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Based on observation, policy and procedure, and interviews with staff it was determined the hospital failed to ensure all medications were secured and disposed of properly. This deficient practice had the potential to affect all patients admitted to the facility.

Findings include:

Policy: Disposal of Medications
Date Revised: 2-2015

Policy:

It is the policy of BHC (Behavioral Healthcare Center) {Previous name of Unity Psychiatric Care} to dispose of all medications properly and in accordance with all state and federal guidelines.

Procedure:

1. All unused controlled substances will be destroyed on site by the pharmacy consultant and a member of the nursing staff.

2. Documentation of drugs destroyed will be logged in a binder with the date, quantity, and type of medication. The binder is maintained in the Nurse Manager's office.

...3. All medical waste associated with dispensing or administering medications will be properly disposed of in approved medical waste containers and taken off site by a licensed disposal company.

A tour was conducted on 4/30/19 at 1:45 PM with Employee Identifier (EI) # 2, RN (Registered Nurse), Interim DON (Director of Nursing). The surveyor asked EI # 2 where all medications in the facility were stored. EI # 2 stated all medications were either in the locked medication room, or locked on the medication carts. The following was observed in the DON office:

In the corner of the room was a paper sack containing syringes. Upon further inspection the bottom of the bag contained multiple medications. EI # 2 stated she/he first saw the medications last week and did not know why the medications were there. EI # 2 failed to return the medications to the secured medication room.

Also in the DON office were two filing cabinet drawers filled with medications. The dates filled on the medications ranged from 10/24/18 to 4/23/19. Some of the medications contained names of current patients.

The following medications were observed in the DON Office:

2 - Advair disc
3 - Amatadine 100 milligram (mg)
2 - Amitriptyline 50 mg
6 - Amlodipine 5 mg
6 - Amlodipine 10 mg
6 - Amlodipine 25 mg
1 - Amoxicillin 875 mg
26 - Amoxicillin 500 mg
3 - Aripiprazole 5 mg
13 - Aripiprazole 10 mg
18 - Aripiprazole 20 mg
11 - Aripiprazole 15 mg
4 - Armur Thyroid 15 mg
1 - Aspercreme tube
2 - bottles Aspirin 325 mg
10 - Artane 2 mg
1 - Atenolol 25 mg
6 - Atorvastin 20 mg
1 - Baclofen 20 mg
1 - bottle Bactrim
1 - Bentropine 0.5 mg
1 - bottle Biotin
5 - Bupropion 150 mg
5 - Buspirone 5 mg
1 - Buspirone 15 mg
2 - Bystolic 5 mg
2 - bottles Calcium 500 mg
1 - Carbamazepine 100 mg
6 - Carbamazepine 200 mg
3 - Carvedilol 3.125 mg
26 - Carvedilol 25 mg
40 - Carbidopa/levodopa 25/100 mg
3 - Carbidopa/levodopa 300 mg
8 - Cefdinir 300 mg
2 - Ceftriaxone 1gm (gram)
1 - Cholestyramine 1
2 - Cilostazol 100 mg
12 - Citalopram 20 mg
5 - Clopidogril 75 mg
1 - bottle Co Q 10
3 - Cyanocobalamine 1000 mg/ml (milliliters)
1 - Depakote 250 mg
6 - Desvenlafaxine 50 mg
3 - Diclofenac topical
5 - Diltiazem 90 mg
3 - Diltiazem 120 mg
2 - Digoxin 0.125 mg
28 - Divalproex 125 mg
48 - Divalproex 500 mg
1 - Divalproex 250 mg
13 - Divalproex sprinkles
9 - Donepezil 5 mg
1 - Donepezil 23 mg
14 - Donepezil 10 mg
27 - Doxecycline 100 mg
1 - Ducosate 1
33 - Duloxetine 60 mg
18 - Duloxetine 20 mg
9 - Duloxetine 30 mg
2 - Eloquis 2.5 mg
1 - Eloquis 2.5 mg
3 - Enalapril 5 mg
1 - Escitalopram 20 mg
4 - Esomeprazole 40 mg
37 - Famotadine 20 mg
4 - Fenofibric 135 mg
2 - Finasteride 5 mg
4 - Fluoxetine 20 mg
1 - Fluoxetine 20 mg
7 - Furosemide 40 mg
4 - Furosemide 20 mg
2 - Furosemide 40 mg
7 - Glipizide 10 mg
1 - Glucosamine 750 mg
10 - Haloperidol 5 mg
2 - liquid Haloperidol
6 vials - Haloperidol 5mg/ml
2 - HCTZ 12.5 mg
42 - Hydralazine 25 mg
6 - Hydroxyzine 50 mg
1 - Hydroxyurea 500 mg
1vial - Influenza vaccine
36 Ipratropium Bromide 0.02 mg
1 - Isorbide 30 mg
3 - Lactulose 10mg/15ml
1 bottle - Lantanoprost opthalmic
12 - Lamotrigine 25 mg
1 vial - Levemir
1 - Levetiracetam 250 mg
6 - Levofloxacin 500 mg
11 - levothyroxine 25 mg
19 - Levothyroxine 50 mg
1 - Levothyroxine 75 mg
1 - Lidocaine top ical
11 - Lisinopril 20 mg
3 - Lisinopril 40 mg
1 - Lithium 150 mg
1 - Lithium 600 mg
141 - Loratadine 10 mg
4 - Losartin 25 mg
4 - Losartin 50 mg
3 - Lovastatin 20 mg
9 - Megestra 40 mg
55 - Melatonin 5 mg
15 - Meloxicam 7.5 mg
6 - Meloxicam 15 mg
9 - Memantine 5 mg
36 - Memantine 10 mg
14 - Metformin 1000 mg
1 - Methocarbamol 750 mg
39 - Metoprolol 25 mg
7 - Metoprolol 50 mg
1 - Metoprolol 100 mg
1 - Metronidazole gel
21 - Mirtazapine 15 mg
13 - Nicotene patches
7 - Nitrofuradantin 100 mg
9 vials - Novolog insulin
14 - Nuedexta 20 mg
3 - Nuplazid 34 mg
1 - Nystatin
1 - Nystatin topical
3 vials - Odansetron 4mg/ml
3 - Odansetron 4 mg
1 - Olanzapine 2.5 mg
1 - Olanzapine 5 mg
24 - Olanzapine 10 mg
1 - Omeprazole 40 mg
3 - Omeprazole 40 mg
2 - Omeprazole 20 mg
9 - Oxcarbazepine 150 mg
12 - Oxcarbazepine 300 mg
3 - Oxcarbazepine 600 mg
3 - Oxybutynin 5 mg
3 - Pantoprazole 40 mg
3 - Paroxetine 20 mg
1 - Paroxetine 40 mg
3 - Phenytoin 100 mg
18 - Potassium 10 mEq (milliequivalent)
1 - Potassium 80 mEq
5 - Potassium 20 mEq
3 - Pramipexole 0.25 mg
3 - Pravastatin 20 mg
7 - Pravastatin 80 mg
1 - Pravastatin 40 mg
10 - Prednisone 20 mg
9 - Promethazine 25 mg
6 - Propanol 10 mg
22 - Quetiapine 25 mg
83 - Quetiapine 50 mg
35 - Quetiapine 100 mg
2 - Quetiapine 200 mg
11 - Ranitidine 150 mg
1 - Risperdal 2.5 mg
3 - Risperdal 0.5 mg
3 - Risperdal 3 mg
22 - Risperdal 2 mg
9 patches - Rivastigmine
1 - Rosuvastatin 20 mg
4 - Sertraline 50 mg
10 - Sertraline 100 mg
10 - Simvastin 20 mg
7 - Soliqua injection
13 - Sotalol 80 mg
1 - Spironolactone 25 mg
3 - Spironolactone 50 mg
9 - Sucralfate 1000 mg
1 - Symbicort Inhaler
16 - Tamulosin 0.4 mg
46 - Trazadone 50 mg
3 - Trazadone 100 mg
3 - Triamterene 37.5 mg
2 - Valproic acid 250 mg
6 - Venlafaxine 75 mg
1 - Venlafaxine 150 mg
11 - Victoza
7 - Vitamin D
1 - Xarelto 15 mg
112 - Ziprazidone 20 mg
3 - Ziprazidone 40 mg
3 - Ziprazidone 60 mg
6 - Ziprazidone 80 mg
3 vials - Zyprexa

An interview was conducted on 5/1/19 at 11:00 AM with EI # 11, Pharmacist Consultant, who comes on site to destroy medications. EI # 11 stated he only destroys narcotics. EI # 11's last visit to the hospital was 3/12/19. EI # 11 stated a medical waste company, named Trilogy, picked up the non-narcotic pharmaceutical waste.

An interview was conducted on 5/1/19 at 12:05 PM with EI # 10, LPN (Licensed Practical Nurse). The surveyor asked what is the process for medications when a patient has been discharged. EI # 10 explained the medication goes in the drop boxes mounted on the wall in the medication room, one is for narcotics and one is for non-narcotics. EI # 10 stated, "...when they get full we notify the DON and she/he does something with them... the DON has the key, but I'm not sure who has it since she/he left." The hospital failed to maintain secure storage of narcotics and non-narcotics for patients following discharge.

The surveyor placed a call on 5/2/19 at 9:00 AM to Trilogy, the medical waste disposal company used by the hospital. The customer service representative stated she/he looked back one year of records, and found no documentation of pharmaceutical waste pickup at the facility.

An interview was conducted on 5/2/19 at 12:21 PM with EI # 1, who confirmed the above findings.

Based on review of medical records (MR), policy and procedure, and interview with staff it was determined the facility failed to include pertinent diagnoses with related goals and interventions in the Master Treatment Plan. This affected 1 of 5 MR's reviewed, and did affect MR # 5. This had the potential to affect all patients admitted to the facility.

Findings include:

Policy: Treatment Plan
Date Revised: 3-2016

Policy:

Each patient will have an individual comprehensive treatment plan that will be based on an inventory of the patient's strengths and disabilities. The treatment team will meet no less than every 7 days to review treatment plan.

Procedure:

...5. The treatment plan should include:
a. Both physical and mental problems that are actively being treated.
b. Treatment goals which are measurable...
e. Specific interventions addressing each goal.

...7. The interdisciplinary treatment team meets weekly to review and accept changes to the master treatment plan.

8. Progress notes will reference specific goals/ problems/ objectives as identified in the master treatment plan.
a. After completion of the nursing assessment a master problem list will be developed detailing specific problems identified.
b. Problems and modalities identified from each assessment will be added to the treatment plan.
c. Problems and interventions may be added anytime during the course of treatment.

9. Each patient's master treatment plan is reviewed weekly by the treatment team to evaluate progress, need to continue treatment, changes in interventions and status of discharge...

1. MR # 5 was admitted to the hospital on 3/28/19 with diagnoses including Major Depressive Disorder, Recurrent, with Psychosis. MR # 5 was discharged on 4/3/19.

Review of the Social Services Admission Note dated 3/31/19 revealed diagnoses including Seizure Disorder.

Review of the Master Treatment Plan dated 3/29/19 revealed the following problem list:
1. Disruptive and/ or Impulsive Behaviors
2. Delusions
3. Risk of Falls

Review of the Patient Care Notes dated 3/31/19 revealed the following documentation by the RN (Registered Nurse) at 0910 (9:10 AM), "... While sitting with pt (patient) for monitoring, pt began having a seizure... MD (Medical Doctor) notified with N.O. (New Order) to send to ER (Emergency Room)..."

An interview was conducted on 5/2/19 at 12:21 PM with Employee Identifier # 1, Administrator, who confirmed the Master Treatment Plan failed to include seizures, and was not updated to include seizures following the ER visit.

Based on review of policies and procedures, Daily Staffing Sheets, Staffing Matrix, Daily Census Report, Employee Timesheets, Employee List, and interviews with staff, it was determined the facility failed to ensure:

a) Adequate staffing was maintained according to patient census.

b) All Registered Nurses, Licensed Practical Nurses, and Mental Health Technicians received required Crisis Intervention training.

c) All Certified Registered Nurse Practioners and Registered Nurses functioning as charge nurse received required orientation, competencies and Crisis Intervention training.

Please refer to tag B 150.

Based on review of Daily Staffing Sheets, Daily Census Report, Employee Timesheets, Staffing Matrix, Employee List, policies and procedures, and interviews with staff it was determined the facility failed to ensure:

a) Adequate staffing was maintained according to patient census.

b) All Registered Nurses (RN), Licensed Practical Nurses (LPN), and Mental Health Technicians (MHT) received required Crisis Intervention training.

c) All Certified Registered Nurse Practioners (CRNP) and Registered Nurses functioning as charge nurse received required orientation, competencies, and Crisis Intervention training.

These deficient practices had the potential to affect all patients admitted to the facility.

Findings include:

Policy: Orientation and Training
Policy Number: 4299410
Date Revised: 02/2013

Policy:

BHC (Behavioral Healthcare Center) {Previous name of Unity Psychiatric Care} requires that all full time, part time, and contract employees complete an orientation and training program. This program assures that the employee has a thorough understanding of programs, services and requirements. Orientation and training allows the hospital to build the competency necessary to provide proper services to its patients.

Procedure:

...4. All training shall be documented in writing in the employee's personnel record.
a. Training includes ...
Identification of unsafe environmental procedures
Emergency Management
Evacuation Procedures
Critical Incidents (falls, death, skin tears, altercations) reporting/ identifying
...First Aid/ CPR
...Crisis Prevention...

6. The H.R. Manager will ensure that the new BHC staff members participate in a facility, new employee and clinical orientation.

7. The H.R. Manager will ensure each staff member will be assessed on a regular basis. Documentation will be maintained in identified employee records ...

Policy: Nursing Staff Allocation
Policy Number: None Listed
Date Revised: 5-2013

Policy: It is the responsibility of the DON (Director of Nursing) to develop, approve and implement criteria for employment, deployment, and assignment of nursing staff members.

Procedure:
...1. Staffing Patterns
a. Number of Staff- Nursing units are staffed according to full time "equivalents" ...
b. Staffing Mix- Consideration is given to the staffing plan to the utilization of registered nurses, licensed nurses, and/or assistive personnel ...
c. Sufficient Staffing- Staffing, both in numbers and competency will be sufficient at all times ...

Policy: Staff Safety and Liability
Policy Number: 4299687
Date Revised: 01/2008

Policy:

Behavioral Healthcare Center ... staff members are required to serve the needs of patients in the hospital setting. Staff are oriented to personal safety, preventing risk and emergency procedures while delivering services during their new employee orientation.

Procedure:

1. Staff are oriented and trained to be mindful of the safety concerns of all patients ...
3. Staff are trained to anticipate risk associated with providing services to prevent risky situations ...
6. Staff are trained in Crisis Prevention upon hire and yearly refreshed.

Staffing Matrix
Census- 8 to 14
7-3 (7:00 AM to 3:00 PM) 1 RN, 1 LPN, 2 MHT's.
3-11 (3:00 PM to 11:00 PM) 1 RN, 1 LPN, 2 MHT's.
11-7 (11:00 PM to 7:00 AM) 1 RN, 1 LPN, 2 MHT's.

Title: Job Description for Licensed Practical Nurse (LPN) or Licensed Vocational Nurse (LVN)

Policy: Under general supervision, the LPN/ LVN will provide a combination of nursing services, instruction, and assessments throughout the hospital; to assist with prevention and alleviation of mental illness and promote mental health. ...

Procedure:

A. Qualifications

4. Cardio-Pulmonary certified (CPR) and Crisis Prevention Institute (CPI) required (or trailing completed prior to direct patient care) with yearly refreshers. Centers for Medicare and Medicaid (CMS) Restraint and Seclusion training ( or training completed prior to direct patient care.

Title: Job Description for Mental Health Technician (MHT)

Policy: ... MHT's provide the provision of a safe, therapeutic environment, and crisis intervention. Because they serve in close contact with patients. MHT's may encounter violent patients or crisis intervention.

Procedures:

A. Qualifications

3. Certification - CPI certification training required upon hire with yearly refreshers. Restraint and seclusion training upon hire with yearly refreshers. CPR certification is not required upon hire (MHT's will be working with a CPR certified nurse while on the floor at all times)...

1. Review of the Daily Census Report for January 2019 revealed a census of 10 patients on 1/13/19. Review of the Employee Time Sheets dated 1/13/19 to 1/14/19 revealed one RN from 11:10 PM to 7:00 AM, and no additional nurse per policy for a census of 8 to 14.

A review of the Daily Staffing Sheet dated 4/22/19 and the April 2019 schedule revealed the scheduled RN charge nurse for the 7:00 PM to 7:00 AM shift had a line drawn through the name. The surveyor asked Employee Identifier (EI) # 1, Administrator, who was the RN charge nurse for that shift. EI # 1 stated the CRNP (EI # 3), was the charge nurse. The surveyor asked EI # 1 if EI # 3 had an employee file documenting orientation, competencies, and Crisis Intervention training, per policy. EI # 1 stated, "No, EI # 3 is a CRNP with IBH (Integrated Behavioral Health) {IBH is the physician group that provides psychiatric services to the hospital}, and rounds regularly in the facility."

Review of the Daily Staffing Sheet dated 4/25/19 revealed no RN charge nurse for the 7:00 PM to 7:00 AM shift, and one LPN orientee (Date of Hire: 3/25/19). The census for 4/25/19 was 11. The surveyor asked EI # 1 who was the charge nurse? EI # 1 stated the CRNP (EI # 8). EI # 8 was not listed on the employee list. The surveyor asked EI # 1 if EI # 8 had an employee file documenting orientation, competencies, and Crisis Intervention training, per policy. EI # 1 stated, "No."

A review of the Daily Staffing Sheet dated 4/27/19 revealed CRNP (EI # 4), was listed as the charge nurse for the 7:00 PM to 7:00 AM shift. Review of the employee list provided to the surveyor, did not include EI # 4. The surveyor asked EI # 1 if EI # 4 had an employee file documenting orientation, competencies, and Crisis Intervention training, per policy. EI # 1 stated, "No."

A review of the Daily Staffing Sheet dated 4/28/19 revealed the RN charge nurse listed for the 7:00 PM to 7:00 AM shift had a line drawn through the name. The surveyor asked EI # 1 who was the charge nurse for that shift. EI # 1 stated RN (EI # 5), worked as charge nurse. The surveyor asked EI # 1 if EI # 5 had an employee file documenting orientation, competencies, and Crisis Intervention training, per policy. EI # 1 stated, "No."

Review of the Daily Staffing Sheet dated 4/29/19 had a line drawn through both the RN charge nurse and second nurse for the 7:00 PM to 7:00 AM shift. The surveyor asked EI # 1 who worked this shift. EI # 1 stated a CRNP (EI # 6) and an LPN (EI # 16) worked. Review of the employee list revealed EI # 6 was not an employee of the facility. The surveyor asked EI # 1 if EI # 6 had an employee file documenting orientation, competencies, and Crisis Intervention training, per policy. EI # 1 stated, "No."

During an interview on 5/2/19 at 12:32 PM with EI # 1, the above findings were confirmed.


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2. A review of the employee/ personnel file conducted on 5/1/19 revealed the following findings:

EI # 12, Registered Nurse and EI # 16, License Practical Nurse (LPN) did not have a documented orientation, competency skills check off and CPI training with return demonstration on file.

EI # 13, Interim DON (Director of Nursing) did not have a current documented CPI training with return demonstration on file.

EI # 14, Mental Health Technician (MHT) did not have a current documented CPI on file.

EI # 15, MHT did not have a documented competency skills check.

EI # 17, LPN did not have a documented CPI training and return demonstration on file.

An interview was conducted on 5/2/19 at 1:30 PM with EI # 1, Administrator who confirmed the above mentioned findings.