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1. Based on record review and confirmation by staff interview, it was determined that the medical staff failed to include and establish medical treatment parameters for the reporting of abnormal values in the monitoring and management of patients' blood glucose levels, and/or vital signs in five ( 5) of ten (10) records reviewed (Patients # 2, 9, 12, 13 and 14).

The findings include:

Nursing Procedure Manual # QIR-205, titled Blood Glucose Monitoring, last revised August 10, 2008, included the following directive under item # 3 of ' General Guidelines ' : " If the blood sugar is greater than 300, or less than 50, the test must be repeated. All abnormal results must be documented in the progress notes and reported to the physician. Parameters for notifying the physician of abnormal results must be established beforehand by the physician. "

Patient #2 was admitted January 31, 2011 under FD 12 involuntary psychiatric commitment directive, after he/she became manic and threatening to others at the community residential facility. The past medical history was significant for the following psychiatric and medical diagnoses: Bipolar Disorder [recent episode mixed, severe] with Psychotic Features; Vascular Dementia; Diabetes Mellitus Type II (poorly-controlled); Hypertension (HTN); Morbid Obesity; and Bilateral Lower Extremity Edema.

The current physician's orders, dated May 11, 2011 through August 17, 2011, included and directed the following diabetic management orders: " Glucophage (Metformin HCL) 850 mg oral tablet twice a day; Finger stick (FS)/Blood sugar check order, Q (every) weekly. Do FS every Wednesday " .

Additionally, the 'Comprehensive Initial Nursing Assessment' , completed on February 1, 2011, included the following directives under 'Physical Health': "Monitor vital signs and finger sticks as ordered and report to physician for any abnormalities."

Review of the physician's order for diabetic monitoring with weekly finger sticks revealed that the physician failed to adhere to the facility's policy and procedures to include in the diabetic order a set of medical treatment parameters for reporting abnormal values. It was further revealed that the nursing staff failed to obtain clarification from the physician to include the required notification parameters.

A face-to-face interview was conducted with the unit's nurse manager on July 20, 2011 at approximately 12:15 P.M. He/she reviewed, acknowledged and verified the above referenced findings. The record was reviewed July 20, 2011.


Patient #9 was admitted May 27, 2011 with diagnoses which include Depressive Disorder, Recurrent Cerebrovascular Accident with Psychotic Features, Hypertension, Type II Diabetes Mellitus and Hyperlipidemia. Review of the medical record on July 20, 2011 at approximately 11:10 AM revealed the patient was to have vital signs (VS) and finger stick blood sugar (FSBG) checked daily with nursing staff to call the physician of abnormal results. The medical record lacked parameters for the monitoring of and/or response to abnormal blood sugar levels, and/or abnormal blood pressures.

Patient #12 was admitted July 13, 2011 with diagnoses including Undifferentiated Schizophrenia, and Tachycardia. Review of the medical record on July 20, 2011 at approximately 2:30 PM revealed the patient was to have vital signs performed daily with nursing staff to notify physician of abnormal results. The patient was noted to have hypotension (low blood pressure) several mornings. The medical record lacked documented evidence of parameters for the monitoring of and/or response to abnormal blood pressures.

Patient #13 was admitted October 4, 1996 with diagnoses which include Paranoid Type Schizophrenia, Adjustment Disorder with Anxiety, Hypertension, and Hyperlipidemia. Review of the medical record on July 19, 2011 at approximately 11:10 AM revealed the patient was to have VS checked daily, and FSBG checked every Monday. The medical record lacked parameters for the monitoring of and/or response to abnormal blood sugar levels, and/or abnormal blood pressures.

Patient #14 was admitted March 11, 20101 with diagnoses which include Residual Type Schizophrenia, Alcohol Dependence, and Type II Diabetes Mellitus. Review of the medical record on July 19, 2011 at approximately 3:00 PM revealed the patient was to have FSBS performed every Monday. The medical record lacked parameters for the monitoring of and/or response to abnormal blood sugar levels.

The above findings were reviewed and acknowledged by the Nurse Manager on July 19, 2011.


2. Based on medical record review and confirmation by staff interview it was determined that the medical staff failed to write a complete order for wound care/treatment in an isolated occurrence (Patient #4).

The findings include:

Patient #4 was admitted July 25, 1985 with diagnoses of Bipolar Disorder, Pedophilia, Vascular Dementia, Antisocial Personality Disorder, Diabetes, Hypercholesterolemia, Benign Hypertension, Hyperplasia Prostate, Neurogenic Bladder, Urinary Obstruction and Dysphagia with gastrostomy tube for feeding and medications.

Review of the medical record on July 20, 2011 at approximately 10:45 AM revealed the following order on the eMAR: "Duoderm CGF Border Dressing (Hydrocolloid Dressing) 4 x 4 topical bandages every other day. Apply to Open Skin Wound as Directed. Skin, unspec, " dated March 29, 2011 03:09 PM - July 19, 2011 10:26 AM (DC). The treatment order lacked documented evidence of a specific skin/wound site(s).

Interview with the Nurse Manager on July 21, 2011 at approximately 12:00 noon revealed that the patient was hospitalized several times, and returned with skin breakage, no more than Stage 2, located in the sacral area. The Duoderm dressing was to be used until the area healed. The Manager further explained that the wound has been healed for sometime although s/he does not remember the exact time. When queried regarding the notification of the GMO of the healed wound, the Manager acknowledged that the staff should have notified the GMO when the wound healed although the order was discontinued on July 19, 2011.

The above findings were reviewed and acknowledged by the Nurse Manager.

3. Based on medical record and policy review and confirmation by staff interview it was determined that the medical order and nursing staff failed to complete tuberculosis screening test (TST) timely in a single record review (Patient #6).

The findings include:

Saint Elizabeth's Hospital Policy, Number 15, no revision date, entitled " Tuberculosis Control Plan " Section IV - Standards, Item A-3 stipulates " a. All first time patients will be screened for infection with tubercle bacilli on admission ... Section IV, Item A-4(b) stipulates " all patients shall have an annual TST test, except patients with a history of skin test positivity will be screened by a chest x-ray ad a physician ' s clinical assessment ... "

Patient #6 was admitted June 22, 2010 with diagnoses of Schizophrenia, Paranoid Type, Neuroleptic Tardive Dyskinesia, Vascular Dementia with Delusions, Renal Failure, Essential Hypertension, Hyperparathyroidism, and Malignant Neoplasm of Stomach. Review of the medical record on July 20, 2011 at 9:30 AM revealed the initial history and physical examination was completed on June 23, 2010 at 12:26 PM, and stipulated " PPD status unknown " .

On July 21, 2011 at approximately 11:30 AM the GMO presented the surveyor with a copy of an electronic document referencing a pharmacy order. Review of the document revealed a PPD was placed on September 28, 2010 at 6:47 PM by the nursing staff and "To be read after 48 hours per the GMO." A subsequent entry by the nursing staff was dated October 5, 2010 at 7:07 PM "Late entry for 09-30-10: PPD reading negative." The medical staff failed to order the tuberculin skin test on admission; and, the nursing staff failed to read and document the PPD reading within 48 hours after the placement of the PPD.

The findings were discussed with the Nurse Manger, who acknowledged and confirmed the findings regarding the PPD orders and placement during an interview on July 20, 2011 at approximately 10:30 AM.


4. Based on medical record, policy review and confirmation by staff interview it was determined that the medical staff failed to complete an annual physical examination for in one (1) of twelve (12) records reviewed (Patient#6).

The findings include:

Hospital policy number 208-10 revision date April 4, 2011, entitled General Medical Services, Section III - Standards and Procedures, Item 3, Annual Assessment Updates stipulates " ...The GMO or NP shall complete an Annual Medical Assessment and Plan (AMAP) on the designated History and Physical form ... "

Patient #6 was admitted June 22, 2010 with diagnoses of Schizophrenia, Paranoid Type, Neuroleptic Tardive Dyskinesia, Vascular Dementia with Delusions, Renal Failure, Essential Hypertension, Hyperparathyroidism, and Malignant Neoplasm of Stomach. Review of the medical record on July 20, 2011 at 9:30 AM revealed the initial history and physical examination was completed June 23, 2010 at 12:26 PM. The medical record lacked documented evidence that an annual assessment by the General Medical Officer (GMO) and/or Nurse Practitioner (NP) by July 21, 2011 at 12:00 noon. The GMO and/or NP failed to complete an annual assessment for patient.

The findings were discussed with the Nurse Manger, who acknowledged and confirmed the findings during an interview on July 20, 2011 at approximately 10:30 AM.

Based on record review and confirmation by staff interview, it was determined that the General Medical Officer (GMO) failed to ensure that the patient received timely and appropriate medical care and evaluation to effectively manage a persistent and potentially dangerous cardiac dysrhythmia manifested by repeated episodes of Bradycardia of unknown etiology in single record review (Patient # 16).

The findings include:

The 'General Medical Services' policy # 208-10, last revised April 4, 2011, stipulates in Section I: "The Hospital shall ensure that individuals in care receive timely and appropriate routine and emergency medical care to support their safety and wellness. All individuals shall have 24-hour, seven days a week access to a licensed physician or nurse practitioner for timely assessment, treatment and monitoring of their medical/surgical status as well as referrals to the appropriate specialized medical/surgical services when the level of care and treatment exceeds the capability of The Hospital."

Additionally, under Section III, Standards and Procedures, item # 12, titled 'On-site Medical Clinic Services' , the following directives were included: b.) An individual who requires examination and/or consultation shall be referred to the appropriate clinic in an expeditious manner; and d.) Upon receiving the referral, the Medical Clinic Coordinator shall identify and notify the unit of the appointment time and date, along with any special instructions regarding preparations needed for the clinic visit."

Patient # 16 was admitted December 3, 200 with current diagnoses (as of July 12, 2011) of Schizoaffective Disorder; Neuroleptic-Induced Parkinsonism; Morbid Obesity; Essential Hypertension (HTN); Iron Deficiency Anemia; and Cardiac Dysrhytmias-Chronic Bradycardia.

Review of available clinical progress notes, dated April 1, 2011 through July 20, 2011, provided documented evidence that the patient had been experiencing repeated episodes of Bradycardia, untreated and not evaluated for etiology, for an extended period of time.

Documentation entered by the clinical administrator on the 'Clinical Formulation' progress note, dated July 12, 2011, contained the following assessment/plan under item # 2 in the 'Medical Issues' section: "Chronic bradycardia: It is unknown why the patient has chronic bradycardia. He/she frequently refuses medical appointments, stating the he/she is a doctor. However, at present he/she is agreeing to being referred to (an outside Hospital) Cardiology Clinic."

Concurrent review of the patient's available vital signs' logs confirmed that Patient # 16's heart rate (HR) had initially ranged between 67-88 beats per minute (bpm) during January 2011; and, recorded HRs of 60 to 70 bpm during February 2011. Recent vital sign and progress note reviews revealed a significant decrease in the patient's HR to the low 30's and 40's during June and July 2011.

A face-to-face inquiry was conducted with the GMO responsible for the medical care of Patient # 16 on July 20, 2011 at approximately 10:35 AM. Inquiry and discussion was made as to the reason for delay in obtaining cardiac evaluation for continued brady-dysrhymia; and the hospital ' s current policy and practice related to the provision of specialized medical care not available on the hospital campus.

The GMO acknowledged that the patient had episodes of bradycardia for extended period of time but the etiology of the dysrhythmia was not known nor had been evaluated by a specialist. He/she stated that a cardiology consult was only recently requested (June 2011). He/she was unsure of the exact date of request.

The GMO stated that prior requests to evaluate the patient's abnormal heart rhythm had not been initiated because the patient had verbally refused. The physician did not offer a reason for the patient's refusal nor did he/she offer an explanation as to why the patient was not sent to rule out a potentially dangerous cardiac event, despite the verbal refusal.

The GMO was further queried as to whether the patient had an electrocardiogram (EKG) performed to accurately identify and evaluate the severity of his/her dysrhythmia. He/she responded, "yes" . However, medical record review revealed that the patient refused requests for EKGs on April 14, 2011; May 25, 2011 and June 29, 2011.

The last recorded EKG performed on the patient was dated June 21, 2010. Written interpretation by the physician, at that time, documented: Sinus Bradycardia (HR-67); Premature Ventricular/Atrial Complexes ...refer Cardiology for Holter Monitor." There was no documented evidence that the patient was sent for cardiology, at that time, or that holter monitor evaluation was performed.

The GMO was queried as to the current practice and process for obtaining an outside cardiology evaluation. He/she stated that requests for consults were initiated by the physicians and scheduled by the medical clinic. The GMO acknowledged that since his/her initial request was forwarded to the medical clinic for scheduling, he/she had not followed up or inquired with the clinic coordinator a date for the cardiology consult or a reason for delay in scheduling.

An on-site visit was conducted with the office of the medical clinic coordinator responsible for appointment scheduling on July 21, 2011 at approximately 11:15 AM. The patient ' s GMO was present with the surveyor at the time.

Observation of the systems operations was done. After discussion with the medical clinic coordinator, the following findings were revealed: The physician had forwarded the Medical Consultation Form requesting the patient to be scheduled for evaluation at the cardiology clinic on June 29, 2011. However, the medical clinic had failed to review and process the request upon receipt and within a timely and expeditious manner. The request form had not be reviewed by the clinic appointment staff and remained in the medical clinic's request for scheduling in-box on July 21, 2011, the date of surveyor discovery. The medical clinic coordinator acknowledged that the requests were normally completed within two (2) days, but that he/she had been working alone and only recently received additional staffing assistance.

Subsequently, the request for cardiology clinic evaluation, originally requested 23 days earlier, on June 29, 2011, was not processed and scheduled until after inquiry by the surveyor, on July 21, 2011.

Subsequent face-to-face inquiries, conducted with the patient's GMO and the medical clinic coordinator on the respective dates and times referenced above, verified the aforementioned findings concerning: failure of the attending physician to ensure that the patient received timely and appropriate medical care and evaluation of a persistent and potentially dangerous cardiac dysrhythmia; and the hospital's 23-day delay in scheduling a cardiology evaluation for the patient with a potentially dangerous dysrhythmia. The record was reviewed July 21, 2011.

Based on observation, record review and confirmation by staff interview, it was determined that the governing body failed to ensure the quality of services being provided by its contracted respiratory department, as evidenced by the following: the contract respiratory therapists failed to adhere to established policy and procedures of the department, related to the monitoring and maintenance of respiratory equipment for safe and proper functioning in an isolated occurence ( Patient # 1).

The findings include:

The Respiratory Care Services Policy and Procedure Manual, lasted updated February 2011, stipulated the following under the subsection titled 'Disposable Equipment': "All disposable/single use equipment (O2 cannula aerosol Tx set-up, face mask, O2 tubing, etc.) are to be charged/replaced on 7th, 17th, and 27th of each month. Set up bags will include patient name and date of change. All above items may be changed daily if soiled. PRN equipment should be unopened, with patient ' s name, and dated at time of use and be subject to aforementioned equipment charge schedule."

Patient #1 was admitted April 21, 2007 with diagnoses of Intermittent Explosive Disorder; Borderline Personality Disorder; Diabetes Mellitus Type II; Chronic Obstructive Pulmonary Disease (COPD) with Cor Pulmonale; Congestive Heart Failure; and Renal Insufficiency.

A review of the Physician's order/Medication Administration Record (MAR) dated March 24, 2010 through July 20, 2011, include the following order: "2 Liters Oxygen by nasal cannula-continue to advise patient that if he/she does not use it, he/she may go back to the hospital."

On day one (1) of the survey, July 19, 2011, an inspection tour was conducted on one (1) of the in-patient units at approximately 10:40 A.M. During the inspection of Patient #1's room, an Oxygen (O2) concentrator unit was observed unplugged by the patient's bedside.

On closer inspection of the unit, the following were observed:
The patient's disposable O2 equipment (O2 tubing and nasal cannula) had been placed inside a previously used and opened set-up bag and sitting atop the concentrator unit.

According to handwritten data on the outside of the set-up bag, the patient's oxygen equipment had not been inspected or changed by respiratory therapy for three (3) months, April 2011.

Furthermore, the humidification bottle, which was approximately one-third (1/3) filled with water, was unlabeled. There was no corresponding date, time, or initials to verify when or how long the bottle had been placed in use.

Inspection of the O2 concentrator base unit also revealed that it had not been tested or inspected by the respiratory department for proper functioning and service since March 2011.

The unit was subsequently plugged in and tested, in the presence of the unit nurse manager and the administrator in attendance, at approximately 10:45 A.M. It was discovered that the O2 flow meter dial was broken; the unit was non-functional; and, the concentrator unable to deliver any amounts of oxygen or provide for nebulization treatments, if needed.

A face-to-face interview was conducted with the contract respiratory therapist on July 19, 2011 at approximately 11:40 A.M . Discussion was to clarify the roles and responsibilities, along with the policy and procedures, of the respiratory department in the daily evaluation and maintenance of patient oxygen equipment for proper functioning.

Information shared by the contract respiratory therapist (RT) was inconsistent and conflicting. The RT acknowledged the policies and procedures referencing the dates when the "disposable equipment " was to be changed or replaced. The RT also stated that he/she was responsible for checking each oxygen unit and all related equipment on a daily basis because " that's just what I do" .

However, the contract RT confirmed that his/her department failed to maintain a detailed written log to verify the dates and times that respiratory equipment was checked and evaluated for safety and proper functioning. Subsequently, there was no verifiable evidence to demonstrate their compliance with department standards of practice.

When queried specifically concerning the O2 concentrator in Patient #1's room, the contract RT stated that he/she always checked the unit and that it had been checked the previous day, on July 18, 2011.

However, when asked to demonstrate its functioning, the RT acknowledged that the unit was inoperable and broken. The RT was not able to provide any written confirmation or documentation as to when the O2 concentrator unit was last evaluated and functioning appropriately. Nor could he/she provide written documentation as to when the unit was last used by the patient.

A face-to-face interview was subsequently conducted with the unit nurse manager, in the presence of the administrator in attendance, on July 19, 2011 at approximately 12:20 P.M. In addition to the aforementioned findings, the unit manager also acknowledged and confirmed the following: the contracted respiratory therapy department (RD) failed to monitor and maintain the O2 concentrators for safe patient use and proper functioning for four (4) months; and, failed to maintain a written log to verify proper daily, weekly and/or monthly inspection of respiratory equipment and supplies for three (3) months. The observations and records were reviewed July 19, 2011.

2. Based on medical record review and confirmation by staff interview, it was determined that the governing body failed to monitor and ensure the quality of services being provided by its contracted respiratory department, as evidenced by the following: the respiratory therapists failed to differentiate and clarify the physician's order which included both the administration of a bronchodilator inhalation solution and the performance of chest physiotherapy treatments; and, failed to adhere to the Respiratory Care Services procedures related to the management of patients who continually refuse respiratory therapy treatments in a single record review ( Patient # 1).

The findings include:

Patient #1 was admitted on April 21, 2007 with diagnoses of Intermittent Explosive Disorder; Borderline Personality Disorder; Diabetes Mellitus Type II; Chronic Obstructive Pulmonary Disease (COPD) with Cor Pulmonale; Congestive Heart Failure; and Renal Insufficiency.

The Physician's order/Electronic Medication Administration Record (e-MAR) dated May 1, 2011 through July 20, 2011 included the following orders: "Albuterol Sulfate 5mg/ml inhalation solution twice a day as needed for shortness of breath and bronchodilation, also do Chest Physiotherapy (CPT) for bronchial hygiene. Reason: COPD."

A. Respiratory therapists failed to differentiate and clarify the physician's order which included both the administration of a bronchodilator inhalation solution and the performance of chest physiotherapy treatment.

A review of the eMAR Administration Events record, for the same time periods referenced above, revealed documented entry dates and times from the Respiratory Therapist (RT) for the successful and unsuccessful administration of the physician's order for Albuterol inhalation breathing treatments.

However, the eMAR Administration Events records did not list and differentiate the physician's order to perform CPT treatments as a separate and distinct respiratory treatment order.

There was no documented evidence present in the eMAR, with corroborating dates, times and signatures to verify the RT's compliance with the physician's order to perform (or attempt to perform) CPT.

A.face-to-face interview was conducted with the unit nurse manager on July 19, 2011 at approximately 2:15 P.M. He/she reviewed the order and acknowledged that administration of the inhalation medication and chest physiotherapy, as separate treatments, had not been differentiated and demonstrated by the respiratory therapist. The record was reviewed July 19, 2011.

B. Respiratory therapists failed to adhere to the Respiratory Care Services procedures related to the management of patients who continually refuse respiratory therapy treatments.

The Respiratory Care Services Policy and Procedure Manual, lasted updated February 2011, stipulates the following under the subsection entitled 'Patient Refusal and Cancellation of Respiratory Therapy Treatment' : Procedure, A. Refusal of Respiratory Therapy: "In the event that a client refuses respiratory care, measures are taken to re-educate them about the purpose for the therapy and its benefits. This is for positive reinforcement; If client continues to refuse respiratory therapy treatment, Nurse and GMO (General Medical Officer) must be informed. Document in Avatar eMAR as Patient Refused and reason ... "

A review of the eMAR Administration Events record, for the time periods of May 1, 2011 through July 20, 2011, included the documented dates and times from the Respiratory Therapist (RT) for the successful and unsuccessful administration of the physician ' s order to perform Albuterol inhalation breathing treatments.

A total of 42 inhalation therapy treatment orders were reviewed for the time period referenced. It was documented that the patient refused 20 of the 42 breathing treatments. Documented entries from the respiratory therapists noted that "patient refused neb (nebulization) treatments, nurse aware" .

There was no documented evidence that appropriate measures were taken by the respiratory therapists to re-educate the patient about the purpose for the therapy and its benefits. Nor was there a documented reason for the patient's refusal to receive the ordered treatments or evidence that attempts were made to re-approach the patient, as stipulated in the Respiratory Care Services Policy and Procedure Manual.

A face-to-face interview was conducted with the unit nurse manager on July 19, 2011 at approximately 2:15 P.M. After eMAR and record review, he/she acknowledged and verified the aforementioned findings relative to non-compliance of the respiratory therapists. The record was reviewed July 19, 2011.

Based on medical record review and confirmation by staff interview for an isolated open record, it was determined that the nursing staff failed to adhere to the physician's order to administer the patient's antipsychotic medications (meds) within specifically established parameters ( Patient # 1).

The findings include:

The Nursing Procedure Manual Policy # NPM 3-8.4 titled 'Utilizing E-MAR-Medication Administration' , stipulates the following under section V,H-3 'Administering Medication': " If the medications are dependent upon set parameters (i.e., pulse, blood pressure, glucose), then the results must be assessed and compared before patient receives the medications and recorded on the e-MAR and patient' s flow sheets. If deemed to be below or above range, notify the physician."

In addition, section VI, A-2, titled 'Documentation Requirements' , stipulates the following: "All abnormal symptoms, lab values, and parameters will be documented in the patient ' s progress notes and reported to the physician."

Patient #1 was admitted April 21, 2007 with diagnoses of Intermittent Explosive Disorder; Borderline Personality Disorder; Diabetes Mellitus Type II; Chronic Obstructive Pulmonary Disease (COPD) with Cor Pulmonale; Congestive Heart Failure; and Renal Insufficiency.

The current physician's orders, dated March 24, 2011 through August 17, 2011, included orders for administration of the following medications: "Risperdal 2 mg every morning. Do not give if BP (blood pressure) is below 95/55; Risperdal 1mg every night at bedtime. Do not give if BP (blood pressure) is below 95/55; and, Metoprolol Tartrate 12.5mg every evening for Congestive Heart Failure (CHF). "

According to the 2011 24th edition of the Mosby's Nursing Drug Reference, the following cardiovascular (cv) pharmacological side effects were included for the antipsychotic medication, Risperdal: Orthostatic Hypotension, Tachycardia, Heart Failure, and Sudden death (geriatric patients).

Additionally, the antihypertensive, anti-anginal Beta Blocker: Metoprolol, prescribed for the management of the patient's CHF, also included the following cv pharmacological side effects: Hypotension, Bradycardia, CHF, AV Block and Cardiac Arrest.

A concurrent review of the hospital's electronic Medication Administration Record (e-MAR) and the patient's vital signs log recording was done for the period of May 1, 2011 through July 20, 2011.

The following findings were revealed: the medication nurse failed to withhold the administration of the Risperdal on 34 separate occasions when the patient had recorded low, hypotensive readings which fell outside the safe treatment parameters established by the physician and failed to provide documented evidence that the patient's vital signs were measured and recorded on 15 other occasions, prior to medication administration. There was no documented evidence that the physician was notified in accordance with the hospital' s established policy and procedure.

Additionally, staff recorded patient's refusal to have vital signs recorded on 23 occasions, with no documented explanation for the refusals or documented evidence of staff ' s attempts to re-assess vitals prior to medication. Despite patient's previously documented hypotensive readings, the medication nurse failed to contact the physician for instructions and administered the medications without first establishing safe parameters.

A face-to-face interview was conducted with the unit's nurse manager on July 19, 2011 at approximately 12:15 P.M. He/she reviewed, acknowledged and verified the above referenced findings. The record was reviewed July 19, 2011. Patient did not experience any effects.

2. Based on record review and confirmation by staff interview, it was determined that the nursing staff failed to adhere to the physician's order to administer the patient's antihypertensive medications (meds) within specifically established parameters in a single record review ( Patients # 2).

The findings include:

The Nursing Procedure Manual Policy # NPM 3-8.4 entitled 'Utilizing E-MAR-Medication Administration' , included and stipulated the following directive under section V,H-3 ' Administering Mediation': "If the medications are dependent upon set parameters (i.e., pulse, blood pressure, glucose), then the results must be assessed and compared before patient receives the medications and recorded on the e-MAR and patient's flow sheets. If deemed to be below or above range, notify the physician."

Patient #2 was admitted on January 31, 2011 under FD 12 involuntary psychiatric commitment directive, after he/she became manic and threatening to others at the community residential facility (CFR). The past medical history was significant for the following psychiatric and medical diagnoses: Bipolar Disorder, Most recent episode mixed, severe with Psychotic Features; Vascular Dementia; Diabetes Mellitus Type II (poorly-controlled); Hypertension (HTN); Morbid Obesity; and Bilateral Lower Extremity Edema.

The current physician's orders, dated April 12, 2011 through August 17, 2011, included the administration of the following antihypertensive medications: "Hydrochlorothiazide 12.5 mg oral capsule everyday. Hold for BP (blood pressure) less than 100/60 mm/Hg; and "Prinivil (Lisinopril) 20 mg oral tablet everyday. Hold for BP (blood pressure) less than 100/60 mm/Hg".

A concurrent review of the hospital's electronic Medication Administration Record (e-MAR) and the patient's vital signs log recording was done for the same period referenced above.
There was no documented evidence that the medication nurse obtained and assessed the patient's BP reading prior to administration of the antihypertensive meds, as per the specific directives given by the physician.

A face-to-face interview was conducted with the unit's nurse manager on July 20, 2011 at approximately 12:00 P.M. He/she reviewed, acknowledged and verified the above referenced findings. The record was reviewed July 20, 2011.

1. Based on the review of records and confirmation by staff interview, the hospital failed to implement an effective record monitoring mechanism to ensure that all laboratory tests performed by the reference laboratory are reported accurately in each patient's medical record for two (2) of the two (2) patient test results reviewed (Patient #s 19 and 20).

The findings include:

A. The Governing Body failed to establish a reporting mechanism to ensure that laboratory test results reported from the reference laboratory are accurately transmitted to the AVATAR system. AVATAR is the hospital's main information system utilized by physicians and other care givers for retrieving laboratory results. It's also used as the patients' electronic medical record.

According to staff interview conducted on July 22, 2011 at approximately 11:30 AM, laboratory test results are printed from the reference laboratory's information system then manually entered to the TD Synergy (the hospital's laboratory information system) which is interfaced with AVATAR.

There was no evidence that the necessary revisions to the AVATAR system had been made to ensure that patient test reports accurately reflect the date and time the specimen is collected, the date and time the specimen is received by the reference laboratory and the date and time the test result is reported by the reference laboratory on the laboratory test report.

Review of randomly selected test results for Patient#s 19 and 20 revealed that although the laboratory staff entered the date and time the specimen is collected, the date and time the specimen is received by the reference laboratory and the date and time the test result is reported by the reference laboratory in to TD Synergy system, this information is not transmitted to the AVATAR system accurately as detailed below:

Results printed from the reference laboratory's information system for Patient # 19 reflected that the patient had specimens collected on June 26, 2011 at 06:20 for CBC with differential and Health Profile #1 (a chemistry panel for 24 tests). Further review revealed the results for both CBC with differential and Health Profile#1 were reported by the reference laboratory on July 27, at 3:23 PM. However review of the test result from the AVATAR system revealed "Specimen Date/Time 6/26/2011/06:40 AM" for the same specimens and tests.

Results printed from the reference laboratory' s information system for Patient# 20 reflected that the patient had specimens collected on June 28, 2011 at 06:00 AM for urinalysis and drug screen, and on June 28, 2011 at 05:25 PM for CBC with differential, Hemoglobin A1C and Health Profile #55.

Further review revealed that the specimens for urinalysis and drug screen were received on June 28, 2011 at 12:58 PM and the results were reported on June 29, 2011 at 07:08 AM. The specimens for the CBC with differential, Hemoglobin A1C were received on June 28, 2011 at 12:55 PM and the results were reported on June 29, 2011 at 8:56 PM.

However review of the test result for the urinalysis, drug screen, CBC with differential, hemoglobin A1C and Health Profile #55 from the AVATAR system revealed "Specimen Date/Time 6/28/2011/07:32 AM" for the same specimens/test" for CBC with Differential, urinalysis, urine drug screen, and Health Profile # 55.
The above findings were reviewed and acknowledged by the Manager on June 29, 2011.

B. There was no evidence that AVATAR and TD Synergy were set up to accept results for Estimated Glomerular Filtration Rate eFGR as reported by the reference laboratory.

Review of test results printed from the reference laboratory's information system for Patient #s 19 and 20 dated June 27, 2011 at 3:23 PM and June 29, 2011 at 8:56 PM, respectively, revealed results for eGFR. However review of results from that AVATAR and TD Synergy for the same date and time failed to show the results for eGFR.

Interview with a laboratory staff member conducted on July 22 at approximately 11:45 AM revealed that both AVATAR and TD Synergy systems are not programmed to accept results for eGFR.

2. Based on the review of records and confirmation by staff interview, the hospital failed to establish an effective monitoring mechanism to ensure accurate documentation of finger stick glucose results for one (1) of the sixteen (16) randomly selected patients whose glucose monitoring records were reviewed (Patient #22).

The findings include:

There was no evidence that the hospital has implemented a monitoring mechanism to ensure accurate documentation of finger stick glucose results.

Review of electronic records for Patient # 22, in the presence of a management staff revealed that the nursing staff failed to accurately document the patent's finger stick glucose performed on July 21 at 7:00 AM. According to the review of the patient's electronic medical record the patient's glucose was documented as being 124 mg/dl, however, review of the scrap paper used to transfer the results to the patient's electronic medical record revealed that the patient's finger stick glucose was 144 mg/dl.

Interview with the management staff on July 21, 2011 at approximately 10:45 AM revealed that the staff made a transcription error and documented 124 mg/dl instead of 144 mg/dl.

3. Based on the review of records and confirmation by staff interview, with the Manager, the hospital failed to establish an effective monitoring mechanism to ensure that the finger stick glucose results reflected accurate time that the testing is performed.

The findings include:

There was no evidence that the hospital has implemented a monitoring mechanism to ensure that finger stick glucose results reflected the actual time the test is performed.

Review of the hospital's finger stick testing mechanism conducted on July 21, 2011 between 10:30 AM to 2:00 PM revealed inconsistent documentation practice. According to staff, when the finger stick glucose test is performed in the medication room where the computer is located, results are entered into the AVATAR system at the same time. AVATAR is the hospital's main information system utilized by physicians and other care givers for retrieving laboratory test results. Further interview with the Unit Manager revealed that when the test is performed in the general treatment area or in a patient's room, the results are documented on a scrap paper or a glucose monitoring sheet then transferred to the AVATAR.

For example, inspection of Unit 1B on July 21, 20011 at approximately 11:00 AM revealed that two (2) of the eight (8) patient's finger stick glucose results that were reportedly performed before 7:30 AM on July 21, 2011 had not been entered into the AVATAR system at 11:00 AM.

It should be noted that the staff member in Unit 1B was observed entering approximate times when documenting the time the finger stick glucoses were done when entering two (2) of the eight (8) patient test results that were reportedly performed prior to 7:30 AM on July 21, 2011.

Based on medical record, policy review and confirmation by staff interview it was determined that the medical staff failed to complete annual physical examination for one (1) of twelve (12) records reviewed (Patient#6) .

The findings include:

Hospital policy number 208-10 revision date April 4, 2011, entitled General Medical Services, Section III - Standards and Procedures, Item 3, Annual Assessment Updates stipulates " ...The GMO or NP shall complete an Annual Medical Assessment and Plan (AMAP) on the designated History and Physical form ... "

Patient #6 was admitted June 22, 2010 with diagnoses of Schizophrenia, Paranoid Type, Neuroleptic Tardive Dyskinesia, Vascular Dementia with Delusions, Renal Failure, Essential Hypertension, Hyperparathyroidism, and Malignant Neoplasm of Stomach. Review of the medical record on July 20, 2011 at 9:30 AM revealed the initial history and physical examination was completed June 23, 2010 at 12:26 PM. The medical record lacked documented evidence that an annual assessment by the General Medical Officer (GMO) and/or Nurse Practitioner (NP) by July 21, 2011 at 12:00 noon. The GMO and/or NP failed to complete an annual assessment for patient.

The findings were discussed on interview with the Nurse Manger, who acknowledged and confirmed the findings on July 20, 2011 at approximately 10:30 AM.

1. Based on medical record and policy review and confirmation by staff interview it was determined that the hospital staff failed to screen admitted individuals for tuberculosis in a timely fashion in three (3) of twelve (12) medical records reviewed (Patients #6, 9 and 11).

The findings include:


Saint Elizabeth's Hospital Policy, Number 15, no revision date, entitled "Tuberculosis Control Plan" Section IV - Standards, Item A-3 stipulates "a. All first time patients will be screened for infection with tubercle bacilli on admission ... g. Skin-test positive and negative patients shall be clinically evaluated on an annual basis with documentation regarding the presence or absence of symptoms consistent with tuberculosis. "

Section IV, Item A-4(b) stipulates "all patients shall have an annual TST test, except patients with a history of skin test positivity will be screened by a chest x-ray ad a physician's clinical assessment ... "

Saint Elizabeths Hospital Policy 601-02 entitled Medical Records, revised April 4, 2011, Section III - Standards, stipulates "F.9. ...All documentation shall refer by name to the specific individual to whom the record belongs ..."

Patient #6 was admitted June 22, 2010 with diagnoses of Schizophrenia, Paranoid Type, Neuroleptic Tardive Dyskinesia, Vascular Dementia with Delusions, Renal Failure, Essential Hypertension, Hyperparathyroidism, and Malignant Neoplasm of Stomach. Review of the medical record on July 20, 2011 at 9:30 AM revealed the initial history and physical examination was completed on June 23, 2010 at 12:26 PM, and stipulated " PPD status unknown " . On July 21, 2011 at approximately 11:30 AM the GMO presented the surveyor with a copy of an electronic document from the medical record referencing a pharmacy order. Review of the document revealed a PPD was placed on September 28, 2010 at 6:47 PM by the nursing staff and "To be read after 48 hours per the GMO." The medical staff failed to order the tuberculin skin test on admission; and, the nursing staff failed to read and/or document the PPD reading within 48 hours after the placement of the PPD.

The findings were reviewed with the nursing staff present during the chart review on July 21, 2011 at 12:30 PM.


Patient #9 was admitted May 27, 2011 with diagnoses which include Depressive Disorder, Recurrent Cerebrovascular Accident with Psychotic Features, Hypertension, Type II Diabetes Mellitus and Hyperlipidemia. Review of the medical record on July 20, 2011 at approximately 11:10 AM revealed the physician ordered the placement of the Tuberculin Skin Test (TST) on admission. The nursing staff documented that TSTs were placed July 5 and 13, 2011. The record reflected that the TST was interpreted on July 15, 2011. The record lacked documented evidence that the TSTs of May 27 and July 5, 2011 were placed and/or interpreted, as well as the refusal of the TST by the patient. The hospital staff failed to perform tuberculosis screening in a timely fashion.


Further review of the medical record revealed Interdisciplinary Recovery Plans (IRP) dated June 22, 2100 and on or about June 3 and 10, 2011. Within the section of the IRPs entitled Focus Area - Physical Health, the second Objective statement and associated first and third Interventions statements referred to a name other than the patient ' s. The clinical staff failed to accurately document information specific to the patient in the medical record.


Patient #11 was admitted May 18, 2011 with diagnoses which include Undifferentiated Schizophrenia, and Normal Pressure Hydrocephaly status post Ventricular Shunt Placement. Review of the medical record on July 20, 2011 at approximately 3:15 PM revealed the nursing staff documented a TST was placed May 19, 2011. The record lacked documented evidence that the TST was interpreted. The hospital staff failed to complete the performance of tuberculosis screening.


A face to face interview was held with nursing staff of the admission unit on July 20, 2011 at approximately 3:15 PM. The staff acknowledged and confirmed the findings. When asked about documentation, the nurses agreed that due dates of results were documented on a calendar in the charting area as a reminder to interpret TSTs and results were documented in the electronic medical record (EMR), although sometimes different nurses document in different areas/sections of the EMR. Review of the different areas of the EMR revealed only the results of July 15, 2011.


2. Based on medical record review it was determined that the clinical staff failed to accurately document patient information in the medical record in a single record review ( Patient #9).


The findings include:


Saint Elizabeths Hospital Policy 601-02 entitled Medical Records, revised April 4, 2011, Section III - Standards, stipulates "F.9. ...All documentation shall refer by name to the specific individual to whom the record belongs ..."


Patient #9 was admitted May 27, 2011 with diagnoses which include Depressive Disorder, Recurrent Cerebrovascular Accident with Psychotic Features, Hypertension, Type II Diabetes Mellitus and Hyperlipidemia. Review of the medical record on July 20, 2011 at approximately 11:10 AM revealed on June 22, 2011 an Interdisciplinary Recovery Plan (IRP) was completed for the patient. Within the section of the IRP entitled Focus Area - Physical Health, the second Objective statement and associated first and third Interventions statements referred to a name other than the patient ' s. The clinical staff failed to accurately document patient information in the medical record.


3. Based on medical record review and confirmation by staff interview it was determined that the nursing staff failed to follow physician orders regarding blood glucose monitoring in four (4) of six (6) records reviewed (Patients #3, 4, 5, and 8).
The findings include:
Patient #3 was admitted February 9, 2007 with diagnoses of Undifferentiated Schizophrenia, Personality Disorder, Type II Diabetes, Benign Hypertension, and Obesity.

Review of the electronic medical record (EMR) on July 19 and 20, 2011 at approximately 2:00 PM and 10:00 AM respectively revealed a physician order for " Fingerstick/Blood Sugar Check Order twice a day- Pre Breakfast and Pre Dinner daily at 7:30 AM and 5:00 PM. Notify physician if FS below 70 Mg% or above 250 Mg% " and associated start date April 7, 2011 and stop date August 21, 2011.

Additional orders were written on April 12, 2011 for "Novolog (Insulin Aspart) 100 units/ml subcutaneous 4 [four] units every morning " and on May 16, 2011 at 10:36 AM "Lantus (Insulin Glargine) 100 units/ml subcutaneous 40 units Q HS. Notify GMO if FS 70Mg% or below and Hold Lantus." Both insulin orders were associated with the following parameter " If Patient refuses this medication or this medication is not available, please contact physician immediately " . The stop date for both insulin orders was August 21, 2011.

Review of the electronic Medication Administration Record (eMAR) Administration Events from May 1, through June 30, 2011 revealed the lack of documented evidence that the 7:30 AM fingersticks were completed on May 9, 10, 14, 20, 29 and 31, 2011, and there was no associated documentation of the explanation for the omitted fingersticks.

Further, the patient consistently refused PM fingersticks May 1 through June 30, 2011. The nursing staff documented on May 2, 19, 25, and June 22, 2011 that the patient stated "I do FS once a day" when PM fingersticks were attempted. The patient refused PM fingersticks 46 of 61 times. The nursing staff documented notification of the physician nine (9) of 46 times when the PM fingersticks were refused.

Additionally, the patient refused the PM insulin from May 16 to June 30, 2011. The nursing staff failed to consistently notify the physician that the patient was refusing medication.

The nursing staff failed to follow physicians' orders regarding fingersticks and notification of the physician when the patient refused to follow the treatment plan.

Interview with the Charge Nurse on July 20, 2011 at approximately 10:30 AM revealed that the physicians are aware the patient consistently refuses blood work as well as PM fingersticks, but new orders have not been issued. The findings were discussed with the Nurse Manager, who acknowledged and confirmed the findings, on July 21, 2011 at approximately 12:00 noon.

Patient # 4 was admitted July 25, 1985 with diagnoses of Bipolar Disorder, Pedophilia, Vascular Dementia, Antisocial Personality Disorder, Diabetes, Hypercholesterolemia, and Benign Hypertension and Dysphagia with gastrostomy tube for feeding and medications.

Review of the medical record on July 20, 2011 at approximately 10:45 AM revealed an order for fingersticks twice daily (AM and PM), which included orders and parameters for sliding scale insulin coverage. The start date was January 23, 2010, and stop date August 31, 2011.

A random review of the eMAR and nursing notes from June 16 through July 19, 2011 revealed there was no documented evidence that the nursing staff completed the fingersticks on the following dates: June 21, 22, 27, AM or PM; July 5 - AM; and June 16, and July 2, 2011 - PM fingersticks. There also was no documented explanation for the uncompleted fingersticks.

The nursing staff failed to follow the physician's orders. The findings were discussed with the Nurse Manager, who acknowledged and confirmed the findings, on July 21, 2011 at approximately 12:00 noon.

Patient #5 was admitted on November 23, 2010 with diagnoses of Schizophrenia, Paranoid Type, Somatization Disorder, Hypertension, Type II Diabetes, Hypothyroidism, Sickle Cell Trait and Obesity. Review of the medical record on July 19, 2011 at approximately 3:30 PM revealed the physician ordered fingersticks before breakfast (7:00 AM), lunch (11:00 AM), and dinner (4:00 PM) on July 7, 2011 through August 31, 2012 which included an order for Novolog Insulin six (6) unit sq 10 minutes before each meal. Review of the eMAR and nursing notes from July 7 through 18, 2011 revealed the nursing staff failed to complete a fingerstick on July 8, 2011 at 4:00 PM without a documented explanation and physician notification. The nursing staff failed to follow the physician's order.

The findings were discussed, and acknowledged by the Nurse Manager on July 21, 2011 at approximately 12:00 noon.

Patient #8 was admitted April 2, 2009 with diagnoses of Schizoaffective Disorder, Cocaine Dependence, Neuroleptic-Induced Parkinsonism and Tardive Dyskinesia, Borderline Personality Disorder, Diabetes Mellitus and Obesity. Review of the medical record on July 20, 2011 at approximately 3:20 PM revealed an order for "Fingersticks for blood sugar check ; administration times 8:00 AM and 5:30 PM twice a day; Give Novolog Sliding Scale " start date March 25, 2011, stop date July 5, 2011. Review of the eMAR and nursing notes revealed the nursing staff failed to document evidence of fingerstick completion in the AM on June 6, 7, 9, 11, 12, 15, 17, 19, and 20, 2011; and failed to document completion of PM fingersticks on June 7, 15, 17, 18, 20 and 27, 2011.

On July 5, 2011 the fingersticks order was changed to every seven (7) days with start date July 5, 2011 and stop August 21, 2011. Review of the eMAR and nursing notes revealed the nursing staff failed to document fingersticks on July 12 and 19, 2011, according to the seven (7) day interval. The nursing staff failed to document completion of fingersticks per physician orders.

The findings were discussed with the Nurse Manager on July 20, 2011 at 3: 50 PM, who acknowledged and confirmed the findings. The Manager stated that the patient refused everything, and the patient just had blood work recently, because she refused everything.

4. Based on medical record and policy review and staff interview confirmation it was determined that the medical staff failed to complete annual physical examination for one (1) of twelve (12) records reviewed (Patient#6) .

The findings include:

Hospital policy number 208-10 revision date April 4, 2011, entitled General Medical Services, Section III - Standards and Procedures, Item 3, Annual Assessment Updates stipulates "...The GMO or NP shall complete an Annual Medical Assessment and Plan (AMAP) on the designated History and Physical form ..."

Patient #6 was admitted June 22, 2010 with diagnoses of Schizophrenia, Paranoid Type, Neuroleptic Tardive Dyskinesia, Vascular Dementia with Delusions, Renal Failure, Essential Hypertension, Hyperparathyroidism, and Malignant Neoplasm of Stomach. Review of the medical record on July 20, 2011 at 9:30 AM revealed the initial history and physical examination was completed June 23, 2010 at 12:26 PM. The medical record lacked documented evidence that an annual assessment by the General Medical Officer (GMO) and/or Nurse Practitioner (NP) by July 21, 2011 at 12:00 noon. The GMO and/or NP failed to complete an annual assessment for patient.

The findings were discussed with the Nurse Manger, who acknowledged and confirmed the findings on July 20, 2011 at approximately 10:30 AM.

Based on medical record review and confirmation by staff interview it was determined that the clinical staff failed to obtain consults timely in one (1) of twelve (12) records reviewed (Patient #9).

The findings include:

Saint Elizabeths Hospital Policy 208-10 entitled General Medical Services, revised April 4, 2011, Chapter III Standards and Procedures, Item 12 stipulates "... b. An individual who requires examination and/or consultation shall be referred to the appropriate clinic in an expeditious manner... e. The clinic consultant receiving the referral shall respond to the referral within two days,"

Patient #9 was admitted May 27, 2011 with diagnoses which include Depressive Disorder, Recurrent Cerebrovascular Accident with Psychotic Features, Hypertension, Type II Diabetes Mellitus and Hyperlipidemia. Review of the medical record on July 20, 2011 at approximately 11:10 AM revealed the Nurse Practitioner (NP) evaluated the patient on May 31, June 17, and June 23, 2011. The NP's progress notes of dated May 31 and June 17, 2011 reflected a Physical Therapy (PT) evaluation of the patient was to be done. The Plan of Care dated June 23, also reflected the patient ' s physical health intervention as referral for PT assessment. The medical record reflected that orders requesting PT were entered on June 17, and 23, 2011. The record lacked documented evidence that a consultation had been processed and or called to the appropriate service. The clinical staff failed to assure consults were obtained timely.

The above findings were reviewed and acknowledged by the Nurse Manager July 20, 2011.

Based on the review of records and confirmation by the staff interview, the nursing staff failed to ensure the availability of a current physician's order for testing finger stick glucose prior to testing finger stick glucose twice daily for one (1) of the four (4) randomly selected patients whose glucose monitoring records were reviewed (Patient #21).

The finding include:

Review of Patient #21's electronic record revealed that the patient's finger stick glucose was being monitored twice daily. However, review of the patient's non medication order revealed that the order for performing twice a day finger stick glucose has a "Start Date/Time: 12/21/2010 11: 52 AM ... and a "Stop Date/Time: 1/17/2011 11:51 AM"

Interview with the management/supervisory staff on July 22, 2011 at approximately 10:00 AM confirmed the lack of a current order for performing twice daily finger stick glucose testing for Patient #21

Based on staff interview and the review of records, the hospital failed to ensure that the hospital's laboratory has a current Clinical Laboratory Improvement Amendments of 1988 (CLIA) certificate for one (1) of the (1) test performed by the hospital in accordance with section 353 of the Public Health Service Act (42 U.S.C. ?263a).

The finding include:

According to CLIA'88 section ?353 of the Public Health Service Act (42 U.S.C. ?263a) is amended to extend jurisdiction of the Department of Health and Human Services (HHS) to regulate all laboratories that test human specimens for the purpose of providing information for diagnosis, prevention, or treatment of any disease or impairment of, or the assessment of, the health of human beings.

Review of records (finger stick glucose logs and patients' electronic medical record) revealed that the hospital performs finger stick glucose testing.

Review of the hospital laboratory's CLIA certificate revealed that the CLIA Certificate of Waiver (CLIA ID 09D0721763) expired on March 18, 2011.

Interview with the management staff on July 22, 2011 at approximately 12:30 PM confirmed the lack of current CLIA certificate for performing finger stick glucose testing.

Based on observations during the survey period, it was determined that dietary services were not adequate to ensure that foods are served in a safe and sanitary manner.

The findings include:

1. The horizontal and vertical surfaces of milk crates were observed to be soiled with debris in refrigerator KsD in four (4) of five (5) observations at 10:30 AM on July 19, 2011.

2. One gallon containers of Tropicana Orange Juice were stored in walk in refrigerator # KsD (Milk and Dairy Box) beyond the use by date of July 18, 2011 in four (4) of four (4) observations at 10:35 AM on July 19, 2011.

3. Mold and mildew growth was observed on the sliced surfaces of oranges stored on a tray in walk-in refrigerator # KsC in one (1) of one (1) observation at 10:40 AM July 19, 2011.

4. Floors, walls, ceiling, and the exterior surfaces of compressor fans were covered with ice in the walk-in freezer KsB in four (4) of four (4)
observations at 10:45 AM on July 19, 2011.

5. The exterior surfaces of condiment jars such as Bay Leaves, Cloves, Hot Sauce and Ginger stored on a shelf were soiled on the exterior from
spillages and jars lacked an open date in four (4) of four (4) observations at approximately 11:00 AM on July 19, 2011.

6. Scoops used for dispensing flour and sugar were stored outside of bins on the counter tops without covers exposing scoops to potential
contamination in two (2) of two (2) observations at 11:10 Am on July 19, 2011.

8. Flying gnats were observed in the Main Kitchen near two (2) open drains under sinks in the cooks preparation areas, inside of a soiled Janitorial Closet sink, the interior areas of the soiled Troth Voyer drain adjacent to the dishwasher in four (4) of five (5) observations between 11:00 AM and 11:30 PM on July 19, 2011.

9. Accumulated mineral deposits and stains were observed on the exterior doors and soiled deposits were observed on the body surfaces of the dish machine in one (1) of one (1) observation at 11:55 AM on July 19, 2011.

10. During an observation of the Pot and Pan Scrubber it was determined that the final rinse temperature failed to reach 180 Fahrenheit during in one (1) of one (1) observation at 11:45 AM on July 19, 2011.

11. The Power Scrubber Cycle located on the dish washer in the Main kitchen failed to reach the manufactures recommended temperature between 160 Fahrenheit and 190 degrees Fahrenheit during an observation of the dishwasher and Power Booster Cycle, as evidenced by the 140 degree temperature reading on the Power Booster gauge in three (3) of three (3) observations between 12:20 PM and 1:30 Pm on July 19, 2011.

12. The interior and exterior surfaces of hotel pans washed in the Pot and Pan Wash Area were not thoroughly cleaned as evidenced by leftover food residue on the interior and bottom surfaces of pans and pans were not allowed to dry before storing on shelves for reuse in the following instances on July 19, 2011; A. Hotel Pans 14 x 30 x 10 in two (2) of four (4) observations; B. 10 x 12 x 10 inch in four (4) of eight (8) observations; C. Sheet Pans in six (6) of seven (7) observations.

13. Cutting boards (red and white) stored on a rack in the Pot and Pan Wash Area were worn and board surfaces were not thoroughly cleaned before placing on racks for reuse in three (3) of three (3) observations at 2:00 Pm on July 31, 2011.

14. Breads such as Kosher Rolls and Bagels stored in the walk in refrigerator were observed to be labeled with Julian calendar use by dates, the Julian calendar date on July 19, 2011 was 200, therefore the following breads were held beyond the use by dates; six (6) packages of Kosher Rolls dated 169; six (6) packages of Bagels dated 172 and three (3) packages of Bagels with a labeled date of 179.

Based on observations during the survey period it was determined that housekeeping and maintenance services were not adequate to ensure that the facility is maintained in a safe and sanitary manner.

The findings include:

1. The following findings were observed during a tour of Unit 1A between 4:47 pm and 5:30 pm on July 19, 2011.

A. Strong body odors were observed to be present near the entrance to the center pod.

B. Wall surfaces were marred near and behind sofas in the sitting areas of each pod and the seat surfaces of chairs and sofas were soiled.

C. The bathroom privacy curtain hooks were detached, paint was observed to be peeling in the ceiling, and wall surfaces were marred in room 1A49.

D. Wall surfaces were observed to be damaged and marred throughout the west hallway.

E. The horizontal surfaces of bed frames were soiled with dust, the fall protection mat located on the floor under the patient's bed was soiled with accumulated debris in room 137.

F. The top surfaces of cabinets ' were soiled with dust in room 1A37.

G. Floor surfaces to be uneven an elevated in the hallways and the reclining chair in center sitting area was damaged and the seat surfaces were soiled.

H. The toilet in rest room 1A46 was out of order and the was no notice posted to indicate that the toilet was in disrepair and a dark brown substance was observed on the floor surfaces which had been confirmed by a surveyor during an earlier visit to the unit at approximately 11:45 am.

I. The horizontal surfaces of the patients bed frame was soiled with dust, abundant clothing was observed on floor surfaces in room 1A39.

J. Wall surfaces were soiled in the conference area adjacent to the nourishment room and the ice machine water and ice chute surfaces were soiled with mineral deposits in room 1A03.

K. Plastic ware stored in a large bin lacked a cover to prevent contamination of utensils.

L. The code cart located in the medication room lacked a tag or sticker to indicate the expiration date of medications within the cart.

M. The horizontal surfaces of the patients bed frame was soiled with dust and the top surface of the closet was soiled with dust in rooms 1A28, 1A33, 1A54 and 1A61.

N. Sprinkler heads were soiled with dust and wall surfaces were marred in the west side lounge area.

O. Paint was observed to be peeling at the entrance and sprinkler heads were rusty in shower room 1A53.

P. The privacy curtain was missing at the entrance in room 1A54.

Q. Soiled mops and brooms were improperly stored on floor surfaces in the janitorial closet.

R. The interior surfaces of exhaust vents were soiled with dust in the staff rest room.

T. The lower surfaces of storage carts were soiled with accumulated dust in the soiled linen room and floor surfaces at the entrance to the unit were uneven and damaged.

2. The following findings were observed during a tour of unit 1B.

A. Walls surfaces were marred and soiled in the lounge areas.

B. Peeling paint was observed in the ceiling near the entrance to room 1B23.

C. The exterior surfaces of windows and closet door tracks were soiled in room 1B34 and 1B49.

D. The horizontal surfaces of bed frames were soiled with dust in rooms 1B32, 1B33, and 1B34.

E. The top surfaces of the patient ' s desk was observed to have cigarette burns, the horizontal surfaces of bed frames were soiled, windows were soiled on the exterior in room 1B45.

F. The exterior surfaces of a patient's oxygen (02) concentrator # (114114) and filter were soiled with accumulated dust in the lounge area.

G. The following findings were observed during a tour of the east wing right side.

H. The lower wall surfaces were soiled and stained in the shower room 1B53.

I. The top surfaces of the patient ' s closet were soiled with dust in rooms 1B62.

J. Wall surfaces, window sills and bed frames were soiled with dust in room 1B60.

K. A large bin containing disposable serving ware was observed to be uncovered exposing the items to contamination in the nutritional area.

L. Floor and walls were soiled and stained in room 1B09.

3. The following findings were observed during a tour of Unit 1C between 11:30 am on July 20, 2011.

A. Wall tiles were damaged in the shower 1C52 and floor and ceiling tiles were damaged near the entrance to 1C53.

B. The faucet failed to turn off the water supply and water ran continuously in the supply in room 1C54.

C. The top surfaces of patients closet were soiled with dust in rooms 1C39, 1C57 and 1C63.

D. Floor surfaces were in need of additional cleaning in rooms 1C24 and 1C63.

E. Closet door surfaces were stained and track surfaces were in need of additional cleaning in rooms 1C34, 1C57, and 1C61.


G. A strong pugnacious odor was detected at the entrance, the door jamb was observed to be rusty in shower area 1C47.

H. The access panel in the day room was not secured to ceiling surfaces.

I. Floor surfaces were observed to be damaged and cracked around the edges of the floor drain and exhaust vents were soiled in 1C46.

J. Floor, window sills and the lower surfaces of the entrance door was soiled in room 1C46.

K. Paint was observed to be peeling from wall surfaces, floor tiles were in need of recaulking in 1C23 shower area.

L. The access panel was soiled and rusty in toilet area 1C25.

M. The horizontal surfaces of the patients bed was soiled with dust and closet door tracks were soiled room 1C34.

N. Wall surfaces were damaged in the hallway near 1C32.

O. The lower shelves of the soiled linen cart were soiled with dust and debris in the soiled linen room.

P. Cleaning equipment was improperly stored on floor surfaces in the janitorial closet and the entrance door surfaces were marred.

4. The following findings were observed during a tour of Unit 1D between 12:12 pm and 1:15 pm on July 20, 2011.

A. Sofas and chairs in the lounge areas were soiled with grease,

B. Shower curtain hooks were detached and the curtain was missing in the west side bathroom 1D52.

C. Wall surfaces were marred behind the entrance door and over the toilet in 1D54.

D. Window surfaces were soiled on the exterior of the building in room 1D54.

E. Floor surfaces were very soiled and damaged in the day room 1D60.

F. The privacy curtain was missing, sprinkler heads were rusty.

G. Wall surfaces were soiled and stained in the lounge area on the east side.

H. The soap dispenser was observed to be damaged; floor tiles were in need of recaulking in 1D25.

I. The lower surfaces of two (2) linen carts were observed to be soiled with accumulated dust; clean linen was stored on the top of a cabinet in the soiled linen room.

J. Floor surfaces were wet with an abundance of water on floor surfaces in the janitorial closet.

K. The ice machines water and ice chutes were soiled with accumulated mineral deposits and soiled products.

L. Wall surfaces in the hallway were marred and damaged near 1D43.

M. The exterior surfaces of the victory refrigerator was soiled in the nourishment room.

5. The following findings were observed during a tour unit 1E between 1:55 pm and 3:00 pm on July 20, 2011.

A. Privacy curtain hooks were detached in rooms 1E23 and 1E24.

B. Floor surfaces were soiled in corners and in the rear of furnishings in room 1E33.

C. Floor surfaces were damaged in the hallway outside of 1E31.


D. The lower rear surfaces of the entrance door was damaged in the shower room and shower hooks were detached in shower room 1E49.

E. The privacy curtain was missing at the entrance to room 1E46.

F. Gnats were observed to be present and the top of the patient ' s closet was soiled with dust in room 1E39.

G. The access panel in the community room was not secured over furnishings.

H. The following findings were observed on the east side; shower curtains were not long enough to provide complete privacy, paint was observed to be peeling and the rear door was observed to be damaged in room 1E52 and 1E53.

I. Floor surfaces were marred in room 1E63.

J. The kick plate on the door was observed to be soiled in 1E57.

K. The interior surfaces of exhaust vents were soiled with dust in the soiled linen room and staff bathroom.

L. Seven (7) penetrations were observed in wall surfaces around conduit pipes and the kick plate was soiled at the entrance in supply room 1E08.

M. A large bin containing disposable ware was observed to be uncovered exposing disposable to potential contamination in the nourishment room.

6. The following findings were observed during a tour of Unit 2D between 4:00 pm and 4:20 pm on July 20, 2011.

A. Wall surfaces were soiled in the lounge area outside of the west Pod.

B. Shower curtains were too short and failed to provide full privacy vertically and wall surfaces were soiled in room 2D53 and privacy curtains hooks were detached in room in 2D55.

C. The inner surfaces of closet door tracks were soiled with debris and the top surfaces of closets were soiled with dust in room 2D57 and 2D60.

D. The access panel located in the ceiling in the community lounge was not fully secured.

E. Floor tiles located at the entrance to the shower were damaged and paint was observed to be peeling in the ceiling over the door and the shower curtain located at the entrance was too short vertically to provide complete privacy in room 2D49.

F. The interior and exterior surfaces of exhaust vents were soiled with dust, privacy curtain hooks were detached in 2D47.

G. Floor surfaces were very scarred in ambulating areas in room 2D38.

H. Floor surfaces were damaged and an abundance of clothing was observed on floor surfaces in room 2D45.

I. Floor mat surfaces were soiled and stained and floor surfaces around the patients ' closet were soiled in 2D39.

J. The shower curtain was too short vertically to provide privacy in room 2D33.

K. The interior surfaces of exhaust vents were soiled, floor surfaces were marred in ambulating areas of the room and privacy curtain hooks were detached in room 2D26.

L. Excessive personal clothing was observed on floor surfaces in room in the treatment room.

M. The janitorial closet floor and mop sink were soiled and exhaust vents were soiled with dust on the interior surfaces.

N. Door jamb surfaces were marred at the entrance to the nutritional room.

7. The following findinigs were observed during a tour of Unit 2B between 9:45 am and 10:45 am on July 21, 2011.

A. The vertical height of shower curtrains were too short to provide complete privacy in rooms 2B23, 2B24, 2B48 and 2B49.

B. The interior areas of exhaust vents were soiled with dust in room 2B26.

C. Floor surfaces were obseved to be damaged near the head of the bed in 2B32.

D. The interior surfaces of exhaust vents were soiled with dust in rooms 2B46, 2B48, 2B54 and 2B55.

E. Window sill surfaces were soiled with dust in room 2B45.

F. The ledge surfaces around the perimeter of the wall in the east side day room were soiled and marred.

G. Plastic shower curtains were soiled and were too short vertically to provide complete privacy.

H. The base surfaces of the toilet were damaged and were in need of recaulkinig.

I. The interior surfaces of the ice machine chutes were soiled with mineral deposits and other debris in the nourishment room.

J. Wall surfaces were soiled and marred near the entrance to room 2B03.

K. The bottom shelf surfaces of the soiled linen cart were soiled with dust.

L. The metal self surfaces of the clean linen cart were soiled with accumulated dust in the clean linen room.

8. The following findings were observed during a tour of the Medical Clinic at 10:55 am on July 21, 2011.

A. Floor surfaces were soiled and were in need of additional cleaning in the treatment areas.

B. Multiple electric wires were observed on floor surfaces in the dental clinic, presenting a trip hazard to patients and staff.

C. Supplies were ibserved improperly stored uner the sink in the dental clinic.

D. Clean towels were observed on counter tops without covers exposing towels to potential contaminiation window ledge surfaces were soiled with dust in the poditary clinic.

E. The lower surfaces of walls in the break out room were marred in the break out room.

F. How water supplied to sinks in the dental clinic was not suitavble for handwashing the obsered temperature was 74 degrees fahrenheit.

G. Documentation was not available on log sheets to substantiate that refrigerator temperatured are monitored daily in July 2011 and the top surfaces of the panares machine were soiled with dust in the dental clinic.

Based on observations and interviews during the Dietary Survey it was determined that documentation was not available to show that the Ansul Fire Suppressor System was tested semi annually as required.

The findings include:

Through staff interviews and observations during the dietary survey, it was determined that written documentation was not available to substantiate that the Ansul System was tested and serviced within the last six months, nor was the pull station tagged to show when the system was serviced or tested in three (3) of three (3) observations between 11:10 AM and 3:45 on July 19, 2011.

Based on record review and interview, the facility failed to base the individual comprehensive treatment plan on identified strengths for 1 of 2 active sample patients (A1). This deficiency compromises the quality of the treatment plan by failing to integrate the patient's inherent assets into the formulation of therapeutic interventions and an estimate of the prognosis in terms of achieving optimal functioning.

Findings include:

A. Record Review

Patient A1, admitted on 5/17/1971, had a treatment plan update on 9/13/2011. In the section titled "Life Goal and Strengths," the section for strengths was left blank.

B. Staff Interview

In an interview on 9/27/11 at 1PM, the Medical Director acknowledged that despite prompting by the Avatar EMR system, the required information is sometimes omitted.

Based on observations, staff interviews and document review, it was determined that 1 of 2 active sample patients (A1) and 2 of 4 non-sample patients added for review (A12 and A13), lacked an active treatment program. The aggressive acting-out of some patients distracted attention for patients and staff alike; for patients who did not feel motivated to leave their rooms, there was no evidence that treatment alternatives to the various group therapies were offered. Lack of active psychiatric treatment results in patients being hospitalized without all interventions for patient recovery being provided to them, potentially delaying improvement.

Findings include:

A. Observations

1. In an observation on 9/27/11 at 11:30a.m. on Unit 1A, active sample Patient A1 and six non-sample patients were in the dining room/group room to start lunch. Non-sample patient A13 walked in and sat down next to another non-sample patient. When A13 took some food from the other patient's lunch-tray, a scuffle ensued, accompanied by yelling and deprecatory remarks. No nursing staff was in the room at the time; the food server came from behind his counter and separated the two patients who had the conflict. Patient A1 went to a different part of the room, and was observed to continue to isolate for the rest of the afternoon.

B. Record Review


1. Patient A12: In the treatment plan dated 9/14/11, non-sample Patient A12 was rated for "risk of harm to others" as "moderate." The plan identified "poor impulse control" as a problem. The listed interventions were "Monitoring of effect of recent medication changes" and "Unit staff to provide empathy and support for patient." Patient A12 was scheduled for daily participation in athletic exercises. His/her medications included ziprasidone (20 mg IM twice daily), lithium, valproate, olanzapine, lorazepam and diphenhydramine. These medications were adjusted per physician order on 9/27/11 in response to the patient's continued hostile, aggressive and intrusive behaviors. On 9/27/11, the patient's behavior was described in a progress note as "throwing chairs in [sic] the large windows in the dayroom...flipped the dayroom table over...removed the desk from [A12's] room, pushing it into the exit door at the end of the hallway,...spitting on floor and all staff." While acting-out behaviors had been described in progress notes as an ongoing problem, the medication adjustment only occurred on 9/27/11 during the survey.

3. Patient A13: In the treatment plan dated 9/13/11, non-sample Patient A13's problem was described as "has been aggressive." The intervention was "Nursing staff will assist [A13]...to reduce [A13's] risk of aggression." At the time of the patient's aggressive behavior incident observed at lunch on 9/27/11 (noted in item #1 above), no nursing staff was present to assist. The break-up of the fight was left to the food server.

C. Staff Interviews

1. In an interview on 9/27/11 at 12p.m., which included a discussion of the dining room incident (noted above), staff psychologist Psy1 acknowledged that the situation on the treatment unit had been "intense," but said, "This is an exception. Usually it's pretty quiet here." Psy1 had been one of the staff on the unit gathering the patients for lunch the day of the incident with Patient A13 and came to the dining room shortly after the food server's intervention,

2. In an interview on 9/27/11 at 1PM, the Medical Director acknowledged that aggressive behaviors, both verbal and physical, occur and can become a distraction. Regarding the incident at lunch on 9/27/11, the Medical Director reported that the offending non-sample patient (A13) had "just arrived from a nursing home." He stated, "They told us [s/he] had these kinds of problems."

Based on observations, staff interviews and medical record review, it was determined that the Medical Director failed to ensure that:

I. Clinical staff provided an active treatment program for 1 of 2 active sample patients (A1 and 2 of 4 patients added to the sample for review (A12 and A13). The aggressive acting-out of some patients distracted attention for patients and staff alike. For patients who did not feel motivated to leave their rooms, there was no evidence that treatment alternatives to the various group therapies were offered. Lack of active psychiatric treatment results in patients being hospitalized without all interventions for patient recovery being provided to them, potentially delaying their improvement. (Refer to B125)

II. Physicians based individual comprehensive treatment plans on identified strengths for 1 of 2 active sample patients (A1). This deficiency compromises the quality of the treatment plan by failing to integrate the patient's assets into the formulation of therapeutic interventions and an estimate of the prognosis in terms of achievable optimal functioning. (Refer to B119)

III. Clinical staff provided adequate treatment activities on weekends and evenings for 2 of 2 active sample patients (A1, A3), and 4 of 4 patients (A9, A10, A12 and A13) added for review. This failure results in patients having a great deal of idle time uninvolved in the rehabilitative section of their treatment plans. (Refer to B157)

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

I. Ensure that risk factors contributing to falls were addressed, utilizing data that the facility had collected. As a result of this failure, patients are at risk for falls, potentially leading to adverse medical outcomes.

Findings include:

A. Document Review

Review of Policy #NPM 3-31 - "Fall Prevention/Injury Reduction and Risk Assessment," revised 4/13/11, revealed the following content on "Fall Prevention Interventions and Post Fall Intervention":
"...Initial fall prevention interventions shall be implemented based on an individual's identified fall risk level of low, medium, or high. Examples of these interventions are outlined below.
For individuals identified as low risk for falls, interventions primarily preventive in nature shall be implemented.

"For Individuals identified as medium risk for falls, the same interventions as for low risk shall be implemented, along with the following:

"Nursing staff shall place a "fall risk" sticker on the safety warning sign above the individual's bed and on the individual's door.
The RN shall notify the Clinical Administrator.
The Interdisciplinary Recovery Planning (IRPT) shall develop a goal, objective, and interventions...to address the fall risk."

"For individuals identified as high risk for falls, the same interventions as for low and medium risk shall be implemented, along with the following:

"The Clinical Administrator shall notify the Performance Improvement Department, who is responsible for tracking individuals at high risk for falls in accordance with SEH Policy #302.5-5-10, High Risk Indicator Tracking and Review.
Nursing staff shall communicate information about individuals who are at risk for falls via various mechanisms such as the Staff Assignment Sheet and during change of shift report.
Nursing staff utilize the Quality of Care Environmental Audit Survey (See Form #NPM3-15a) to monitor the environment and to help maintain safety for all individuals in care. Refer to SHE Nursing Procedure # NPM 3-15, Environment: Monitoring for specific details.
Nursing staff shall provide teaching as applicable to individuals to help prevent falls/reduce the risk of falls. Teaching shall be customized based on the individual's need and strengths and in accordance with his/her IRP (Individual Recovery Plan-Treatment Plan). Examples of teaching may include (but are not limited to) the following:

"Orient the individual to his/her surroundings upon admission and inter-unit transfer.
Provide the individual with instructions as to proper fitting shoes, non -skid soles, and importance of keeping shoe laces tied.
Counsel the individual to refrain from running
Provide the individual with instructions/guidance as needed on transfer techniques to and from bed/chair/tub. Emphasize the importance requesting assistance if needed.
Teach the individual with postural hypotension or those on medications that may affect blood pressure how to get out of bed/chair slowly and gradually so that the body has time to adjust to position changes. Emphasize the importance of reporting symptoms of dizziness or unsteady gait to the nursing staff and physician.
Teach the individual about the benefits of maintaining a "clutter free" environment.
Provide the individual with instructions to use good body mechanics.
Provide the individual with instructions regarding appropriate clothing."

2. Procedure/Policy Review Verification Signature Sheets for Fall Prevention/Injury Reduction and Risk Assessment (5/6/11 to 9/5/11):

Although there were some logs with signatures related to staff training on falls prevention, there was no evidence or document presented to the surveyors related to training modules on the extensive list of options (noted in item #2 above). The signature sheets listed the staff from 1A and 1E that had been re-trained on the new Falls Prevention policy from 5/6/11 to 9/5/11 for Units 1A and 1E. Fourteen staff had been retrained, including six RNs, one LPN (licensed practical nurse) and seven RAs (Recovery Assistants).

In addition to reviewing the Signature sheets (Fall Policy Review), the surveyor reviewed the list of fall trainings for staff present during the survey, and working days and evenings for the Units surveyed. The selection included RAs (Recovery Assistants, LPNs (Licensed Practical Nurses) and RNs (Registered Nurses). None of the Class Registrations were for training on falls prevention or the falls prevention policy.

3. The facility has several data collection methodologies used to track patient falls (see below). However, these data were not analyzed to determine what factors related to patient falls, and what specific preventive measures resulted in a lower fall risk for patients.

a. PRISM (Performance Related Information for Staff and managers) Data Tables 2011-8 (from September, 2010 to August, 2011).

Falls for Unit 1A - 53 from September, 2010 to August, 2011; 19 since the re-training of staff on the new fall policy implemented on April 13, 2011.

Falls for Unit 1E - 11 from September, 2010 to August, 2011; 5 since the re-training of staff.

b. Unusual Incident Report and Investigation findings (falls) (7/1/11 to 9/26/11 Units 1A, 1B, 1D, 1E, 2D)

There were 36 fall incidents (with fall descriptions); seven (7) were repeat fall patients as follows:
FF (frequent falls):
Unit 1A
FF1 - 2 falls (7/31/11, 8/1/11)
FF2 - 4 falls (7/3/11, 7/21/11, 7/31/11, and 9/25/11)
Unit 1B
FF3 - 2 falls (7/7/11, 9/4/11)
FF4 - 6 falls (7/8/11, 7/11/11, 9/7/11, 9/9/11, 9/13/11, and 9/14)
FF5 - 3 falls (8/27/11, 8/29/11, and 9/1/11)
FF6 - 5 falls (8/17/11, 8/22/11, 8/23/18/11, 9/18/11, 9/22/11)
Unit 2D
FF7 - 2 falls (8/7/11, 9/16/11)

c. Major Unusual Incidents - Falls with injuries on the units surveyed, August, 2011
Unit 1A - 4 patients
Unit 1B - 4 patients
Unit 1E - 2 patients
Unit 1D - 0 patients
Unit 2B - 1 patient
Unit 2D - 7 patients

d. Transfers to outside Facilities for Medical Treatment (hospitals for fall related injuries) report since 4/13/11, the date the new fall policy was implemented and staff training.

3 patients (3 events):

7/11/11 - "Laceration requiring surgical repair"
8/17/11 - "Acute occipital subdural hemorrhage; bi-frontal chronic subdural
8/22/11 - "R/O acute brain bleed evaluation"

e. Risk Management and Safety Committee Minutes (June 16, 2011, July 28, 2011, and August 31, 2011)

Falls were not addressed in the minutes.

B. Staff Interview

In an interview on 9/28/11 at approximately 10AM, the Chief Nurse Executive was interviewed in reference to the number of falls and subsequent injuries. He stated that he was aware of it and was in the process of hiring more RNs. He stated that the hospital was under a decision by the Department of Justice to hire 50 RNs and had needed to hire approximately 20 more to meet that mandate.

II. The Chief Executive Nurse failed to take safety measures to reduce the amount of aggression on the units with training and re-training of staff, utilizing data collected that relates to aggression. As a result of this failure, patients are at risk for aggression against other patients and staff, which has the potential for adverse physical/medical outcomes. (Refer to B125.)

Based on document review and interview, the hospital failed to provide adequate treatment activities on weekends and evenings for 2 of 2 active sample patients (A1, A3), and 4 of 4 non-sample patients (A9. A10, A12 and A13) added for review. This failure results in patients having a great deal of idle time uninvolved in structured rehabilitative activities.

Findings include:

A. Document Review

Review of the posted Unit Program Schedules for the units of the sample patients units 1A, 1B, 1C, 1D, 2C and 2D revealed that none of the schedules included evening or weekend activities.

B. Interviews

In an interview on 9/27/11 at approximately 4:15 PM, the Director of Activities showed the surveyors an activity schedule for evenings and weekends. There were only four or five activities on this schedule. Some of those activities, e.g., "chess" which was offered on Saturday afternoons, would attract very few patients in this population. When the Activities Director was asked why the schedule did not include more weekend or evening activities. she replied, "The nursing staff can always pull the activity schedule up; it is in the computer." When asked how patients could all be served with the limited options available, the Activities Director stated, "Nursing staff is also supposed to have activities with patients on the units."