of treatment and a method of delivery (individual or group sessions). In addition, the nursing group listed on the facility schedule was not included on MTPs as an active treatment intervention. These deficiencies result in treatment plans that failed to reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment and potentially leads to inconsistent and/or ineffective treatment.


Findings include:


I. Failure to include specific and individualized active treatment interventions


A. Record Review


The Master Treatment Plans (MTPs) for the following patients were reviewed. They revealed the following deficient intervention statements that were non-specific and contained generic clinical functions. Examples include ordering safety precautions and medications, administering medications, encouraging patients, and monitoring activities, by the assigned psychiatrist (MD), registered nurse (RN), therapist/social worker staff (SW), and recreational therapist (RT).


1. Patient A1: The MTP, dated 3/17/17, included the following non-specific and/or generic or routine clinical functions written as active treatment interventions for the problem of, "Depression with SI [Suicidal Ideation]. Suicidal thoughts and/or actions."


MD Interventions: "MD will order precautions for safety as indicated: Appropriate medications as indicated (Depression: [Space for inserting written information was left blank.]: "Monitor response to therapy, medications, and lead treatment team staffing." The section titled, "Activities" included, "Medication Management, 2- 3x/Week." These non-individualized statements were all normal clinical functions of the MD and did not have any specific focus related to this patient's identified problems. These identical or similarly worded statements were also included on MTPs for active sample patients A2, A4, A5, A6, A7, and A8.


RN Intervention: "Nursing will encourage client to utilize 3 adaptive coping skills." The section titled, "Activities" included, "Medication Administration ... 6-7x/Week. These statements were routine nursing functions of encouraging patients and administering medications. The intervention statement did not include a method of delivery (meeting with the patient in individual or group sessions) to provide information about adaptive coping skills or specific medications.


SW Interventions: "Therapist will assist client in exploring 3 triggers to depressive symptoms and healthy ways to cope." The section titled, "Activities" included, "Individual Therapy, 1x/Week." This intervention statement was non-specific and failed to identify which presenting depressive symptoms were the focus of treatment and suggested coping skills that would be appropriate for this patient based on clinically assessed needs. "Therapist will encourage client to identify 3 reasons it is important to comply with aftercare plan during group therapy." Activities included, "Inpatient Group Therapy, 1 - 2x/Week." This intervention statement was a normal social work function of encouraging patients. The identical or similarly worded statement was also included on MTPs for active sample patients A3, A4, and A6.


RT Intervention: "RT will assist the client in identifying at least 2 recreational activities that can be used as coping strategies." The section titled, "Activities" included, "Recreational Therapy Group, 4 - 5x/Week." The intervention and activities statements were non-specific and did not identify specific groups. Given numerous coping strategies, possible appropriate strategies were not identified that could be used by this patient based on assessed clinical needs.


2. Patient A2: The MTP, updated 3/15/17, included the following non-specific and/or generic or routine clinical functions written as active treatment interventions for the problem of, "Behavior. Aggression. History of aggression and assaultive behavior."


MD Interventions: "MD will order precautions for aggression as indicated: Order appropriate medications for aggression as indicated: [Space to insert written information was left blank.]; Monitor response to therapy, meds [medications], and lead tx [treatment] team staffing." The section titled, "Activities" included, "Medication Management, 2- 3x/Week." The MD intervention statements had the same deficiencies as noted for active sample patient A1.


RN Intervention: "Nursing will encourage client to utilize 3 problem solving skills." The section titled, "Activities" included, "Medication Administration ... 6-7x/Week. The statements were routine nursing functions of encouraging patients and administering medications. The intervention statement did not include a method of delivery (meeting with the patient in individual or group sessions) to provide information about problem solving skills or specific medications.


RT Intervention: "RT will provide opportunities to use at least 3 appropriate problem solving skills and conflict resolution skills." The section titled, "Activities" included, "Recreational Therapy Group, 3 - 4x/Week." The intervention statement was non-specific and not individualized. The activities section of the intervention identified the frequency of group contract, without specific groups being identified or any specific focus related to the patient's problem of aggression. Given the myriad of problem solving and conflict resolution skills, this section did not include possible skills that would be appropriate based on this patient clinically assessed needs.


3. Patient A3: The MTP, updated 3/1/17, included the following non-specific and/or generic or routine clinical functions written active treatment interventions for the problem of "Mood. Labile and psychosis with potential to harm self and others."


MD Interventions: "MD will order precautions for safety as indicated: Appropriate medications as indicated (Mood Stabilizer): [Space to insert written information regarding medication was left blank.]: The section titled, "Activities" included, "Medication Management, 2- 3x/Week." The MD intervention statements had the same deficiencies as noted for active sample patient A1.


RN Intervention: "Nursing will reinforce client for using 3 impulse control skills rather than reacting in a negative manner to feelings of irritability." The section titled, "Activities" included, "Medication Administration ... 6-7x/Week. The intervention statement did not include a method of delivery (meeting with the patient in individual or group sessions) to provide information about "impulse control skills" the patient could use to manage the problem identified on the MTP.


SW Intervention: "Therapist will encourage client to identify 3 reasons it is important to comply with aftercare plan during group therapy." The section titled, "Activities" included, "Inpatient Group Therapy, 1 - 2x/Week." This intervention statement had the same deficiency as noted for active sample patient A1.


RT Intervention: "RT to provide games and physical activities to assist in relieving stress and learning new ways to channel energy." The section titled, "Activities" included, "Recreational Therapy Group, 3 - 4x/Week." This intervention statement was non-specific, not individualized, and was identical or similarly worded for active sample patients A4 and A7 despite different presenting symptoms and problems.


4. Patient A4: The MTP, dated 3/12/17, included the following non-specific and/or generic or routine clinical functions for the problem of, "Depression with SI [Suicidal Ideation]. Suicidal thoughts and/or actions."


MD Interventions: "MD will order precautions for safety as indicated: Appropriate medications as indicated (Mood Stabilizer): [Space to insert written information was left blank.]: The section titled, "Activities" included, "Medication Management, 4- 5x/Week." The MD interventions had the same deficiencies as noted for active sample patient A1.


RN Intervention: "Nursing will assist client in identifying 2 benefits of taking prescribed medication and 2 possible side effects." The section titled, "Activities" included, "Medication Administration ... 6-7x/week." The intervention statement did not include a method of delivery (meeting with the patient in individual or group sessions) to provide information about the specific medications this patient was receiving. This identical or similarly worded RN intervention statement was also included on MTPs for active sample patients A5, A6, and A7 despite different presenting symptoms and problems.


SW Interventions: "Therapist will assist client in utilizing 3 anger management techniques through the use of role-play, rehearsal, Modeling and/or art therapy." The section titled, "Activities" included, "Individual Therapy, 1x/Week." This intervention was non-specific, not individualized, and the identical statement was also identified for active sample patient A7 despite different presenting problems and symptoms. "Therapist will encourage client to identify 3 reasons it is important to comply with aftercare plan during group therapy." The section titled, "Activities" included, "Inpatient Group Therapy, 1 - 2x/Week." This SW intervention had the same deficiency as noted for active sample patient A1.


RT Intervention: "RT to provide games and physical activities to assist in relieving stress and learning new ways to channel energy." The section titled, "Activities" included, "Recreational Therapy Group, 3 - 4x/Week." This intervention statement was non-specific, not individualized, and did not identify specific groups based on assessed needs.


5. Patient A5: The MTP, dated 3/13/17, included the following non-specific and/or generic or routine clinical functions written as active treatment interventions for the problem of, "Depression w/SI - Suicidal thoughts and/or actions."


MD Interventions: "MD will order safety precautions as indicated: Appropriate medications as indicated (Depression): Increase Prozac ... The section titled, "Activities" included, "Medication Management, 6- 7x/Week." Except for medications being identified, this intervention statement had the same deficiencies as noted for active sample patients A1.


RN Intervention: "Nursing will assist client in identifying 2 benefits of taking prescribed medication and 2 possible side effects." The section titled, "Activities" The section titled, "Activities" included, "Medication Administration ... 6-7x/Week." This intervention had the same deficiencies as noted for active sample patient A4.


SW Intervention: "Therapist will encourage the client to express 3 feelings and develop supportive relationships during group therapy. The section titled, "Activities "included, "Inpatient Group Therapy, 1 - 2x/Week." This intervention statement was a normal social work function of encouraging patients.


RT Intervention: "RT will assist the client in identifying at least 3 recreational activities that can be used as coping strategies." The section titled, "Activities "included, "Recreational Therapy Group, 3 - 4x/Week." This intervention statement was non-specific and did not identify specific groups or coping skills that would be the focus of active treatment.


6. Patient A6: The MTP, dated 3/18/17, included the following non-specific and/or generic or routine clinical functions written as active treatment interventions for the identified problem of, "Mood. Labile mood w/potential to harm self and others."


MD Interventions: "MD will order safety precautions as indicated: Appropriate medications as indicated (Mood Stabilizer): ... clonidine ... Sertraline (dep [depression]) ... monitor tx [treatment] response." The section titled, "Activities "included, "Medication Management, 6- 7x/Week." Except for medications being identified, this intervention statement had the same deficiencies as noted for active sample patients A1.


RN Interventions: "Nursing will assist client in identifying 2 benefits
of taking prescribed medication and 2 possible side effects." The section titled, "Activities "included, "Medication Administration ... 6-7x/Week." This intervention had the same deficiencies as noted for active sample patient A4.


SW Interventions: "Therapist will encourage client to state 3 reasons why it is important to comply with aftercare plan during group therapy. The section titled, "Activities "included, "Inpatient Group Therapy, 1 - 2x/Week." This was non-specific and not individualized.


7. Patient A7: The MTP, dated 2/8/17, included the following non-specific and/or generic or routine clinical functions written as active treatment interventions for the identified problem of, "Mood. Labile and psychosis with potential to harm self and others."


MD Interventions: "MD will order safety precautions as indicated: Appropriate medications as indicated (Mood Stabilizer): ... clonidine ... Zyprexa... monitor tx [treatment] response." The section titled, "Activities" included, "Medication Management, 6- 7x/Week." Except for medications being identified, this intervention statement had the same deficiencies as noted for active sample patients A1.


RN Intervention: "Nursing will assist client in identifying 2 benefits of taking prescribed medication and 2 possible side effects." The section titled, "Activities" included, "Medication Administration ... 4-5x/Week." This intervention had the same deficiencies as noted for active sample patient A4.


SW Interventions: "Therapist will assist client in utilizing 3 anger management techniques through the use of role-play, rehearsal, and modeling." The section titled, "Activities" included, "Individual Therapy 1x/Week." This intervention was not individualized and the identical statement was also identified for active sample patient A4 despite this patient having different presenting symptoms. "Therapist will encourage client to build healthy social relationships through at least 2 positive peer interaction on the unit and in group therapy." The section titled, "Activities" included, "Inpatient Group Therapy, 1 - 2x/Week." This intervention statement was non-specific and included a normal social work function of encouraging patients.


RT Intervention: "RT to provide games and physical activities to assist in relieving stress and learning new ways to channel energy." Activities included, "Recreational Therapy Group, 4 - 5x/Week." This intervention statement was non-specific, not individualized, and had the same deficiencies as noted for active sample patient A3.


8. Patient A8: The MTP, updated 3/15/17, included the following non-specific and/or generic or routine clinical functions written as active treatment interventions for the identified problem of, "Defiance of Authority and Oppositionality ..."


MD Interventions: "MD will order safety precautions as indicated: Monitor response to therapy, meds [medications], and lead treatment team staffings [sic]." The section titled, "Activities" included, "Medication Management, 6- 7x/Week." The MD intervention statements had the same deficiencies as noted for active sample patient A1.


RN Intervention: "Nursing will positively reinforce/praise client for following instructions without arguing and using at least 1 coping skill." The section titled, "Activities" included, "Medication Administration ... 6-7x/Week." This intervention failed to include a method of delivery (individual and/or group sessions) to provide this patient with information regarding managing defiant behavior(s) and identifying coping skills.


RT Intervention: "RT will engage the client in at least 3 activities that promote cooperation while providing praise for positive social interaction." The section titled, "Activities" included, "Recreational Group, 3 - 4x/Week." This intervention was non-specific and failed to identify groups that would help this patient with managing the identified problem of defiance of authority.


B. Interviews


1. In an interview on 3/22/17 at 12:25 p.m. with the Director of Nursing, MTPs were reviewed. She did not dispute the findings that nursing interventions were normal nursing duties and not specific active treatment interventions related to each patient's presenting problems. She stated, "I am not surprised. Joint Commission found some of the same things."


2. An interview was conducted with the Medical Director 3/22/17 at 2:05 p.m. He did dispute the findings that MD interventions were normal MD functions. He agreed that intervention statements did not reflect the psychiatrist meeting with patients to provide information about their medications and identified psychiatric problems.


II. Failure to include nursing group on MTPs


A. Document Review


The unit schedule for the facility was reviewed and showed that a group titled, "Nursing Group" was scheduled on Tuesdays and Thursdays on Acute Unit 1 at 4:00 p.m. and Sub Acute Unit 4 at 4:30 p.m. This group was not held on 3/21/17 as scheduled on the regular facility schedule reportedly because it was not on the schedule revised for the "Spring Break" sessions. A review of the MTPs for all 8 active sample patients revealed that this group was not included as an active treatment intervention.


B. Interview


In an interview on 3/22/17 at 12:25 p.m. with the Director of Nursing, the facility's treatment schedule was reviewed. She acknowledged that this group was an active treatment intervention conducted by RNs. She admitted that the group was not included on MTPs.

Based on record review and interview, the facility failed to ensure that registered nurses documented treatment notes for nursing interventions listed on Master Treatment Plans (MTPs) for three (3) of eight (8) active sample patients (A5, A6, and A7). Specifically, there was no treatment notes documented to show patients' participation or non-participation in active treatment interventions listed on MTPs. In addition, there was no documentation regarding the topic(s) discussed during interventions and patient response to the active treatment interventions provided. This failure potentially hampers the treatment team's ability to determine patients' response to treatment interventions, evaluate whether there are measurable changes in patients' condition, and revise the treatment plan if/when needed.


Findings include:


A. Record Review


1. Patient A5: The MTP, updated 3/1/17, included the following intervention assigned to registered nurses for the problem of, "Substance Abuse. THC ['tetrahydrocannabinol] Abuse. Continued substance abuse despite persistent problems directly related to their use." The objective was, "Client will verbalize x2 consequences of THC abuse ..." The intervention was "Nursing will monitor for possible adverse reactions to THC abuse." The section titled, "Activities" included, "Nursing education, 2 - 3x/week." This intervention was a normal nursing staff and failed to identify any specific focus or whether this education would be taught in individual or group modalities.


A review of the electronic record for this patient revealed no treatment notes showing a RN provided nursing education regarding substance abuse. In addition, there was no evidence found that treatment notes were documented to include: whether the patient refused or participated in the intervention; what topics were discussed (verbal and written information provided); the duration and frequency of contact; and the patient's response to this intervention (level of participation, level of understanding, behaviors exhibited, and any comments by the patient).


2. Patient A6: The MTP, dated 3/18/17, included the following intervention assigned to registered nurses for the problem of, "Defiance. Often acts as if people in authority are the enemy." The objective narrative was, "Identify at least 2 situations, thoughts, and feelings that trigger angry feelings, problem behaviors, and the target of those actions ..." The intervention was "Nursing will positively reinforce/praise client for following instructions without arguing and using at least 1 coping skill." The section titled, "Activities" included, "Nursing education, 2 - 3x/week."
This intervention failed to identify any specific focus or whether the education activity would be taught in individual or group modalities.


A review of the electronic record for this patient revealed no treatment notes showing a RN provided nursing education regarding positive consequences of following instruction or coping skills. In addition, there was no evidence found that treatment notes were documented to include: whether the patient refused or participated in the intervention; what topics were discussed (verbal and written information provided); the duration and frequency of contact; and the patient's response to this intervention (level of participation, level of understanding, behaviors exhibited, and any comments by the patient).


3. Patient A7: The MTP, dated 2/8/17, included the following intervention assigned to registered nurses for the problem of, "Defiance. Often blames others for their [sic] mistakes or misbehavior." The objective narrative stated, "Identify at least 2 situations, thoughts, and feelings that trigger angry feelings, problem behaviors, and the target of those actions ..." The intervention was "Nursing will positively reinforce/praise client for following instructions without arguing and using at least 1 coping skill." The section titled, "Activities" included, "Nursing education, 2 - 3x/Week."


A review of the electronic record for this patient revealed no documented evidence that RNs provided nursing education and document treatment notes regarding "positive consequences of following instruction" or "coping skills." In addition, there was no evidence found that treatment notes were documented to include: whether the patient refused or participated in the intervention; what topics were discussed (verbal and written information provided); the duration and frequency of contact; and the patient's response to this intervention (level of participation, level of understanding, behaviors exhibited, and any comments by the patient).


B. Interview


In an interview on 3/28/17 at 3:15 p.m. the Director of Nursing conducted a search of the electronic medical record for treatment notes regarding the nursing education identified on MTPs. She was unable to locate any treatment notes regarding nursing education that documented whether the patient refused or participated in the nursing education, individual or groups with topic discussed, information provided during session, and patients' response to interventions. She stated, "Nursing education usually occurs when patients receive their medications." She agreed that information at medication administration was informal and did not include education about coping skills and substance abuse.

Based on observation, document review, and interview, the facility failed to: (1) Provide sufficient therapeutic scheduled programming (including on unit) for weekdays and weekends for eight (8) or eightr (8) active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8). (2) Provide age appropriate programming for two (2) of eight (8) sample patients (A4 and A7). This lack of active treatment therapies resulted in these patients being hospitalized without all interventions for patient recovery being provided to them, potentially delaying their improvement.


Findings include:


A. Observations


1. On 3/22/17 at 10:00 a.m. on Unit 2, three teenagers and Patient A4 (7 years old) were watching TV. A "Structured Activity" was scheduled but not held.


2. On 3/21/17 at 11:00 a.m., there were nine (9) patients (including 7-year-old Patient A4) on Unit 2 with no group or activity.


2. On 3/21/17 and 3/22/17 on Unit 3 at 11:00 a.m. the scheduled "Process Group" did not occur because the therapist was not available. All the patients, including Patient A6 (age 8) watched an inappropriate movie with sex scenes (on 3/21/17). On 3/22/17 they watched cartoons during the time designated for a "Process Group."


3. On Unit 1 on 3/22/17 at 9:45 a.m., there were four (4) patients (including Patient A4) in the hall with no therapeutic or leisure activities available.


4. On 3/21/17 at 2:30 p.m., all the patients from Unit 1 were in a therapy group. This group included ages from five (5) years old to 17 years old.


B. Document Review


1. The "Spring Break" program schedule for the week of March 20-23, 2017 revealed that (1) "Process Group" was scheduled each day.


2. The "Weekday Schedule" revealed that (1) "Process Group" was scheduled each day and (1) "Nursing Group" was scheduled on Tuesdays and Thursdays.


3. The "Weekend Schedule" revealed that there was (1) "Nursing Group" scheduled each weekend day.


4. The Rules and Regulations for Hospitals and Related Institutions in Arkansas (dated 2016) stated, under Section 43: Psychiatric Hospitals, "Patients shall be grouped according to age (children, adolescents and adults), sex and treatment needs." The facility failed to follow this policy regulation.


C. Interviews


1. On 3/21/17 at 10:15 a.m., RN3 on Unit 2 stated, "All ages have activities and groups together. We do not separate the little kids from the teenagers."


2. On 3/21/17 at 10:25 a.m., Patient A3 stated, "I am not allowed to go to groups. I am on unit restriction and they don't give you anything to do. I am very bored."


3. On 3/21/17 at 11:00 a.m., RN4 on Unit 1 stated, "The kids on unit restriction can watch TV when the other kids are in groups off the unit."


4. On 3/21/17 at 1:00 p.m., Patient A2 stated, "It is boring and depressing here. They don't let the people on unit restriction do anything."


5. On 3/21/17 at 1:15 p.m., Behavioral Instructor 1 stated, "We don't have anything for them to do when they are on unit restriction."


6. On 3/21/17 at 2:30 p.m., Social Worker 1 stated, "It is really difficult to have all ages in one activity."


7. On 3/22/17 at 9:45 a.m., the Director of Nursing stated, "The patients on unit restriction should have something to do."


8. On 3/22/17 at 11:15 a.m., Behavioral Instructor 2 stated, "We have concerns about the smaller kids in groups with the older kids."


9. On 3/22/17 at 3:45 p.m., the Director of Recreation stated, "It is not good that all the ages are together in one group."

Based on observation, record review, document review and interview, the Medical Director failed to monitor and provide adequate medical oversight to ensure quality medical services. Specifically, the Medical Director failed to:


I. Ensure that Master Treatment Plans (MTPs) were comprehensive, individualized, and behaviorally descriptive with all necessary components to provide active treatment. Specifically, the MTPs were missing the following components:


A. Behaviorally descriptive psychiatric problem statements based on how each patient manifested presenting symptoms for four (4) of eight (8) active sample patients. (A3 A5, A6, and A7). (Refer to B119).


B. Individualized, measurable, and behaviorally descriptive goals and objectives for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). (Refer to B121).


C. Individualized and specific active treatment interventions with the focus of treatment to address each patient's presenting psychiatric problems for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). (Refer to B122).


Failure to develop individualized MTPs with all the necessary components impedes the staff's ability to provide coordinated interdisciplinary care; potentially resulting in patient's active treatment needs not being met.


II. Ensure the provision of sufficient therapeutic scheduled programming (on unit) for weekdays and weekends for 8 of 8 sample patients (A1, A2, A3, A4, A5, A6, A7, and A8) and age appropriate programming for two (2) of eight (8) sample patients (A4 and A7). This lack of active treatment therapies results in patients being hospitalized without all interventions for patient recovery being provided to them, potentially delaying their improvement. (Refer to B125).


III. Ensure a credible review process for one (1) patient (E1) who died shortly after discharge. The absence of such a process results in a failure to identify practices that could have contributed to an adverse outcome, educate peers about these failures, and reduce the risk of reoccurrence of similar adverse events.


Findings include:


A. Record Review


1. Patient E (DOB 1/6/01) was admitted to the facility on 8/19/16 with diagnoses of Major Depressive Disorder with Psychotic Features, Unspecified Cannabis Related Disorder, and Unknown Substance Use Disorder Severe. The patient had a history of suicide ideation and overdoses. On admission, s/he was placed on suicide precautions and Sertraline 150mg p.o. QAM and Quetiapine 100mg p.o. QAM and 200 mg QHS.


2. During hospitalization, it was documented in progress notes that the patient expressed the contention on 8/20/16 that s/he "would kill self with a gun that [s/he] had access to at home." Subsequently, on 8/27/16 s/he again stated that s/he "would shoot self" post discharge.


3. The patient was discharged to home with grandparents on the afternoon of 9/8/16. S/he had an outpatient therapy appointment on 9/12/16. Although unsure of the exact date and time, the facility learned of the death by gunshot the following week. S/he expired at some point between discharge on 9/8/16 and his/her 8:00 a.m. appointment with the outpatient therapist on 9/12/16 (a period of 90 hours).


B. Document Review


The facility's Sentinel Events policy (last review January 2007) stated, "The [sentinel] event is: Suicide [of] any patient receiving care, treatment, and services in a staffed around-the-clock setting or within 72 hours of discharge." Furthermore, "A root cause analysis and action plan must be initiated within forty-five (45) days of the event occurrence or the organization's becoming aware of the event. The process is conducted by a workgroup assembled by the Hospital Administrator, or Medical Director. The workgroup must include participation by the hospital leadership and by individuals most closely involved in the processes and systems under review."


C. Interviews


1. On 3/21/17 at 9:15 a.m., the Hospital Administrator stated that, "The death was not cited as a reportable or sentinel event because it occurred more than 72 hours after discharge."


2. On 3/22/17 at 2:00 p.m., the Medical Director stated, "There was no mortality review of this case. We do not have a process for a mortality review."


3. On 3/23/17 at 10:30 a.m., the Hospital Administrator stated, "We do not have a policy for morbidity and mortality reviews."


4. On 3/23/17 at 2:30 p.m., the Hospital Administrator stated, "The death could have occurred 80 hours after discharge."

Based on document review and interview, the facility failed to have a Director of Nursing with a Master's Degree, psychiatric nursing experience and on-going training, or consultation from a nurse with a Master's in Psychiatric Nursing.


Findings include:


A. Document Review


The resume of the Director of Nursing revealed that she was a graduate of a diploma school of nursing.


B. Interview


1. On 3/22/17 at 12:25 p.m., the Director of Nursing confirmed that she was a diploma nursing graduate. The Director of Nursing stated, "No, I do not have further education and I do not consult with a Master of Psychiatric/Mental Health nurse."


2. On 3/21/17 at 11:00 a.m., the Administrator of the hospital stated, "No, the DON (Director of Nursing) does not have a master's degree. We do not have a Master's prepared Psychiatric/Mental Health nurse for consultation."

Based on observation, record review, document review, and interview, the Director of Nursing failed to:


I. Ensure that Master Treatment Plans (MTPs) for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8) included individualized and specific active treatment interventions based on the unique psychiatric symptoms of each patient. Specifically, nursing intervention statements were generic or routine discipline functions. MTPs included intervention statements that failed identify a focus of treatment and/or a method of delivery (individual or group sessions). In addition, the nursing group listed on the facility schedule was not included on MTPs as an active treatment intervention. These deficiencies result in treatment plans that failed to reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment and potentially leads to inconsistent and/or ineffective treatment. (Refer to B122).


II. Ensure the provision of sufficient therapeutic scheduled programming (on unit) for weekdays and weekends for 8 of 8 sample patients (A1, A2, A3, A4, A5, A6, A7, and A8) and age appropriate nursing programming for two (2) of eight (8) sample patients (A4 and A7). This lack of active treatment therapies results in patients being hospitalized without all interventions for patient recovery being provided to them, potentially delaying their improvement. (Refer to B125).

Based on observation, document review and interview, the Director of Social Work failed to:


I. Ensure that social work assessments met professional social work standards including conclusions and recommendations that described anticipated social work roles in treatment and discharge planning for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). This deficiency results in no information being available to other members of the multidisciplinary treatment team as to anticipated social service efforts toward discharge planning. (Refer to B108).


II. Ensure the provision of sufficient therapeutic scheduled programming on weekdays and weekends for 8 of 8 sample patients (A1, A2, A3, A4, A5, A6, A7 and A8) and age appropriate social work programming for two (2) of eight (8) sample patients (A4 and A7). This lack of active treatment therapies results in patients being hospitalized without all interventions for patient recovery being provided to them, potentially delaying their improvement. (Refer to B125).

Based on observation, record review, document review, and interview, the Recreation Therapy Department failed to:


I. Monitor therapeutic activity interventions outlined on Master Treatment Plans (MTPs) to ensure that they were individualized and provided specific modalities based on the unique needs of eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). This deficiency results in MTPs that do not reflect individualized and specific recreational therapy approaches and potentially results in inconsistent and/or ineffective treatment. (Refer to B122).


II. Provide sufficient therapeutic scheduled programming (including on unit) for weekdays and weekends for eight (8) of eight (8) sample patients (A1, A2, A3, A4, A5, A6, A7, and A8) and age appropriate recreational therapy programming for two (2) of eight (8) active sample patients (A4 and A7). This lack of active treatment therapies results in patients being hospitalized without all interventions for patient recovery being provided to them, potentially delaying their improvement. (Refer to B125).