HospitalInspections.org

Based on record review and staff interview, the hospital's governing body and administration failed to ensure that an ongoing program for quality improvement and patient safety was implemented and maintained thoughout the hospital (refer to A-309). The hospital's governing body further failed to ensure that the patients were treated in a safe environment (refer to A-144). The cumulative effect of these deficient practices resulted in the hospital's governing body and administration not being able to ensure that patients were cared for in a safe environment.

Based on record review and staff interview, the hospital failed to ensure that the patients received care in a safe environment by not (1) generating complete 2015 data regarding medication variance reports and incident reports for submission to the hospital's Quality Council, which functions as the quality assessment & performance improvement (QAPI) committee; (2) developing and implementing a comprehensive procedure to ensure that patients do not bring contraband, including knives, into the hospital; (3) creating a staff environment in which caregivers feel free to report issues regarding patient safety to administration and receive a positive, constructive response for doing so; (4) having an active and ongoing Infection Control committee; (5) appointing a qualified Infection Control Officer; (6) precluding the discharge of patients to lower level of care facilities during a norovirus outbreak at the hospital (refer to A-144). The hospital further failed to ensure that Patient (Pt) #15 was fully assessed after a fall for 1 (#15) of 32 (#1-32) sampled patients. Pt #15 was up and walking when he entered the hospital on 05/20/15. On 05/22/15, Pt #15 was given antipsychotics and later fell. He was placed in a geri-chair until 05/26/15, when he was sent to another hospital (refer to A-145). The cumulative effect of these systemic deficient practices resulted in the hospital's failure to ensure that the patients were cared for in a safe environment.

Based on record review and staff interview, the hospital failed to ensure the patients were treated in a safe environment by not (1) generating complete 2015 data regarding medication variance reports and incident reports for submission to the hospital's Quality Council, which functions as the quality assessment & performance improvement (QAPI) committee; (2) developing and implementing a comprehensive procedure to ensure that patients do not bring contraband, including knives, into the hospital; (3) creating a staff environment in which caregivers feel free to report issues regarding patient safety to administration and receive a positive, constructive response for doing so; (4) having an active and ongoing Infection Control committee; (5) appointing a qualified Infection Control Officer; and (6) precluding the discharge of patients to lower level of care facilities during a norovirus outbreak at the hospital. These deficient practices could result in the continuing exposure of patients to an unsafe environment. The findings are:

Findings related to Missing Reports:
A. On 06/18/15 at 10:30 am, during an interview, the Senior Vice President of Clinical Quality stated the hospital did not enter into the data base the reports of 15 Medication Variances that occurred since the beginning of the calendar year. She further stated that these reports were found on the Director of Nursing's desk and were being entered into the system on that day. Review of the Quality Council meeting minutes dated 06/11/15 revealed 19 Medication Variances were entered for the first quarter of the year and 2 were entered for the second quarter. Therefore, 71% of the Medication Variances were not entered into the QAPI data base and reported to the QAPI committee, which in turn prevented meaningful identification of any patterns/trends relative to medication errors and the actual or potential effect on patients.
1. The Senior Vice President of Clinical Quality further stated the hospital did not enter the data of 25 Incident Reports that happened since the beginning of the 2015 calendar year. She further stated that these reports were found on the Director of Nursing's desk and were being entered into the system on that day. Review of the Quality Council meeting minutes dated 06/11/15 revealed 48 Incident Reports were entered for the first quarter of the year and 34 were entered for the second quarter. Therefore, 40% of the Incident Reports were not entered into the QAPI data and reported to the Quality Council, which in turn precluded meaningful identification of any patterns/trends relative to unexpected/unusual occurrences and the actual or potential effect on patients.
2. When asked, the Senior Vice President of Clinical Quality stated that these reports "will definitely change" the reported QAPI outcomes of the hospital for the 2015 calendar year. She further stated that these reports were found on the Director of Nursing's desk on the previous day. She could not provide a reason that they were not entered into the data for the Quality Council.

Findings related to safety:
B. Record review of the medical record of Patient (Pt) #16, admitted on 06/02/15, revealed the following:
1. Progress note dated 06/03/15 at 12:30 pm completed by Registered Nurse/Staff member (S) #22 revealed that "while talking with doctor [during patient evaluation by the physician] tech (technician) found small knife."
2. Progress note dated 06/03/15 at 6:00 pm completed by Registered Nurse/S #22 revealed, "Pt became aggressive. . . . Pt had made a weapon out of a pencil which he had sharpened somehow. He stated he was going to start hurting us if we didn't let him out of prison."
3. Progress Notes entry dated 06/04/15 at 1701 (5:01 pm) completed by an unidentified Social Worker (SW) revealed, "Pt [was] witnessed in his room, yelling obscenities [sic] and vulgar quotes. He was physically aggressive [sic] and threatening to staff. It was advised yesterday this patient had a knife that he attempted to use as a weapon. . . . It is a small white handle, a blade appx [approximately] 3 inches long with a blue blade holder. . . . It is witnessed he has filed down a pencil as well. It is very sharp, flat, and hid inside his shoe."
4. According to the Psychiatric Evaluation of Pt #16, conducted on 06/03/15 (the day following the patient's admission), the reason for the involuntary admission of Pt #16 is severe psychosis. Psychiatrist #1 states in the Psychiatric Evaluation, "Hallucinations, the patient denies, however, my suspicion is that the patient is having hallucinations." The psychiatrist adds that Patient #16 "is under incredible psychosocial stress."
5. Review of the "Patient Belongings" documentation at intake revealed that the inventory of Pt #16's belongings (including clothing and any personal items) was conducted on 06/02/15 at 8:20 pm by S #21, a behavioral health tech. No mention of a knife appears on the "Personal Belongings" documentation.

C. On 06/15/15 at 3:15 pm, during interview, S #21 stated that she had received no written or oral instruction about how to conduct a thorough "search" of a patient to identify all items of clothing, personal belongings, and any contraband. S #21 stated that "each tech does it differently," and that one tech had provided one demonstration, and that she [S #21] had in turn "returned the demonstration" for that tech. When S #21 was asked if she had requested Pt #16 to remove his socks during the search, she responded that she had not; she said she "only checked his pockets."

D. Record review of the hospital's "Contraband" policy and procedure, revised in May 2014, and (per notation in in the document) expired in May 2015 submitted by the Acting Vice President of Quality and Risk Management as the currently available policy and procedure, revealed the following:
1. Respective to "Policy," the document states, "Upon admission a thorough search will be made of the patient, purses, pockets, luggage, and belongings."
2. Respective to "Procedure," the total instruction consists of three points: "Staff will attempt to send back with family or place contraband items in the designated locations," "Staff will consider the following to be contraband" (a list of items is provided), and "Staff will advise visitors that any gift or item brought to the patient must be checked in by the Nursing Staff."

E. On 06/15/15 at 3:30 pm, during interview, the Director of Nursing (DON) acknowledged that the "contraband" policy & procedure does not explain how to conduct a search for contraband. At 1:50 pm on the same day, the DON stated that he himself had not determined which staff member or members had conducted the contraband search of Pt #16, but that whoever did it "may not have checked the patient as well as we should have."

F. On 06/16/15 at 3:30 pm, during interview, the Acting Vice President of Quality & Risk Management stated that a training on the search of each patient upon admission was "in process."

G. On 06/16/15, the Director of Nursing (DON) submitted for review a "Clinical Quality Target Education" document entitled "Searches - Patients and Visitors." Excerpts from the document include the following:
"Patients are not to be left alone with their belongings and each patient must be thoroughly searched before they are considered a reduced risk to themselves, other patients, the direct care staff, and the integrity of the milieu."
"When a patient arrives onto the unit, they could potentially bring contraband items into the hospital that is a major risk: Sharps - knives, razors, needles . . . to name a few possible sharps."
"If the patient arrives in their own clothing, they shall be given an appropriate sized set of disposable scrubs and anti-slip socks and directed to change into these scrubs and socks as part of our admissions process."
"The patient's clothing shall be checked thoroughly - checking seams, collars, pockets, linings, and turned inside out and checked for hidden pockets and compartments, Linings and inner soles of shoes shall be lifted and checked for hidden items."

H. On 06/15/15 at 4:45 pm, during interview, the Acting Vice President of Quality & Risk Management stated that currently no staff member audits the "Personal Belongings" documents -- which serve as record of searches of patients and visitors for belongings, including valuables and contraband -- for proper completion.

Findings related to Administration not responding to reports:
I. The following individuals made statements that they do inform the administration about issues/problems regarding patient care (including the safety of patients), but they do not feel and have not seen that the administration has done anything about the issue/problem that was brought to their attention.
1. Staff #4 on 06/10/15 at 3:30 pm.
2. Staff #5 on 06/10/15 at 4:15 pm.
3. Staff #6 on 06/10/15 at 4:30 pm.
4. Staff #7 on 06/10/15 at 5:00 pm.
5. Staff #10 on 06/11/15 at 8:30 am.
6. Staff #11 on 06/11/15 at 9:30 am.
7. Staff #12 on 06/11/15 at 10:30 am.
8. Staff #14 on 06/15/15 at 9:30 am.
9. Staff #15 on 06/15/15 at 11:00 am.
10. Staff #16 on 06/16/15 at 10:30 am.
11. Staff #18 on 06/16/15 at 3:30 pm.
12. Staff #19 on 06/17/15 at 12:30 am.

Findings related to Infection Control Review:
J. Record review of the Infection Control Committee minutes indicated that the last meeting was held in 2013.

K. On 06/11/15 at 3:00 pm, during interview, the DON stated, "I have not kept up with the Infection Control book and I have monthly phone conversations with an Infection Control Consultant, but I don't write anything down from these meetings." The DON did not indicate that he communicated the information from the meetings to the staff.

Findings related to Infection Control Officer:
L. Record review of the DON's continuing education for infection control included the following: NY (New York) Mandated Infection Control for Healthcare Professionals completed on 12/30/12 and C Difficile Threatens Hospitalized Patients completed on 02/16/13.

M. On 06/11/15 at 3:00 pm, during interview, the DON stated that he was designated as the infection control officer (ICO) by being the DON, which is indicated on the job description. When asked if he has attended any recent infection control training, he replied that he had not.

N. Record review of the hospital's job description for Director of Nursing dated 07/29/13, last revised on 06/2013 revealed the following: Under Infection Control Officer Functions: "Infection Prevention Surveillance - Conduct infection control surveillance. Oversee, track, analyze & report infection rates & trends of patient & staff infections. Provide results to the Infection Prevention/Control Committee, Quality Council and Medical Executive Committee. Infection Prevention Plan - Review the Infection Prevention Plan minimum annually and revise as indicated. Present the Infection Prevention Plan to the Infection Prevention/Control Committee, Quality Council, Medical Executive Committee and Governing Board for review and approval annually and anytime it requires revision. Conduct an annual evaluation of the effectiveness of the Infection Prevention Control Program. Regulatory Reporting - Maintain knowledge of the reporting requirements related to infections. Report required infections to appropriate agencies according to federal, state, and local regulations. Training - Provide infection prevention and control training for employees during new employee orientation, annually and as needed to address identified ongoing training needs. Training will include equipment cleaning and disinfection, influenza, hand hygiene, bloodborne pathogens and other identified training needs based on patient population, outbreaks, etc. Assess ongoing staff competency through direct observation and verbal/written tests. Immunizations - Oversee the staff immunization program including influenza, TB and Hepatitis B. Coordination with the Infection Prevention Consultant - Coordinate development/revisions of the Infection Prevention Plan, forms and processes with the Infection Prevention Consultant. Provide quarterly and annual reports to the Infection Prevention Consultant for review and feedback. Utilize the Infection Prevention Consultant in the event of outbreaks, educational needs, etc."

Findings related to Norovirus Response:
O. Record review of the Infection Control Monitors: [Name of hospital] for the year of 2015 revealed the following: for the Patient Safety Indicator for the month of May, "Infection Monitoring" under "Staff Reported Infections" indicated 11, and "Total Healthcare Acquired Infections" indicated 11, for a "Total Identified Patient Infections" of 22. Under "Topic/Indicator: Outbreak: Norovirus April 2015, Findings/Conclusions: The strain affecting New Mexico was a mutated type that was present beyond the identified season - from late October to April. Our hospital experienced its outbreak April 26th until May 8th. Containment efforts represented a collaboration with the State Epidemiology Department."

P. Record review of the "Nursing Department Monthly Meeting" minutes dated 04/30/15 did not indicate any evidence of discussion about the norovirus outbreak, such as how many patients or staff had become infected, or the DON's discussion with the State Epidemiology Department during the time the hospital was experiencing the outbreak.

Q. Record review of the hospital's Admission Register dated for the period 04/26/15 to 05/16/15 revealed that the hospital admitted four (4) patients the afternoon of 04/27/15, while the hospital Administration was aware of the norovirus outbreak.

R. On 06/11/15 at 11:15 am, during interview, the Administrator and Infection Control Officer/DON stated that the hospital had stopped admitting patients to the hospital on 04/27/15, when they realized there was a norovirus outbreak. The facility started admitting patients on 05/16/15.

S. On 06/17/15 at 10:20 am, during interview via phone, the Active Bacterial Core Coordinator with the Department of Health (DOH) Epidemiology and Response Division was asked how she thought the ICO/DON handled the norovirus outbreak at the facility. She stated that the DON was proactive but there was some confusion regarding the norovirus guidelines, specifically relating to the transfer of asymptomatic (without symptoms of the norovirus) patients to other facilities. She indicated in an email on 04/29/15 that asymptomatic patients should not be transferred to another facility, though patients may be discharged to their private residences. She stated to the ICO/DON that the guidelines were merely suggestions and not regulatory.

T. Record review of the facility's Discharge Register dated from 04/26/15 to 05/16/15 indicated that there were a total of 30 discharges during this time. Three (3) of the patients were discharged to an assisted living facility; one (1) patient was transferred to a local hospital on 04/24/15; six (6) patients were transferred to skilled nursing facilities on 05/01/15, 05/07/15, 05/08/15, 05/08/15, 05/11/15, 05/12/15, respectively, locally and around the state; seven (7) patients were transferred to an intermediate care facility for individuals with intellectual disabilities (ICF/IID) on 05/07/15; one (1) patient was transferred to a Medicare certified nursing home on 05/08/15; and one (1) patient was transferred to another psychiatric facility on 05/01/15.

U. Record review of an email dated 04/29/15 from the ICO/DON to the Active Bacterial Core Coordinator with the DOH Epidemiology and Response Division revealed the following: "...Containment interventions are continuing - restricting patients from community engagements, wipe downs of the unit and patients' rooms with the appropriate bleach solution, no admissions or discharges, meals in rooms..."

V. On 06/17/15 at 1:00 pm, during interview, S #26 stated that the DON had informed the nurses during the norovirus outbreak that it was OK to send patients home if they were asymptomatic and that it was OK to send patients who were asymptomatic to nursing homes, as long as the nursing home staff is informed that the hospital has had a norovirus outbreak.

W. Record review of an email dated 05/14/15 from the Active Bacterial Core Coordinator with the DOH Epidemiology and Response Division to the ICO/DON revealed the following: "Given that your last symptomatic case seen at your facility was on Monday, May 11th, 2015 at approximately 6:31 am, I recommend that you do not admit any new patients or transfer patients to other health care facilities until Friday, May 15th, 2015 at 6:30 am."

X. On 06/16/15 at 3:30 pm, during interview, the Administrator and DON were asked how the patient rooms were cleaned after the norovirus outbreak. The Administrator responded that the hospital did not want strange people coming in and cleaning the patient rooms, so the hospital directed the behavioral health technicians (BHTs) to clean the infected patient rooms after the patients were discharged. When asked how the BHTs were instructed to terminally (thoroughly) clean the rooms, the DON stated that the BHTs were told just to wipe everything down with Clorox wipes. The DON confirmed that none of the staff demonstrated to the BHTs how the patient rooms were to be cleaned, and no staff required the BHTs to show how they had cleaned the rooms. The Administrator stated that the hospital building management housekeeping staff came to terminally clean the dining room and day rooms only.

Based on record review and staff interview, the hospital failed to ensure that Patient (Pt) #15 was fully assessed after a fall for 1 (#15) of 32 (#1-32) sampled patients. Pt #15 was up and walking when he entered the hospital on 05/20/15. On 05/22/15, Pt #15 was given antipsychotics and later fell. He was placed in a geri-chair until 05/26/15, when he was sent to another hospital. This deficient practice led to a patient having a broken pelvis for four days without being assessed. The findings are:

A. Record review of Pt #15's medical record revealed that the patient was admitted to the hospital on 05/20/15 at 9:00 am with dementia with behavioral disturbances.

B. Record review of the Nursing Assessment dated 05/20/15 at 11:03 am, indicated that Pt #15 was independent in walking, eating, dressing and toileting. Review of the Nursing Reassessment dated 05/21/15 at 1430 (2:30 pm) indicated that there was no impairment of ambulation or walking, patient was drinking fluids on his own, appetite was indicated as fair.

C. Record review of the Nursing Reassessment dated 05/22/15 (Friday) at 1445 (2:45 pm) revealed the following: "Appearance was indicated as disheveled, he was orientated to person, his speech was pressured, eye contact as good, he was hostile, angry, depressed and irritable, he was making verbal threats to the staff, his behavior was indicated as yelling out, agitated and that his thought processes were indicated as paranoid and confused. During the medical assessment he was walking with no impairment, drinking fluids on his own and he had a poor appetite."

D. Record review of the Nursing Progress Notes dated 05/22/15 at 1630 (4:30 pm) revealed the following: "Pt alert to self only, confused, paranoid. Thinks people are trying to hurt him. At desk after b'fast [breakfast]. Yelling at staff he wants to go home & making threatening remarks about what he'll do to staff if he doesn't get his way. Refused am meds [medications]. Pt is angry, irritable, oppositional to staff. Unable to reason with pt. Continues yelling at staff. At 10:15 [am] MD (Medical Doctor) made order for Haldol (an antipsychotic medication) 50 mg IM [intramuscular] and Ativan [medication for anxiety and sedation] 2 mg IM to help pt. calm down. After 45 minutes of conversation with pt., finally consented to take IM medications. At 11:00 am, Haldol 50 mg and Ativan 2 mg were given IM in right deltoid [upper arm muscle]. At 12:00 pm, pt. went to room & went to sleep. Sleep all afternoon. At 1500 [3:00 pm] pt. still sleeping. Continue to monitor behaviors."

E. Record review of the Psychiatric Progress Note from the Medical Director dated 05/22/15 and dictated at 18:56 (6:56 pm) revealed the following: "...The patient is again demanding to leave. The patient is yelling and stating that if he is not released immediately, somebody is going to be hurt, implying strongly, that he is going to hurt somebody...Ultimately, I felt that this was a psychiatric emergency and ordered a shot of Haldol and Ativan. The patient at first was very reluctant to take it, but the nursing staff ultimately were able to talk him into taking the shot. The patient did calm down and eventually went to sleep after the shot. In the afternoon, the patient did fall down on his rump, but fortunately did not hit his head. On exam, the patient did not seem to have any injuries."

F. Record review of the Nursing Progress Notes dated 05/23/15 at 1511 (3:11 pm) revealed the following: "Pt currently sitting up in chair visiting with family. Pt most of day wanted to lay [sic] in bed. Pt encouraged to get up and with staff assist. Pt did get up and sat in chair. Pt need prompting and cueing to complete task. Pt tolerates well. Pt is confused and does make comments that do not make sense with conversation example 'my shoes have explosives that will go boom.' Pt has no shoes on. Pt refuses to keep no skid socks on. Continue to monitor and prompt and cue pt can complete task."

G. Record review of the Psychiatric Progress Note from the Medical Director dated 05/24/15, dictated at 8:19 am, revealed the following: "The patient is very sleepy. He was not able to answer any of my questions. He seems to be very confused...He continued to have some difficulties ambulating. He seems to also be depressed. He is not verbalizing having any major side effects from medication...He is having difficulty functioning..."

H. Record review of the Nursing Progress Notes dated 05/24/15 at 1356 (1:56 pm) revealed the following: "Pt currently sitting in dinning [sic] room with other pt's sitting at table. Pt not communicating with others only sitting starring [sic] off [sic] the wall. Pt encouraged to be out in melieu [sic] and to attend group. Pt confused and does not hold conversation. Pt intermittently speaks out however with comments such as 'that's the toilet under there.' Pt pointing at floor in dinning [sic] room. Continue to monitor."

I. Record review of the NursingProgress Notes dated 05/25/15 at 1437 (2:37 pm) revealed the following: "Pt currently sitting in chair with family members at side. Pt med [medication] compliant. Pt does need prompting and cueing to complete all task. Pt is unsteady on feet and requires 2 Behavioral Health Techs (BHT) assist. Pt tolerates well. Continue to monitor."

J. Record review of Progress Notes from Patient Advocate dated 05/26/15 at 1301 (1:01 pm) from revealed the following: "Observing the pt in a geri chair, at approx [approximately] a 100 degree angle. He is laying [sic] back. Yelling at random times. His yells are not structured sentences nor do they make sense or fit any current conversations. Asked him if he needed anything and pt told me 'stop hitting the damn dog,' in a very loud voice. Unable to have further conversation as patient is becoming agitated and moving arms and legs in rapid motion, verbally loud."

K. Record review of the Psychiatric Progress Notes from the Medical Director dated 05/26/15 dictated at 16:09 (4:09 pm) revealed the following: "The patient seems to alternate between being obtunded and being angry and threatening. Today, when the staff tried to get him out of the bed, he complained of hip pain. The patient did take a fall on Friday [05/22/15]. He fell on his rump, and so we are concerned about a possible hip fracture. As the patient woke up, he did transfer himself from the chair we had him [sic] into another chair in the TV room. When I went to see the patient with his daughter, he started yelling at me about medications, although, we had not said anything about it...The patient continues to be angry, although totally confused about what is going on around him...When I ask him about his hip, he says his hip is fine. However, when he has to be moved to the bed for his x-ray, he again complains about hip pain...The patient is angry and uncooperative with the interview...The patient does attempt to strike out at staff, and he is assaultive..."

L. Record review of the Nursing Progress Notes dated 05/26/15 at 1720 (5:20 pm) revealed the following: "Pt was in room with mattress on floor for patient safety. Pt unable to ambulate and was expressing pain to his right hip area. Pt was/is non-weight bearing to right leg. This nurse spoke to attending doctor and orders reviewed to obtain x-ray to right hip to r/o [rule out] fx [fracture]. Pt was aggitated [sic] and screaming out 'I'm passing kidney stones and need to go [to] the emergency room.' Pt very aggitated [sic] and received Ativan 0.5 mg. Pt was compliant with all medications. Continue to monitor pt per policy."

M. Record review of the Nursing Progress Notes dated 05/26/15 at 1739 (5:30 pm) revealed the following: "Received results from x-ray to right hip. Orders received to send patient to emergency room for further follow up of x-ray results."

N. Record review of The Nursing Progress Notes dated 05/26/15 at 1810 (6:10 pm) revealed the following: "Report called to [local hospital] ED [emergency department] to [name of nurse] and accepting Dr. [last name] in ED. Patient #15's daughter was called and notified of pt transport. Pt sitting in geri-chair w/o [without] any s/s [signs and symptoms] of distress. Continue to monitor prior to transport."

O. Record review of the Nursing Progress Notes dated 05/26/15 at 1845 (6:45 pm) revealed the following: "Pt left via ambulance per stretcher..."

P. Record review of the Nursing Progress Notes dated 05/26/15 at 2300 (11:00 pm) revealed the following: "Discharge. Facility notified that pt is admitted to [name of local hospital]."

Q. Record review of the Discharge Summary dated 06/09/15 revealed that Patient #15 had a broken pelvis

R. Record review of the incident reports for May 2015 revealed no incident report for Pt #15 dated 05/22/15, the day of the fall. An incident report dated 05/26/15. Further, there was no post-fall reassessment was found.

S. On 06/15/15 at 1:50 pm, during interview, the DON when asked about the lack of an incident report regarding the fall of Pt #15 and the lack of the documentation regarding the post-fall reassessment. He stated, "There should have been an incident report dated 05/22/15." He further stated, "We may not have checked (assessed) the patient as we should have."

T. On 06/17/15 at 4:30 pm, during interview, the Senior Vice President of Clinical Quality confirmed that the nurses are not completing the fall assessments correctly.

U. Record review of the facility's policy and procedure titled "Identification & Reporting" created 01/2013 and last revised 06/2015 revealed the following:
"Any accident, unusual occurrence, variance, hazard or heft, involving patients, visitors or staff is to be reported timely and in the approved format. Reports are to be made by the staff first aware and/or most knowledgeable about the situation. The Incident Report (IR) and Medication Variance Report (MVR) are to be used to report events or occurrences not consistent with the routine operation of the hospital that have led to a variance, accident, or situation that could have, or has, resulted in an injury to a patient or visitor. The IR is a privileged and confidential document that is intended for risk management use to aid in the evaluation and improvement of the overall quality of care."

V. Record review of the facility's policy and procedure titled "Falls Prevention and Monitoring" originated 07/2013 and last revised on 03/2015 and the "Let's Eliminate All Falls" (LEAF) program which has been modified to coincide with [name of facility] policies and processes revealed the following: "Patient safety is an ongoing responsibility of all staff. In order to reduce the risk of a patient injuries as a result of a fall, nursing staff will assess and re-assess the patient's level of risk for fall and implement appropriate interventions through the following procedures.
A fall is defined as a sudden, unintentional change in position causing an individual to land at a lower level, on an object, the floor or the ground, other than the consequence of overwhelming external force.
Interventions post fall
· An incident report will be completed and submitted to the PI Director after a patient has fallen.
· The medical practitioner will be contacted by the Charge Nurse to determine course of treatment after a patient has fallen.
· The patient will be identified as a fall risk after falling, if not done so upon admission.
· Patient falls risk reassessed and appropriate interventions implemented.
· Changes in interventions indicated in treatment plan.
Physical therapist consulted per physician order."

Based on record review and staff interview, the hospital failed to ensure all of the data regarding incident reports and medical variances were included in the measurable data that is used to analyze the hospital's performance since the beginning of the year (refer to A-286). The hospital further failed to ensure that its staff felt that if they did report issues/problems regarding patient care that the administration would appropriately respond to the issue/problem (refer to A-286). Additionally, the hospital's governing body and administration failed to ensure that an ongoing program for quality improvement and patient safety was implemented and maintained (refer to A-309). The cumulative effect of these deficient practices resulted in inaccurate, misleading data going to the hospital's Quality Committee; and the lack of response by the administration to issues/problems regarding patient care resulted in the hospital's inability to ensure that the hospital made qualitative improvements in patient safety.

Based on record review and staff interview, the hospital failed to ensure the following:
(1) all of the data regarding incident reports and medical variances were included in the measurable data that is used to analyze how the hospital is doing since the beginning of year, (2) the administration responded appropriately when staff reported issues/problems, (3) the Infection Control Committee provided current information/data to the hospital's Quality Council (the hospital's Quality Assessment/ Performance Improvement (QAPI) committee), and (4) the Infection Control Officer also provided the necessary information to the hospital-wide QAPI committee. These deficient practices could result in the failure of the hospital to recognize and respond to occurrences/incidents that jeopardize the health and safety of patients. The findings are:

Findings related to Missing Reports:
A. On 06/18/15 at 10:30 am, during an interview, the Senior Vice President of Clinical Quality stated the hospital did not enter into the data base the reports of 15 Medication Variances that occurred since the beginning of the calendar year. Review of the Quality Council meeting minutes dated 06/11/15 revealed 19 Medication Variances were entered for the first quarter of the year and 2 were entered for the second quarter. Therefore, 71% of the Medication Variances were not entered into the QAPI data base and reported to the QAPI committee, which in turn prevented meaningful identification of any patterns/trends relative to medication errors and the actual or potential effect on patients.
1. The Senior Vice President of Clinical Quality further stated the hospital did not enter the data of 25 Incident Reports that have happened since the beginning of the calendar year. Review of the Quality Council meeting minutes dated 06/11/15 revealed 48 Incident Reports were entered for the first quarter of the year and 34 were entered for the second quarter. Therefore, 40% of the Incident Reports were not entered into the QAPI data and reported to the QAPI committee, which in turn precluded meaningful identification of any patterns/treands relative to unexpected/unusual occurrences and the actual or potential effect on patients.
2. When asked, the Senior Vice President of Clinical Quality stated that these reports "will definitely change" the reported QAPI outcomes of the hospital for this calendar year. She further stated that these reports were found on the Director of Nursing's desk. She could not provide a reason that they were not entered into the data base for the Quality Council.

Findings related to Administration not responding to reports:
B The following individuals made statements that they inform the administration about issues/problems regarding patient care (including the safety of patients), but they do not feel and have not seen that the administration has done anything about the issue/problem that was brought to their attention.
1. Staff #4 on 06/10/15 at 3:30 pm.
2. Staff #5 on 06/10/15 at 4:15 pm.
3. Staff #6 on 06/10/15 at 4:30 pm.
4. Staff #7 on 06/10/15 at 5:00 pm.
5. Staff #10 on 06/11/15 at 8:30 am.
6. Staff #11 on 06/11/15 at 9:30 am.
7. Staff #12 on 06/11/15 at 10:30 am.
8. Staff #14 on 06/15/15 at 9:30 am.
9. Staff #15 on 06/15/15 at 11:00 am.
10. Staff #16 on 06/16/15 at 10:30 am.
11. Staff #18 on 06/16/15 at 3:30 pm.
12. Staff #19 on 06/17/15 at 12:30 am.

C. On 06/10/15 at 4:40 pm, during interview, Staff (S) #22 stated that she had multiple concerns about the hospital. The main concern was the staffing situation of the nurses and BHTs. S #22 stated that elderly male patients were punching the BHTs; S #22 stated that this had been reported to the former nurse manager and to the Director of Nursing (DON), who just said "OK." S #22 further stated that there were at least two patients that fell due to insufficient number of BHT's. S #22 stated that some of those incidents (the falls) were not written up by the nursing staff. S #22 stated that patients were falling while the DON was just sitting at the nurses station, not getting up to assess the patient. S #22 stated that staff were aware of a patient that fell on Friday (05/22/15) and was not sent out [to another hospital for treatment] until Tuesday (05/26/15) with a broken pelvis.

D. On 06/11/15 at 9:55 am, during interview, S #4 stated that they were aware that Patient #15 had fallen, and described the fall that they heard as "if a watermelon had hit the concrete." S #4 stated that they had immediately notified the DON of the fall. The DON went to see the patient. S #4 stated that he DON said to the patient, "You're OK buddy, shake it off" and told a tech to put him into bed. S #4 further stated, "Patient #15 was wailing and in pain as per reports all weekend."

Findings related to Infection Control Review:
E Record review of the Infection Control Committee minutes indicated that the last meeting was held in 2013.

F On 06/11/15 at 3:00 pm, during interview, the DON stated, "I have not kept up with the Infection Control book and I have monthly phone conversations with an Infection Control Consultant, but I don't write anything down from these meetings." The DON did not indicate that he communicated the information from the meetings to the staff.

G Record review of the hospital's job description for Director of Nursing dated 07/29/13, last revised 06/2013, revealed the following: Under Infection Control Officer Functions: "Infection Prevention Surveillance - Conduct infection control surveillance. Oversee, track, analyze & report infection rates & trends of patient & staff infections. Provide results to the Infection Prevention/Control Committee, Quality Council and Medical Executive Committee. Infection Prevention Plan - Review the Infection Prevention Plan minimum annually and revise as indicated. Present the Infection Prevention Plan to the Infection Prevention/Control Committee, Quality Council, Medical Executive Committee and Governing Board for review and approval annually and anytime it requires revision. Conduct an annual evaluation of the effectiveness of the Infection Prevention Control Program. Regulatory Reporting - Maintain knowledge of the reporting requirements related to infections. Report required infections to appropriate agencies according to federal, state, and local regulations. Training - Provide infection prevention and control training for employees during new employee orientation, annually and as needed to address identified ongoing training needs. Training will include equipment cleaning and disinfection, influenza, hand hygiene, bloodborne pathogens and other identified training needs based on patient population, outbreaks, etc. Assess ongoing staff competency through direct observation and verbal/written tests. Immunizations - Oversee the staff immunization program including influenza, TB and Hepatitis B. Coordination with the Infection Prevention Consultant - Coordinate development/revisions of the Infection Prevention Plan, forms and processes with the Infection Prevention Consultant. Provide quarterly and annual reports to the Infection Prevention Consultant for review and feedback. Utilize the Infection Prevention Consultant in the event of outbreaks, educational needs, etc."

Based on record review and staff interview, the hospital's governing body and administration failed to ensure that an ongoing program for quality improvement and patient safety was implemented and maintained. This deficient practice could result in the failure of the hospital to recognize and respond to occurrences/incidents, including medications errors, that jeopardize the health and safety of patients. The findings are:

Findings related to Missing Reports:
A. On 06/18/15 at 10:30 am, during an interview, the Senior Vice President of Clinical Quality stated the hospital did not enter into the data base the reports of 15 Medication Variances that occurred since the beginning of the calendar year. Review of the Quality Council (the hospital-wide Quality Assessment & Performance Improvement (QAPI) committee) meeting minutes dated 06/11/15 revealed 19 Medication Variances were entered for the first quarter of the year and 2 were entered for the second quarter. Therefore, 71% of the Medication Variances were not entered into the QAPI data base and reported to the QAPI committee, which in turn prevented meaningful identification of any patterns/trends relative to medication errors and the actual or potential effect on patients.
1. The Senior Vice President of Clinical Quality further stated the hospital did not enter the data of 25 Incident Reports that happened since the beginning of the calendar year. Review of the Quality Council meeting minutes dated 06/11/15 revealed 48 Incident Reports were entered for the first quarter of the year and 34 were entered for the second quarter. Therefore, 40% of the Incident Reports were not entered into the QAPI data and reported to the QAPI committee, which in turn precluded meaningful identification of any patterns/treands relative to unexpected/unusual occurrences and the actual or potential effect on patients.
2. When asked, the Senior Vice President of Clinical Quality stated that these reports "will definitely change" the reported QAPI outcomes of the hospital for this calendar year. She further stated that these reports were found on the Director of Nursing's desk. She could not provide a reason that they were not entered into the data base for the Quality Council.

Findings related to safety:
B. Record review of the medical record of Patient (Pt) #16, admitted on 06/02/15, revealed the following:
1. Progress note dated 06/03/15 at 12:30 pm completed by Registered Nurse/S #22 revealed "while talking with doctor [during patient evaluation by the physician] tech [technician]) found small knife."
2. Progress note dated 06/03/15 at 6:00 pm completed by Registered Nurse/S #22 revealed "Pt became aggressive....Pt had made a weapon out of a pencil which he had sharpened somehow. He stated he was going to start hurting us if we didn't let him out of prison."
3. Progress Notes entry dated 06/04/15 at 1701 (5:01 pm) completed by an unidentified Social Worker (SW) revealed, "Pt [was] witnessed in his room, yelling obscenities [sic] and vulgar quotes. He was physically agressive [sic] and threatening to staff. It was advised yesterday this patient had a knife that he attempted to use as a weapon....It is a small white handle, a blade appx [approximately] 3 inches long with a blue blade holder....It is witnessed he has filed down a pencil as well. It is very sharp, flat, and hid inside his shoe."
4. According to the Psychiatric Evaluation of Pt #16, conducted on 06/03/15 (the day following the patient's admission), the reason for the involuntary admission of Pt #16 is severe psychosis. Psychiatrist #1 states in the Psychiatric Evaluation, "Hallucinations, the patient denies, however, my suspicion is that the patient is having hallucinations." The psychiatrist adds that Patient #16 "is under incredible psychosocial stress."
5. Review of the "Patient Belongings" documentation at intake revealed that the inventory of Pt #16's belongings (including clothing and any personal items) was conducted on 06/02/15 at 8:20 pm by S #21, a behavioral health tech (BHT). No mention of a knife appears on the "Personal Belongings" documentation.

C. On 06/15/15 at 3:15 pm, during interview, S #21 stated that she had received no written or oral instruction about how to conduct a thorough "search" of a patient to identify all items of clothing, personal belongings, and any contraband. S #21 stated that "each tech does it differently," and that one tech had provided one demonstration, and that she [S #21] had in turn "returned the demonstration" for that tech. When S #21 was asked if she had requested Pt #16 to remove his socks during the search, she responded that she had not; she said she "only checked his pockets."

D. Record review of the hospital's "Contraband" policy and procedure, revised in May 2014, and (per notation in in the document) expired in May 2015 submitted by the Acting Vice President of Quality and Risk Management as the currently available policy and procedure, revealed the following:
1. Respective to "Policy," the document states, "Upon admission a thorough search will be made of the patient, purses, pockets, luggage, and belongings."
2. Respective to "Procedure," the total instruction consists of three points: "Staff will attempt to send back with family or place contraband items in the designated locations," "Staff will consider the following to be contraband" (a list of items is provided), and "Staff will advise visitors that any gift or item brought to the patient must be checked in by the Nursing Staff."

E. On 06/15/15 at 3:30 pm, during interview, the Director of Nursing (DON) acknowledged that the "contraband" policy & procedure does not explain how to conduct a search for contraband. At 1:50 pm on the same day, the DON stated that he himself had not determined which staff member or members had conducted the contraband search of Pt #16, but that whoever did it "may not have checked the patient as well as we should have."

F. On 06/16/15 at 3:30 pm, during interview, the Acting Vice President of Quality & Risk Management stated that a training on the search of each patient upon admission was "in process."

G. On 06/16/15, the Director of Nursing (DON) submitted for review a "Clinical Quality Target Education" document entitled "Searches - Patients and Visitors." Excerpts from the document include the following:
"Patients are not to be left alone with their belongings and each patient must be thoroughly searched before they are considered a reduced risk to themselves, other patients, the direct care staff, and the integrity of the milieu."
"When a patient arrives onto the unit, they could potentially bring contraband items into the hospital that is a major risk: Sharps - knives, razors, needles ... to name a few possible sharps."
"If the patient arrives in their own clothing, they shall be given an appropriate sized set of disposable scrubs and anti-slip socks and directed to change into these scrubs and socks as part of our admissions process."
"The patient's clothing shall be checked thoroughly - checking seams, collars, pockets, linings, and turned inside out and checked for hidden pockets and compartments, Linings and inner soles of shoes shall be lifted and checked for hidden items."

H. On 06/15/15 at 4:45 pm, during interview, the Acting Vice President of Quality & Risk Management stated that currently no staff member audits the "Personal Belongings" documents -- which serve as record of searches of patients and visitors for belongings, including valuables and contraband -- for proper completion.

Findings related to Administration not responding to reports:
I. The following individuals made statements that they do inform the administration about issues/problems regarding patient care (including the safety of patients), but they do not feel and have not seen that the administration has done anything about the issue/problem that was brought to their attention.
1. Staff #4 on 06/10/15 at 3:30 pm.
2. Staff #5 on 06/10/15 at 4:15 pm.
3. Staff #6 on 06/10/15 at 4:30 pm.
4. Staff #7 on 06/10/15 at 5:00 pm.
5. Staff #10 on 06/11/15 at 8:30 am.
6. Staff #11 on 06/11/15 at 9:30 am.
7. Staff #12 on 06/11/15 at 10:30 am.
8. Staff #14 on 06/15/15 at 9:30 am.
9. Staff #15 on 06/15/15 at 11:00 am.
10. Staff #16 on 06/16/15 at 10:30 am.
11. Staff #18 on 06/16/15 at 3:30 pm.
12. Staff #19 on 06/17/15 at 12:30 am.

Findings related to Infection Control Review:
J. Record review of the Infection Control Committee minutes indicated that the last meeting was held in 2013.

K. On 06/11/15 at 3:00 pm, during interview, the DON stated, "I have not kept up with the Infection Control book and I have monthly phone conversations with an Infection Control Consultant, but I don't write anything down from these meetings." The DON did not indicate that he communicated the information from the meetings to the staff.

L. Record review of the hospital's job description for Director of Nursing dated 07/29/13, last revised on 06/2013, revealed the following under Infection Control Officer Functions: "Infection Prevention Surveillance - Conduct infection control surveillance. Oversee, track, analyze & report infection rates & trends of patient & staff infections. Provide results to the Infection Prevention/Control Committee, Quality Council and Medical Executive Committee. Infection Prevention Plan - Review the Infection Prevention Plan minimum annually and revise as indicated. Present the Infection Prevention Plan to the Infection Prevention/Control Committee, Quality Council, Medical Executive Committee and Governing Board for review and approval annually and anytime it requires revision. Conduct an annual evaluation of the effectiveness of the Infection Prevention Control Program. Regulatory Reporting - Maintain knowledge of the reporting requirements related to infections. Report required infections to appropriate agencies according to federal, state, and local regulations. Training - Provide infection prevention and control training for employees during new employee orientation, annually and as needed to address identified ongoing training needs. Training will include equipment cleaning and disinfection, influenza, hand hygiene, bloodborne pathogens and other identified training needs based on patient population, outbreaks, etc. Assess ongoing staff competency through direct observation and verbal/written tests. Immunizations - Oversee the staff immunization program including influenza, TB and Hepatitis B. Coordination with the Infection Prevention Consultant - Coordinate development/revisions of the Infection Prevention Plan, forms and processes with the Infection Prevention Consultant. Provide quarterly and annual reports to the Infection Prevention Consultant for review and feedback. Utilize the Infection Prevention Consultant in the event of outbreaks, educational needs, etc."

Based on record review and staff interview, it was determined that the hospital failed to ensure that there were adequate numbers of licensed registered nurses (RNs), licensed practical nurses (LPNs), and other personnel [Behavioral Health Technicians (BHT)] to provide nursing care to all patients as needed for 3 (Patient #15, 26, and 30) of 32 (Pt 1 - 32) sampled patients for falls and medication errors (refer to A-392). The hospital further failed to ensure that medications were prepared and administered safely to avoid any medication errors for 1 of 32 sampled patients (#26) (refer to A-405). The cumulative effect of these systemic deficient practices resulted in the hospital's inability to ensure that the patient nursing needs would be met.

Based on record review and staff interviews, hospital's nursing services failed to ensure that there were adequate numbers of licensed registered nurses (RNs), licensed practical nurses (LPNs), and other personnel such as behavioral health technicians (BHTs) to provide nursing care to all patients as needed for 3 (Patient #15, 26, and 30) of 32 (Pt 1 - 32) sampled patients for falls and medication errors. This deficient practice could result in failure to implement measures to prevent falls with injuries, avoid medication errors, and perform nursing assessments as needed. The findings are:

A. On 06/10/15 at 4:15 pm, during interview, the Medical Director stated, "By and large I think we are providing good care." When asked about the staffing situation at the hospital, he replied, "More turnover here in 8 months than in my last job over 19 years. Period. Nursing staff has seen a lot of turnover, although some were justified...This institution is not a smooth-running machine...Our admits are low due to the shortage of nurses...There has been a lot of turmoil with staff coming and going...There has been some grumbling about long hours. If there is a lot of concern, it has not come to me."

B. On 06/10/15 at 4:40 pm, during interview, Staff (S) #22, stated that she had multiple concerns about the hospital. The main concern was the staffing situation of the nurses and BHTs. S #22 stated that elderly male patients were punching the BHTs; S #22 stated that this had been reported to the former nurse manager and to the Director of Nursing (DON), who just said "OK." S #22 further stated that there were at least two patients that fell due to insufficient number of BHT's. S #22 stated that some of those incidents [the falls] were not written up by the nursing staff. S #22 stated that patient's were falling while the DON was just sitting at the nurses station, not getting up to assess the patient. S #22 stated that staff were aware of a patient that fell on Friday (05/22/15) and was not sent out (to another hospital for treatment) until Tuesday (05/26/15) with a broken pelvis. S #22 further stated that there were not enough staff to cover the unit, and the former nurse manager was working 20 hours a day. Additionally, S #22 stated that staff members are required to work overtime and if they don't stay over, the staff members are fired.

C. On 06/11/15 at 5:05 pm, during interview, S #18 stated that their concern was patient safety, regarding understaffing of the nurses and techs, who are always working overtime. S #18 stated that during the past year the nursing and BHTs have never been fully staffed. S #18 further stated that the DON would mandate that staff had to stay and relay this to the former nurse manager, then deny everything that the nurse manager said. S #18 stated, "We have lost a lot of nurses and techs due to the DON's management style." S #18 stated that the DON brings the staff in, promises raises all the time and offers staff bonuses to stay another shift, but the staff never see the raise or the bonuses in their paycheck. S #18 stated that the norm for staffing 30 - 32 patients would be 3 nurses and 3 techs, now there was not enough staff for patient safety.

D. On 06/11/15 at 9:55 am, during interview, S #4 stated that the number one concern was patient safety. S #4 stated, "I have trouble going to bed at night." S #4 stated that they were aware that Patient #15 had fallen, and described the fall that they heard as "if a watermelon had hit the concrete." S #4 stated that they had immediately notified the DON of the fall. The DON went to see the patient. S #4 stated that the DON said to the patient, "You're OK buddy, shake it off," and told the tech to put him into bed. S #4 further stated, "Patient #15 was wailing and in pain as per reports all weekend."

Findings for Patient #15:
E. Record review of Patient #15's medical record revealed that the patient was admitted to the hospital on 05/20/15 at 9:00 am with dementia with behavioral disturbances.

F. Review of the Nursing Assessment dated 05/20/15 at 11:03 am, indicated that Patient #15 was independent in walking, eating, dressing, and toileting. Review of the Nursing Reassessment dated 05/21/15 at 1430 (2:30 pm) indicated that there was no impairment of ambulation or walking, patient was drinking fluids on his own, appetite was indicated as fair.

G. Record review of Progress Notes from the day nurse dated 05/22/15 (Friday) at 1630 (4:30 pm) revealed the following: "Pt [patient] alert to self only, confused, paranoid. Thinks people are trying to hurt him. At desk after b'fast [breakfast]. Yelling at staff he wants to go home & making threatening remarks about what he'll do to staff if he doesn't get his way. Refused am meds [medications]. Pt is angry, irritable, oppositional to staff. Unable to reason with pt. Continues yelling at staff. At 10:15 MD made order for Haldol [an antipsychotic medication] 50 mg IM [intramuscular] and Ativan [medication for anxiety and sedation] 2 mg IM to help pt. calm down. After 45 minutes of conversation with pt. finally consented to take IM medications. At 11:00 am Haldol 50 mg and Ativan 2 mg were given IM in right deltoid. At 12:00 pm pt. went to room & went to sleep. Sleep [sic] all afternoon. At 1500 [3:00 pm] pt. still sleeping. Continue to monitor behaviors."

H. Record review of the Psychiatric Progress Note from the Medical Director dated 05/22/15 and dictated at 18:56 (6:56 pm) revealed the following: "...The patient is again demanding to leave. The patient is yelling and stating that if he is not released immediately, somebody is going to be hurt, implying strongly, that he is going to hurt somebody...Ultimately, I felt that this was a psychiatric emergency and ordered a shot of Haldol and Ativan. The patient at first was very reluctant to take it, but the nursing staff ultimately were able to talk him into taking the shot. The patient did calm down and eventually went to sleep after the shot. In the afternoon, the patient did fall down on his rump, but fortunately did not hit his head. On exam, the patient did not seem to [have] had any injuries."

I. Record review of nursing Progress Notes dated 05/22/15 at 1600 (4:00 pm) revealed the following: "Pt reported to have fallen but BHT states this was heard but not seen. BP 104/59 P 74 R 18 O2 92% RA [on room air]. Assessment does not reveal any visible injuries & pt. denies pain of any kind..."

J. Record review of the Nursing Reassessment dated 05/23/15 at 1956 (7:56 pm) revealed the following under Psychiatric Assessment: "patient's appearance was disheveled, oriented to person, speech was pressured, flat affect, mood was depressed, no aggression, isolative, preoccupied, confused and disoriented."

K. Record review of the Psychiatric Progress Note from the Medical Director dated 05/24/15, dictated at 8:19 am, revealed the following: "The patient is very sleepy. He was not able to answer any of my questions. He seems to be very confused...He continued to have some difficulties ambulating. He seems to also be depressed. He is not verbalizing having any major side effects from medication...He is having difficulty functioning,..."

L. Record review of Progress Notes from the day nurse dated 05/24/15 at 1356 (1:56 pm) revealed the following: "Pt currently setting in dinning [sic] room with other pt's sitting at table. Pt not communicating with others only sitting starring off the wall. Pt encouraged to be out in melieu [sic] and to attend group. Pt confused and does not hold conversation. Pt intermittently speaks out however with comments such as 'that's the toilet under there." Pt pointing at floor in dinning [sic] room. Continue to monitor."

M. Record review of Nursing Reassessment dated 05/24/15 at 1455 (2:55 pm) revealed the following under Psychiatric Assessment indicated: "Patient's appearance was disheveled, oriented to person, speech was pressured, flat affect, no aggression, impulsive, confused and disoriented,"

N. Record review of Nursing Reassessment dated 05/25/15 at 1305 (1:05 pm) revealed the following under Psychiatric Assessment: "Patient's appearance disheveled, oriented to person, speech pressured, flat affect, no aggression, impulsive, isolative, and preoccupied."

O. Record review of Progress Notes from the day nurse dated 05/25/15 at 1437 (2:37 pm) revealed the following: "Pt [patient] currently sitting in chair with family members at side. Pt med [medication] compliant. Pt does need prompting and cueing to complete all task. Pt is unsteady on feet and requires 2 BHT assist. Pt tolerates well. Continue to monitor."

P. Record review of Nursing Reassessment dated 05/25/15 at 2000 (8:00 pm) revealed the following under Psychiatric Assessment: "Patient's appearance disheveled, oriented to person, speech slurred, flat affect, mood irritable, no aggression, yelling out, confused and disoriented."

Q. Record review of Nursing Reassessment dated 05/26/15 (Tuesday) at 1028 (10:28 am) revealed the following under Psychiatric Assessment: "Patient's appearance disheveled, oriented to person, normal speech, flat affect, depressed, no aggression, appropriate behavior, confused and disoriented." Under Medical Assessment it indicated the following: "breathing clear, incontinent of urine, ambulation via wheelchair with staff assistance, skin was bruised and had skin tears, drinking on own, pushing fluids, fair appetite and complains of pain." Under comments: "Pt has bruise to right hip. Patient states, 'I hurt all over.' Pt unable to put any weight to right extremity. X-ray ordered to r/o [rule out] fracture. Pt has skin tear to left hand, covered with tegaderm."

R. Record review of Progress Notes from Patient Advocate dated 05/26/15 at 1301 (1:01 pm) from revealed the following: "Observing the pt in a geri-chair, at approx [approximately] a 100 degree angle. He is laying [sic] back. Yelling at random times. His yells are not structured sentences nor do they make sense or fit any current conversations. Asked him if he needed anything and pt told me 'stop hitting the damn dog,' in a very loud voice. Unable to have further conversation as patient is becoming agitated and moving arms and legs in rapid motion, verbally loud."

S. Record review of the Psychiatric Progress Notes from the Medical Director dated 05/26/15 dictated at 16:09 (4:09 pm) revealed the following: "The patient seem to alternate between being obtunded and being angry and threatening. Today, when the staff tried to get him out of the bed, he complained of hip pain. The patient did take a fall on Friday [05/22/15]. He fell on his rump, and so we are concerned about a possible hip fracture. As the patient woke up, he did transfer himself from the chair we had him into another chair in the TV room. When I went to see the patient with his daughter, he started yelling at me about medications, although, we had not said anything about it...The patient continues to be angry, although totally confused about what is going on around him...When I ask him about his hip, he says his hip is fine. However, when he has to be moved to the bed for this x-ray, he again complains about hip pain...The patient is angry and uncooperative with the interview...The patient does attempt to strike out at staff, and he is assaultive..."

T. Record review of the X-Ray Report dated 05/26/15 at 16:07 (4:07 pm) indicated the following: "The right hip appears intact. On one view, the inferior pubic ramus [pelvis] appears fractured. The ramus is not well-seen on this exam. No femoral neck fracture..."

U. Record review of Progress Notes from the evening nurse dated 05/26/15 at 1720 (5:20 pm) revealed the following: "Pt was in room with mattress on floor for patient safety. Pt unable to ambulate and was expressing pain to his right hip area. Pt was/is non-weight bearing to right leg. This nurse spoke to attending doctor and orders reviewed to obtain x-ray to right hip to r/o fx [fracture]. Pt was aggitated [sic] and screaming out "I'm passing kidney stones and need to got the emergency room." Pt very aggitated [sic] and received Ativan 0.5 mg. Pt was compliant with all medications. Continue to monitor pt per policy."

V. Record review of Progress Notes from the evening nurse dated 05/26/15 at 1739 (5:30 pm) revealed the following: "Received results from x-ray to right hip. Orders received to send patient to emergency room for further follow up of x-ray results."

W. Record review of Progress Notes from the evening nurse dated 05/26/15 at 1810 (6:10 pm) revealed the following: "Pt eating dinner, calm, cooperative. Report called to [local hospital] ED [emergency department] to [name of nurse] and accepting Dr. [last name] in ED. Patient #15's daughter was called and notified of pt transport. Pt sitting in geri-chair w/o [without] any s/s [signs and symptoms] of distress. Continue to monitor prior to transport."

X. Record review of Pt #15's revealed no incident report the date of the fall 05/22/15; there was an incident report dated 05/26/15. There were no post-fall reassessments after 05/22/15.

Y. On 06/15/15 at 1:50 pm, during interview, the DON was asked about the lack of an incident report regarding the fall of Pt #15 and the lack of the documentation regarding the post-fall reassessment. He stated, "There should have been an incident report dated 05/22/15." He further stated, "We may not have checked the patient as well as we should have." When asked if the nurse(s) should have informed the medical doctor that Pt #15 had a change of condition during the weekend (the psychiatrist did make rounds on Pt #15, throughout the holiday weekend), he replied, "Yes."

Z. On 06/17/15 at 4:30 pm, during interview, the Senior Vice President of Clinical Quality confirmed that the nurses are not completing the fall assessments correctly.

AA. Record review of the facility's policy and procedure titled "Identification & Reporting" created 01/2013 and last revised 06/2015 revealed the following:
"Any accident, unusual occurrence, variance, hazard or heft, involving patients, visitors or staff is to be reported timely and in the approved format. Reports are to be made by the staff first aware and/or most knowledgeable about the situation. The Incident Report (IR) and Medication Variance Report (MVR) to be used to report events or occurrences not consistent with the routine operation of the hospital that have led to a variance, accident, or situation that could have, or has, resulted in an injury to a patient or visitor. The IR is a privileged and confidential document that is intended for risk management use to aid in the evaluation and improvement of the overall quality of care."

BB. Record review of the facility's policy and procedure titled "Falls Prevention and Monitoring" (originated 07/2013 and last revised 03/2015) and the "Let's Eliminate All Falls" (LEAF) program that was integrated with [name of facility] policies and processes revealed the following: "Patient safety is an ongoing responsibility of all staff. In order to reduce the risk of a patient injuries as a result of a fall, nursing staff will assess and re-assess the patient's level of risk for fall and implement appropriate interventions through the following procedures...
Interventions post fall:
· An incident report will be completed and submitted to the PI Director after a patient has fallen.
· The medical practitioner will be contacted by the Charge Nurse to determine course of treatment after a patient has fallen.
· The patient will be identified as a fall risk after falling, if not done so upon admission.
· Patient falls risk reassessed and appropriate interventions implemented.
· Changes in interventions indicated in treatment plan.
· Physical therapist consulted per physician order."


CC. Record review of the facility's policy titled "Let's Eliminate All Falls" (L.E.A.F) program, undated, that was in-serviced in May 2015 to the hospital staff revealed the following: "At admission complete the Psychiatric Falls Assessment (PFA) tool. Patient identified as Highest Risk (25+) will have a Brown LEAF placed at the head of their bed and on the patient's door. Those on High Risk (18-24) will have a Orange LEAF placed at the head of their bed and on the patient's room door. Patients identified as Moderate risk (10-17) will have Yellow LEAF placed at the head of their bed and on the patient's door. Those on Low risk (0-9) will not have a LEAF on their door as all patients are on standard risk precautions. Purpose: To initiate a more formalized fall prevention program by identifying patients at risk for falls, develop and maintain evidence based strategies to reduce the number of falls and fall-related injuries...Highest risk for fall prevention interventions al all patient with PFA 25+ in addition to the standard, low, moderate and high risk fall prevention interventions. Highest Fall Risk Interventions:
All standard, low, moderate, high risk precautions
Special treatment planning to determine how to prevent injury
Patient not to be left in bathroom unattended
1:1 staffing or Line of Sight observation if indicated by MD order or nursing judgement
Use of Brown LEAF sign posted at bed side and entrance to the room

Documentation:

Fall Risk Prevention Training for staff review

Pre-fall: Initial assessment/reassessment using the Psychiatric
Fall Risk Assessment result are documented in the treatment plan.

Post-fall: 1. Incident Report is completed and submitted.
2. Medical practitioner will be contacted by the Charge
Nurse to determine course of treatment after patient has fallen.
3. Patient will be identified as a fall risk after falling, if not
done so upon admission.
4. Post-Fall Psychiatric Fall Risk assessment is completed
by nursing staff licensed staff.
5. Reassessment and documentation by licensed staff
every shift for the next 72-hours.
6. Patient falls risk reassessed and appropriate
interventions implemented.
7. Changes in interventions indicated in treatment plan.
8. Physical therapy consulted per physician order, if applicable.

Special Falls Treatment Plan Meeting: This occurs when a patient has had 2 or more falls during hospitalization.

Sentinel Event: Reported to Safety Officer (Director of PI/RM); CER/RCA will be conducted based on the information that is reported..."

Findings related to Schedules:
DD. On 06/15/15 at 3:15 pm, during interview, S #21 was asked about the training that she received during her two months at the hospital. S #21 stated that the hospital "just throws you out there [on the floor, to take care of the patients]. There's a checklist and that the hospital doubles you up with another BHT staff member that has been there awhile, but it's hard for them to train and to work at the same time."

EE. Record review of the staffing schedules for the RNs and BHTs dated for the period from 12/28/14 through 06/13/15 revealed the following:
1. On 04/11/15 Saturday 1 BHT scheduled for nights, instead of 2 BHTs that should be scheduled following the corporate matrix staffing policy. The census was unknown for this night.
2. On 04/30/15 Thursday 1 RN scheduled for days, instead of 2 RNs that are required to be on duty. The census was unknown for this day.
3. On 05/01/15 Friday 1 RN scheduled for days, instead of 3 RNs that should be scheduled following the corporate matrix staffing policy for 32 patients.
4. On 05/14/15 Thursday 1 RN scheduled for days, instead of 2 RNs that should be scheduled following the coporate matrix staffing policy for 9 patients.
5. On 05/15/15 Friday 1 RN scheduled for days, instead of 2 RNs that should be scheduled following the coporate matrix staffing policy for 8 patients.
6. On 05/22/15 Friday 1 RN scheduled for days, instead of 3 RNs that should be scheduled following the coporate matrix staffing policy for 31 patients.

FF. On 06/15/15 at 2:00 pm, during an interview, the DON stated that 2 RNs and at least 2 BHTs should be on the floor for all shifts.

Findings for Patient #26:
GG. Record review of Pt #26's medical record indicated that the patient had been admitted to the hospital on 02/17/15 with major depression, history of alcohol dependence, chronic pain and opiate dependence. The patient was on morphine sulfate (opioid/pain medication) 15 mg by mouth twice a day for chronic pain, ordered on 02/18/15.

HH. Record review of a Medication Variance Report dated 02/25/15 revealed the following:
1. "[Name of S #24] entered medication room and prepped medication for his patient [name of Pt #7]. Who was admitted 02/22/15 [Sunday] and by 02/25/15 [Wednesday] there was no picture of this patient in the MAR [Medication Administration Record] or in his chart."
2. "[Name of S #24] walked into the Day Room and approached a patient that he thought was [name of Pt #7], without identifying the patient by name, SSN [social security number] or DOB [date of birth], he gave the patient [Pt #26] [who had a picture in the chart] medication and left the Day Room, returning to the med room."
3. "Meanwhile, [name of S #26] prepared [Pt #26's] medication and approached him to give him his medications. That was when [Pt #26] informed [name of S #26] the he had already been given his meds. [Name of S #26] returned to the med room, when she mentioned it to [name of S #24], who said that he may have given [name of Pt #26] the wrong meds."
4. "In the meantime, [name of Pt #26] began complaining of stomach ache and was told to lay [sic] down in his bed. About 9:30 am, [name of Pt #26] began withdrawals and loudly complaining of aches and pains. [Name of S #27] reviewed the med error and ordered [name of Pt #26] Ativan to make comfortable."

II. Record review of Pt #7's medical record revealed that he wanted help to stop drinking and the physician ordered naltrexone (a medication given to detoxify a patient for opioid and alcohol use) 50 mg by mouth every morning on 02/24/15.

JJ. Record review of the Nursing Progress Notes for Pt #26 dated 02/26/15 at 1545 (3:45 pm) revealed the following: "Patient A & O x3 [awake and oriented to name, date and place]. Feeling better today. Only complaint is nausea. Refused b'fast. Staying in bed...Remains positive. Support pat [patient] in present needs. At b'fast c/o [complains of] upset stomach. Given Zofran (anti-nausea medication) 4 mg at 0815 (8:15 am). Taking sips of Ginger Ale. At 0845 (8:45 am) 200 cc of emesis - bile mixed with Ginger Ale. States, "I feel so much better since all that came out." CBG's [capillary blood glucose] at 0730 (7:30 am) 191 [mg/dl] - 1 unit coverage held d/t [due to] not eating; CBG at 1130 (11:30 am) 209 [mg/dl] - 2 units coverage held d/t not eating. At about 11:45 am mother & sister here to visit. Prior to lunch given Phenergan [anti-nausea] 50 mg given at 1205 [pm]. Liquid diet served and pt ate all is soup & kept it down."

KK. Record review of the Discharge Summary for Pt #26 dated 03/02/15 revealed the following: "..While the patient was here, the patient was [sic] by mistake received a dose of Naltrexone causing the patient to go into opiate withdrawal syndrome..."

LL. Record review of the facility's document titled "Format for Critical Event Review" dated 03/03/15 revealed the following: "Provision of medication - Outline /Map of current process: [S #24] in med room & gathered meds for [Pt #7] - no pic [picture] in MAR. Walked into day room and administered drugs to [Pt #26]. Failed to use 2 forms of ID it [sic] ensure correct pt. [Pt #26] given Naltrexone - within 30 minutes in withdrawal as pt prescribed morphine for pain (chronic). Evaluated by [S #27] and prescribed Ativan, cannot give Opioid for 24 hours until Naltrexone leaves body. Unclear if [Pt #26] given correct meds after incident as no initials in MAR. RN did not complete MAR forms correctly - no initials/signature or date. Action: Retrain all nurses on proper pt identification when administering medications. Responsible party: DON. Measure of Success Results: Monitor med errors via IR/med variance reports."

MM. Record review of the facility's policy and procedure titled "Medication Administration" origination 07/2013 and last revised 05/2014 revealed the following under Procedure: "Medications should be administered as soon as possible after being prepared...Check patient's Medication Administration Record (MAR) to ensure that the order is accurate:
· Verify patient
· Verify medication
· Verify dosage.
· Verify route
· Verify frequency
· Verify stop date

Consult reference materials, another nurse, a physician, or a pharmacist prior to proceeding further in administering the drug should clarify any questions, inconsistencies, or unclear items.
Review the five rights prior to administering medication.
a. Right Patient-You must use two identifiers:
Patient picture
Patient armband
(alternate) ask patient birth date and verify with MAR
b. Right Medication
c. Right Dosage
d. Right Route
e. Right Time
Do not administer the medication if there are any questions, inconsistencies, or unclear items identified by the six rights. Any questions or inconsistencies should be clarified by consulting the physician, another R.N., a pharmacist and/or reference materials as appropriate.
Document on the MAR the following information in the appropriate column: dose, time, route (if not PO), site (if appropriate), and initials. Sign the bottom of the MAR where indicated...Properly identify patient by: Checking patient armband and picture and Asking the patient to state his/her name..."

Findings for Patient #30:
NN. Record review of Pt #30's medical record indicated that the patient had been admitted on 06/03/15 to the hospital with diabetes, heart disease, hydrocephalus, major neurocognitive disorder and dementia. Patient was taking the following medications: Xanax (anti-anxiety medication) at bedtime and as necessary for anxiety, gabapentin (anticonvulsant for seizures, restless leg syndrome), Remeron (antidepressant) and Zyprexa (antipsychotic).

OO. Record review of the Nursing Progress Notes for Pt #30 dated 06/14/15 at 7:02 am revealed the following: "pt found on floor by BHT and RN. pt c/o right shoulder and arm pain. upon assessment pt collar bone appeared to be displaced. pt's vss [vital signs stable]. pt is alert and oriented. RN called MD new orders received to transport pt to emergency room. s/p [status post] fall for assessment and treatment. Report called to [name of local hospital] RN. pt departed unit at 0705 (7:05 am). Report to oncoming shift."

PP. Record review of the Nursing Progress Notes dated 06/14/15 at 10:12 am revealed the following: "This RN contacted BHT at hospital with pt. BHT reports that pt has a fractured right wrist and is waiting on EMS [Emergency Medical Service] transport back to this facility..."

QQ. Record review of the Psychiatric Falls Risk Assessment dated 06/14/15 at 0700 [7:00 am, the day of fall]. The next Psychiatric Falls Risk Assessment was dated 06/17/15 at 1400 (2:00 pm), three days after the fall. No evidence of a Psychiatric Falls Risk Assessment every shift for the next 72 hours following the post-fall dated 06/14/15 after 11:30 am when pt returned from hospital, as per hospital policy.

RR. Record review of the Psychiatric Falls Risk Assessment dated 06/17/15 for Pt #30 indicated that the patient did not have dementia, or was on antidepressants, anxiolytics or anti-psychotic medications. Pt #30 was taking Xanax at bedtime and as necessary for anxiety, Remeron (antidepressant) and Zyprexa (antipsychotic). The Psychiatric Falls Risk assessment was not completed or scored correctly.

SS. On 06/17/15 at 4:30 pm, during interview, the Senior Vice President of Clinical Quality confirmed that Pt #30's Psychiatric Falls Risk Assessments were not completed according to their policy nor were they completed correctly.

Based on record review, interviews and facility policy, the nursing service and hospital failed to ensure that medications were prepared and administered safely to avoid any medication errors for 1 of 32 sampled patients (#26). This deficient practice resulted in medications intended for one patient being administered to another patient resulting in the patient having adverse side effects from the medication, causing the patient to be hospitalized longer than expected. The findings are:

A. Record review of Patient (Pt) #26's medical record indicated that the patient had been admitted to the hospital on 02/17/15 with major depression, history of alcohol dependence, chronic pain and opiate dependence. Patient was on morphine sulfate (opioid/pain medication) 15 mg by mouth twice a day for chronic pain, ordered on 02/18/15.

B. Record review of a Medication Variance Report dated 02/25/15 revealed the following:
1. "[Name of S #24] entered medication room and prepped medication for his patient [name of Pt #7]. Who was admitted 02/22/15 [Sunday] and by 02/25/15 [Wednesday] there was no picture of this patient in the MAR [Medication Administration Record] or in his chart."
2. "[Name of S #24] walked into the Day Room and approached a patient that he thought was [name of Pt #7], without identifying the patient by name, SSN [social security number] or DOB [date of birth], he gave the patient [Pt #26] [who had a picture in the chart] medication and left the Day Room, returning to the med room."
3. "Meanwhile, [name of S #26] prepared [Pt #26's] medication and approached him to give him his medications. That was when [Pt #26] informed [name of S #26] the he had already been given his meds. [Name of S #26] returned to the med room, when she mentioned it to [name of S #24], who said that he may have given [name of Pt #26] the wrong meds."
4. "In the meantime, [name of Pt #26] began complaining of stomach ache and was told to lay [sic] down in his bed. About 9:30 am, [name of Pt #26] began withdrawals and loudly complaining of aches and pains. [Name of S #27] reviewed the med error and ordered [name of Pt #26] Ativan to make comfortable."

C. Record review of Pt #7's medical record revealed that he wanted help to stop drinking and the physician ordered naltrexone (a medication given to detoxify a patient for opioid and alcohol use) 50 mg by mouth every morning on 02/24/15.

D. Record review of the Discharge Summary dated 03/02/15 for Pt #26 revealed the following: "..He was depressed and suicidal. He was not functioning well. He was feeling hopeless and helpless with low self-esteem. We will continue with the same medication he was taking...The patient was initially detoxed for alcohol. He was started on Prozac and Wellbutrin XL to monitor his depression, and lorazepam to help with the anxiety if needed...He was able to show enough improvement to the point that he was not suicidal, homicidal, or a danger to self and others, and we felt that he was ready to be transferred to a lower level of care. While the patient was here, the patient was by mistake received a dose of Naltrexone causing the patient to go into opiate withdrawal syndrome (due to the abrupt cessation of addictive substances. Symptoms would include chills, runny nose, elevated blood pressure, diarrhea and muscle spasms) ..."

E. Record review of the facility's document titled "Format for Critical Event Review" dated 03/03/15 revealed the following: "Provision of medication - Outline /Map of current process: [S #24] in med room & gathered meds for [Pt #7] - no pic [picture] in MAR. Walked into day room and administered drugs to [Pt #26]. Failed to use 2 forms of ID it [sic] ensure correct pt. [Pt #26] given Naltrexone - within 30 minutes in withdrawal as pt prescribed morphine for pain (chronic). Evaluated by [S #27] and prescribed Ativan, cannot give Opioid for 24 hours until Naltrexone leaves body. Unclear if [Pt #26] given correct meds after incident as no initials in MAR. RN did not complete MAR forms correctly - no initials/signature or date. Action: Retrain all nurses on proper pt identification when administering medications. Responsible party: DON. Measure of Success Results: Monitor med errors via IR/med variance reports."

F. Record review of the facility's policy and procedure titled "Medication Administration" origination 07/2013 and last revised 05/2014 revealed the following under Procedure: "Medications should be administered as soon as possible after being prepared...Check patient's Medication Administration Record (MAR) to ensure that the order is accurate:
· Verify patient
· Verify medication
· Verify dosage.
· Verify route
· Verify frequency
· Verify stop date

Consult reference materials, another nurse, a physician, or a pharmacist prior to proceeding further in administering the drug should clarify any questions, inconsistencies, or unclear items.
Review the five rights prior to administering medication.
a. Right Patient-You must use two identifiers:
Patient picture
Patient armband
(alternate) ask patient birth date and verify with MAR
b. Right Medication
c. Right Dosage
d. Right Route
e. Right Time
Do not administer the medication if there are any questions, inconsistencies, or unclear items identified by the six rights. Any questions or inconsistencies should be clarified by consulting the physician, another R.N., a pharmacist and/or reference materials as appropriate.
Document on the MAR the following information in the appropriate column: dose, time, route (if not PO), site (if appropriate), and initials. Sign the bottom of the MAR where indicated...Properly identify patient by: Checking patient armband and picture and Asking the patient to state his/her name..."

Based on record review and interviews, the hospital failed to ensure that a medical history and physical examination was completed and placed in the patient's medical record within 24 hours after admission for 3 of 32 sampled patients (#3, 15, and 20). This deficient practice could result in a lack recognition of significant medical conditions by the physicians that require treatment. The findings are:

A. Record review of Patient #3's medical record revealed that the patient was admitted to the hospital on 06/05/15 at 10:24 am. No history and physical was found completed for this patient.

B. Record review of Patient #15's medical record revealed that the patient was admitted to the hospital on 05/20/15 at 9:00 am with dementia with behavioral disturbance. A history and physical document that was not completed indicated that the patient had refused the examination. The history and physical indicated that the document was signed by a provider on 05/21/15 at 11:07 am. No other documentation was in the chart.

C. Record review of Patient #20's medical record reviewed that the patient was admitted to the hospital on 01/06/15. No History and Physical was found completed for this patient.

D. On 06/15/15 at 2:30 pm, during an interview, the Director of Nursing confirmed that these records did not have completed history and physicals.

Based on record review and staff interview, the hospital failed to ensure that the designated infection control officer, the Director of Nursing (DON), was qualified through ongoing education, training, experience or certification to oversee the infection control program (refer to A-748). The hospital further failed to ensure a current ongoing system in place for identifying, reporting, preventing, investigating, and controlling infections by not conducting ongoing active surveillance and performing program evaluation and revision (refer to A-749). Additionally, the hospital failed to ensure (1) the designated Infection Control Officer/Director of Nursing (DON) followed the recommendations of the Department of Health (DOH) Epidemiology division, (2) there was an appropriate terminal cleaning (thorough disinfection) of the patient's rooms after discharge during the 2015 outbreak of the norovirus at the facility, and (3) the hospital-wide quality assessment and performance improvement (QAPI) program and training programs addressed the outbreak of the norovirus at the facility (refer to A-756). The cumulative effect of these deficient, systemic practices resulted in the hospital's inability to ensure that the infection control system was able to prevent problems from reaching the patients.

Based on record review and interviews, the hospital failed to ensure that the designated infection control officer, the Director of Nursing (DON), was qualified through ongoing education, training, experience or certification to oversee the infection control program. This deficient practice has the potential to impact patients that are admitted to the unit by not overseeing, tracking, analyzing and reporting infections rates and trends of patients. The findings are:

A. Record review of the DON's continuing education included the following: NY (New York) Mandated Infection Control for Healthcare Professionals completed on 12/30/12 and C [Clostridium] Difficile Threatens Hospitalized Patients completed on 02/16/13.

B. On 06/11/15 at 3:00 pm, during interview, the DON stated that he was designated as the infection control officer by being the DON, which is indicated on the job description. When asked if he had attended any recent infection control training he replied, "No."

C. Record review of the hospital's job description for Director of Nursing dated 07/29/13, last revised on 06/2013 revealed the following: Under Infection Control Officer Functions: "Infection Prevention Surveillance - Conduct infection control surveillance. Oversee, track, analyze & report infection rates & trends of patient & staff infections. Provide results to the Infection Prevention/Control Committee, Quality Council and Medical Executive Committee. Infection Prevention Plan - Review the Infection Prevention Plan minimum annually and revise as indicated. Present the Infection Prevention Plan to the Infection Prevention/Control Committee, Quality Council, Medical Executive Committee and Governing Board for review and approval annually and anytime it requires revision. Conduct an annual evaluation of the effectiveness of the Infection Prevention Control Program. Regulatory Reporting - Maintain knowledge of the reporting requirements related to infections. Report required infections to appropriate agencies according to federal, state, and local regulations. Training - Provide infection prevention and control training for employees during new employee orientation, annually and as needed to address identified ongoing training needs. Training will include equipment cleaning and disinfection, influenza, hand hygiene, bloodborne pathogens and other identified training needs based on patient population, outbreaks, etc. Assess ongoing staff competency through direct observation and verbal/written tests. Immunizations - Oversee the staff immunization program including influenza, TB and Hepatitis B. Coordination with the Infection Prevention Consultant - Coordinate development/revisions of the Infection Prevention Plan, forms and processes with the Infection Prevention Consultant. Provide quarterly and annual reports to the Infection Prevention Consultant for review and feedback. Utilize the Infection Prevention Consultant in the event of outbreaks, educational needs, etc."

D. Record review of the Infection Control meeting minutes revealed that the last meeting was in 2013.

E. Record review of the Infection Prevention Plan for the year 2015, revealed the following: "The Infection Prevention Committee - Will meet at least quarterly and will include: Infection Prevention designate, Medical, Nursing, Administrative, Pharmacy, Environmental Services, Quality Improvement..."

F. On 06/11/15 at 3:00 pm, during interview, the DON stated, "I have not kept up with the Infection Control book and I have monthly meeting via telephone with an Infection Control Consultant. I have monthly meetings but I don't write anything down." The DON did not indicate that he communicated the information from the meetings to the staff.

Based on record reviews and interviews, the hospital failed to ensure a current ongoing system in place for identifying, reporting, preventing, investigating, and controlling infections by not conducting ongoing active surveillance and performing program evaluation and revision. This deficient practice has the potential of increased risk of infection to patients and personnel. The findings are:

A. Record review of the Infection Control Committee minutes indicated that the last meeting was held in 2013.

B. Record review of the Infection Prevention Plan for the year 2015 revealed that the Infection Control Committee should meet quarterly.

C. On 06/11/15 at 3:00 pm, during interview, the Director of Nursing (DON) stated, "I have not kept up with the Infection Control book and I have monthly phone conversations with an Infection Control Consultant. I have monthly meetings but I don't write anything down." The DON did not indicate that he communicated the information from the meetings to the staff.

Based on record reviews and interviews, the hospital failed to ensure that during the hospital's recent norovirus (sometimes referred to as "stomach flu"; highly contagious; the viruses can remain viable and infective on surfaces for up to two weeks, and are found in the stool or vomitus of infected people or on contaminated surfaces not properly cleaned and disinfected) outbreak during April and May of 2015 (1) the designated Infection Control Officer/Director of Nursing (DON) followed the recommendations of the Department of Health (DOH) Epidemiology division during the norovirus outbreak, (2) there was an appropriate terminal cleaning (thorough disinfection) of the symptomatic or asymptomatic patient rooms after the patients' discharge, and (3) the hospital-wide quality assessment and performance improvement (QAPI) program and training programs addressed the outbreak of the norovirus at the facility. These deficient practices resulted in (1) putting lower level of care facilities [nursng homes and assisted living facilities) at risk by the transfer of the hospital's patients to those facilities during the norovirus outbreak, and (2) potentially exposing subsequent patients in the hospital to the norovirus. The findings are:

A. Record review of the Infection Control Monitors: [Name of hospital] for the year of 2015 revealed the following: for the Patient Safety Indicator for the month of May, "Infection Monitoring" under "Staff Reported Infections" indicated 11, and "Total Healthcare Acquired Infections" indicated 11, for a "Total Identified Patient Infections" of 22. Under "Topic/Indicator: Outbreak: Norovirus April 2015. Findings/Conclusions: The strain affecting New Mexico was a mutated type that was present beyond to identified season - from late October to April. Our hospital experienced its outbreak April 26th until May 8th. Containment efforts represented a collaboration with the State Epidemiology Department."

B. Record review of the "Nursing Department Monthly Meeting" minutes dated 04/30/15 did not indicate any evidence of discussion about the norovirus outbreak, such as how many patients or staff had become infected, or the DON's discussion with the State Epidemiology Department during the time the hospital was experiencing the outbreak.

C. Record review of the hospital's Admission Register dated for the period 04/26/15 to 05/16/15 revealed that the hospital admitted four (4) patients the afternoon of 04/27/15, while the hospital administration was aware of the norovirus outbreak.

D. On 06/11/15 at 11:15 am, during interview, the Administrator and Infection Control Officer/DON stated that the hospital had stopped admitting patients to the hospital on 04/27/15 (no mention of how many patients were infected at the beginning of the outbreak). The facility started admitting patients on 05/16/15, given that the last symptomatic case was on 05/11/15.

E. On 06/17/15 at 10:20 am, during interview via phone, the Active Bacterial Core Coordinator with the DOH Epidemiology and Response Division was asked how she thought the ICO/DON handled the norovirus outbreak at the facility. She stated that the DON was proactive but there was some confusion regarding the norovirus guidelines, specifically relating to the transfer of asymptomatic (without symptoms of the norovirus) patients to other facilities.

F. Record review of an email dated 04/29/15 that asymptomatic patients should not be transferred to another facility, though patients may be discharged to their private residences.

G. Record review of an email sent from the ICO/DON to the Active Bacterial Core Coordinator with the DOH Epidemiology and Response Division dated 04/29/15 revealed the following: "...Containment interventions are continuing - restricting patients from community engagements, wipe downs of the unit and patients' rooms with the appropriate bleach solution, no admissions or discharges, meals in rooms..."

H. Record review of the facility's Discharge Register dated from 04/26/15 to 05/16/15 indicated that there were a total of 30 discharges during this time. Three (3) of the patients were discharged to an assisted living facility; one (1) patient was transferred to a local hospital on 04/24/15; six (6) patients were transferred to skilled nursing facilities on 05/01/15, 05/07/15, 05/08/15, 05/08/15, 05/11/15, 05/12/15, respectively, locally and around the state; seven (7) patients were transferred to an intermediate care facility for individuals with intellectual disabilities (ICF/IID) on 05/07/15; one (1) patient was transferred to a Medicare certified nursing home on 05/08/15; and one (1) patient was transferred to another psychiatric facility on 05/01/15.

I. On 06/17/15 at 1:00 pm, during interview, Staff member #13 stated that the DON had informed the nurses during the norovirus outbreak that it was OK to send patients home if they were asymptomatic and that it was OK to send patients who were asymptomatic to nursing homes, as long as the nursing home staff was informed that the patient/resident was coming from a facility with norovirus.

J. Record review of an email dated 06/10/15, Staff member (S) #10 indicated the following: that "during the recent norovirus outbreak, when patients were allowed to be discharged because they were symptom fee, he [DON] nor a member of his staff did not inform the receiving facility that the patient was coming from a facility with norovirus - I had to run interference with a nursing home that called the DON for more information that he never called back. I had to give him [the DON] the nursing information and contact at the state for official information regarding the outbreak and discharge status."

K. On 06/17/15 at 12:05 pm, during interview, S #13 stated that on 05/04/15 the night shift nurse had called S #13 and requested if she (S #13) could come in and work the rest of the night shift because the other scheduled night nurse went home sick. The night staff nurse informed S #13 that she had called the DON twice and had received no answer at his home and that was why she was calling S #13.

L. Record review of an email dated 05/14/15 from the Active Bacterial Core Coordinator with the DOH Epidemiology and Response Division to the ICO/DON revealed the following: "Given that your last symptomatic case seen at your facility was on Monday, May 11th, 2015 at approximately 6:31 am, I recommend that you do not admit any new patients or transfer patients to other health care facilities until Friday, May 15th, 2015 at 6:30 am."

M. Record review of an email dated 05/02/15 indicated the following: "Census holding at 29 secondary to Norovirus restrictions. Staffing: 2.5 RNs and 3 BHTs on the Day Shift, 2 RNs and 4 BHTs on Second shift, 2 RNs and 2 BHTs scheduled for the Third shift...There was a containment breech on the Day shift - someone delivered dirty trays to the front of the kitchen following the noon lunch service...spoke with [name of the contract dietary service] he stated it was good no one had access to the kitchen prep area. He was going to soak..."
Record review of an email dated 05/13/15 indicated the following: "Census 9, May admits: 0 Goal: 70. Wait List: Monday pt's lab results came back negative for C-Diff (different intestinal infection), but Norovirus results still pending..."

N. On 06/11/15 at 10:30 am, during interview, S #4 stated that the facility had 11 patients and 11 staff members had the Norovirus. Specimens were being sent to Quest Laboratory [located in the same building as the hospital] instead of the Scientific Laboratory Division, designated by the Active Bacterial Core Coordinator with the DOH Epidemiology and Response Division.

O. On 06/16/15 at 3:30 pm, during interview, the Administrator and DON were asked how the patient rooms were cleaned after the norovirus outbreak. The Administrator responded that the hospital did not want strange people coming in and cleaning the patient rooms, so the hospital directed the behavioral health technicians (BHTs) to clean the infected patient rooms after the patients were discharged. When asked how the BHTs were instructed to terminally (thoroughly) clean the rooms, the DON stated that the BHTs were told just to wipe everything down with Clorox wipes. The DON confirmed that none of the staff demonstrated to the BHTs how the patient rooms were to be cleaned, and no staff required the BHTs to show how they had cleaned the rooms. The Administrator stated that the hospital building management housekeeping staff came to terminally clean the dining room and day rooms only.

P. Record review of the hospital's Quality Council meeting minutes dated 06/11/15 revealed that the norovirus outbreak that occurred between 04/27/15 through 05/16/15 was not adequately documented.

Q. On 05/16/15 at 3:00 pm, the Senior Vice President of Clinical Quality confirmed that the hospital should have followed the DOH's recommendations.