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Based on record review and interview, the facility failed to evaluate the quality of each contracted service in 5 of 5 contracted services (Housekeeping/Laundry, Therapy, Laboratory, Pharmacy, and Medical Staff) utilized by the facility.

Findings include:

Per interview with Administrator A on 4/24/2018 at 8:50 AM, Administrator A stated the facility does not complete an evaluation of contracted services to determine if the quality of the service provided is acceptable and provided per contract expectations.

Per review of contracts for the contracted services for year of 2017 on 4/25/2018 at 11:00 AM, there was no documentation of an evaluation completed based on the service that was provided by the contracted service.

Based on observation, record review, and interview, staff failed to maintain a safe environment free from risk factors for potential harm, serious harm and/or death on 1 of 1 inpatient psychiatric unit.

Findings include

Facility staff failed to address ligature risks/safety factors. See A-0144.

The cumulative effect of this failure has the potential to affect all patients admitted to the inpatient unit, including the 6 inpatients present during the course of the survey.

Based on record review and interview, staff failed to ensure that the Important Message from Medicare informing Medicare recipients of their discharge appeal rights was given to eligible patients within 48 hours of admission and/or discharge in 2 out of 3 Medicare eligible medical records reviewed out of a total of 32 records reviewed (Patient #10 and 22).

Findings include:

The facilities policy titled, "Medicare Beneficiaries Notice of Their Rights, Including Discharge," dated April 07, 2011, was reviewed on 4/24/2018 at 1:40 PM. The policy states in part, "The Nurse upon an admission and again within 48 hours of discharge will give the IM [Important Message] form to the Medicare patient/guardian upon admission or as far as possible in advance, but not more than two calendar days before discharge. A copy of the signed form shall be placed in the patient's medical chart."

An interview with Client Services Manager E regarding Patient Rights was conducted on 4/24/2018 at 12:45 PM. Regarding the discharge appeal rights for Medicare recipients, and when these patients are informed of these rights, Manager E stated, "Before they come on the unit, during the admission process."

In a follow up interview with Manager E on 4/24/2018 at 1:30 PM, Manager E provided the facility's policy titled, "Medicare Beneficiaries Notice of Their Rights, Including Discharge," and stated, "Registration staff gives the initial one. No one gives it on discharge." Manager E then reviewed the policy and stated, "I guess the nurse is supposed to, but it's not happening."

Patient #10's medical record was reviewed on 4/25/2018 at 2:50 PM. Patient #10 was admitted to the inpatient unit on 2/22/2018 and discharged on 3/20/2018. There is one Medicare Discharge Appeal form dated 3/20/2018. This finding was discussed with and confirmed per interview by Director of Nursing C and Head Nurse D on 4/25/2018 at 5:30 PM. Nurse D stated that when Patient #10 came in Patient #10 was, "Catatonic and all [gender] would do was scream. [Gender] wouldn't sign anything." There is no indication that the Medicare Discharge Appeal form was offered and explained at any other time between 2/22/2018 and 3/20/2018.

Patient #22's medical record was reviewed on 4/25/2018 at 4:06 PM. Patient #22 was admitted to the inpatient unit on 2/18/2018 and discharged on 3/22/2018. There is one Medicare Discharge Appeal form dated 2/18/2018. This finding was discussed with and confirmed per interview by Director of Nursing C and Head Nurse D on 4/25/2018 at 5:30 PM. Director C stated, "I looked, there is only one."

Based on observation, record, and interview, staff failed to maintain a safe environment free from risk factors for potential harm, serious harm and/or death on 1 of 1 inpatient psychiatric unit.

Findings include:

A tour of the inpatient psychiatric unit was conducted on 4/24/2018 at 9:00 AM accompanied by Head Nurse D. The following ligature risk/safety risk observations were made and confirmed by Nurse D:
Hand sanitizer dispensers in patient day room and down pods, 2 of which are not in view of nurses station.
All door handles and door hinges (16 bed unit).
Thermostat cover-metal, square, 6 inch flat surface.
Bed springs and metal frames exposed/beds are moveable and able to block doorways.
Closet doors are attached and approximately 15 inches by 1 inch flat surface on top of door- all rooms
Faucets on room sinks fixed (not moveable) and not flush-all rooms.
Toilet plumbing exposed-all rooms.
Exercise equipment cords are present, long and not always supervised-down women's pod.
Fire alarm box fixed, metal, 3 1/2 inches by 4 inches, flat top surface.
2 Phone cords removable with clip type attachments in day room.
Room 222-the locked bathroom between the restraint room and the seclusion room had a ball point pen on the sink.
Room 219-ball point pen on the sink in the unlocked, unoccupied patient room.

Per interview with Nurse D on 4/24/2018 at 9:20 AM regarding the safety concern findings, Nurse D stated, "A risk assessment has been completed, talk to [director of nursing]." Nurse D also stated that because of the safety concerns 5 minute checks on patients on the unit were initiated. Nurse D stated that all patients come in as a level 1 (5 minute checks) and if they are found to be safe can then go to level 2 (15 minute checks).

Per interview with Director of Nursing C on 4/24/2018 at 4:30 PM regarding the environmental risk factors found on tour of the inpatient unit, Director C stated that an environmental risk assessment was conducted with Director C and Maintenance G on March 22, 2018. The environmental risk assessment was reviewed on 4/24/2018 at 4:45 PM and was found to be extensive and included the same findings that were observed on the unit tour.

The facilities "Statement of Patient Rights," form was reviewed on 4/25/2018 at 8:30 AM. The statement revealed in part, "Your rights include:...7. The right to safe and clean surroundings."

Per interview with Administrator A on 4/25/2018 at 1:00 PM regarding a plan to mitigate the safety concerns, Administrator A stated, "I talked to the human services director and the county board chairman, because of the serious nature of this, they said to go ahead and do the work so we will get started on some of this stuff right away."

Based on record review and interview, the facility failed to include all departments in the quality assurance performance improvement program for 6 of 13 services (Medical Staff, Laundry, Laboratory, Pharmacy, Radiology, and Therapy Services) provided at this hospital.

Findings include:

Per review of Quality Assurance Performance Improvement Plan on 4/24/2018 at 11:20 AM revealed "Norwood Health Center will: Address all systems of care and management practices, Include clinical care, quality of life and resident life, and Reflect the complexities, unique care, and services that the facility provides.

Per review of facility quality assurance performance improvement projects on 4/24/2018 at 10:40 AM with Health Information Management Manager F revealed no quality projects for Medical Staff, Laundry, Laboratory, Pharmacy, Radiology and Therapy Services.

Per interview with Health Information Management Manager F on 4/24/2018 at 10:50 AM, Health Information Management Manager F stated, "Not every department has a project currently in the quality assurance performance improvement program".

Based on observation and interview the facility failed to ensure the confidentiality of patient medical records in 1 of 1 medical storage area in the hospital.

Findings include:

Per observation of the medical records storage area on 4/24/2018 ay 10:15 AM, noted the room is located across the hall from the Health Information Management Manager F's office. There is no staff located in the room. The door is locked but per interview with Health Information Management Manager F on 4/24/2018 at 10:08 AM, Health Information Management Manager F stated, "The housekeeper is allowed in the room to collect garbage and vacuum the room, the door is propped open for the staff". While the contracted housekeeping staff is in the room there is not staff present to monitor the security of the records.

Based on record review and interview, the staff failed to include a time on the documented forms when authenticated by the physicians in 29 of 32 patient (Patient #8, 10, 13, 17, 18, 19, 20, 21, 22, 34, 24, 25, 26, 27, 28, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, and 44) medical records reviewed.

Findings include:

Per review on 4/25/2018 at 1:15 PM of policy titled, Health Information Standards and Management, dated 4/25/2017 revealed, "IV. All Handwritten entries into the medical record, or documents requiring a provider's signature, must be signed, dated, and times to be considered a complete and legal document".

Patient #28's closed medical was reviewed on 4/25/2018 at 5:30 PM. Patient #28 was admitted on 2/6/2018 and discharged 2/9/2018. The Psychiatric Evaluation, Discharge Summary, and progress note dated 2/8/2018 did not have a time they were signed by the physician.

Patient #31's closed medical was reviewed on 4/25/2018 at 12:00 PM. Patient #31 was admitted on 2/7/2018 and discharged 2/9/2018. The Psychiatric Evaluation, Discharge Summary, and progress note dated 2/8/2018 did not have a time they were signed by the physician.

Patient #32's closed medical was reviewed on 4/25/2018 at 1:15 PM. Patient #32 was admitted on 2/6/2018 and discharged 2/9/2018. The Psychiatric Evaluation, Discharge Summary, and progress note dated 2/8/2018 did not have a time they were signed by the physician.

Patient #33's closed medical was reviewed on 4/25/2018 at 1:40 PM. Patient #33 was admitted on 3/21/2018 and discharged 3/28/2018. The Psychiatric Evaluation, Discharge Summary, and 6 progress notes dated between 3/22/2018-3/27/2018 did not have a time they were signed by the physician.

Patient #34's closed medical was reviewed on 4/25/2018 at 2:00 PM. Patient #34 was admitted on 10/6/2017 and discharged 10/9/2017. The Psychiatric Evaluation, Discharge Summary, and progress note dated 10/8/2017 did not have a time they were signed by the physician.

Patient #35's closed medical was reviewed on 4/25/2018 at 2:40 PM. Patient #35 was admitted on 10/3/2017 and discharged 10/17/2017. The Psychiatric Evaluation, Discharge Summary, and 17 progress notes dated between 10/3/2017-10/21/2017 did not have a time they were signed by the physician.

Patient #36's closed medical was reviewed on 4/25/2018 at 3:30 PM. Patient #36 was admitted on 3/30/2018 and discharged 4/2/2018. The Psychiatric Evaluation, Discharge Summary and 2 progress notes dated between 3/31/2018-4/2/2018 did not have a time they were signed by the physician.

Patient #37's closed medical was reviewed on 4/25/2018 at 4:00 PM. Patient #37 was admitted on 2/26/2018 and discharged 2/28/2018. The Psychiatric Evaluation, Discharge Summary, and the Psychotherapy Note dated 2/28/2018 did not have a time they were signed by the physician.

Patient #38's closed medical was reviewed on 4/25/2018 at 4:15 PM. Patient #38 was admitted on 3/21/2018 and discharged 3/28/2018. The Psychiatric Evaluation, Discharge Summary, and 6 progress notes dated between 3/22/2018-3/27/2018 did not have a time they were signed by the physician.

Patient #39's closed medical was reviewed on 4/25/2018 at 4:30 PM. Patient #39 was admitted on 12/10/2017 and discharged 1/2/2018. The Psychiatric Evaluation, Discharge Summary, and 31 progress notes dated between 12/12/2018-1/11/2018 did not have a time they were signed by the physician.

Patient #40's closed medical was reviewed on 4/25/2018 at 4:45 PM. Patient #40 was admitted on 1/16/2018 and discharged 1/25/2018. The Psychiatric Evaluation, Discharge Summary, and 7 progress notes dated between 1/18/2018-1/24/2018 did not have a time they were signed by the physician.

Patient #41's closed medical was reviewed on 4/25/2018 at 5:15 PM. Patient #41 was admitted on 2/3/2018 and discharged 2/15/2018. The Psychiatric Evaluation, Discharge Summary, and 9 progress notes dated between 2/5/2018-2/14/2018 did not have a time they were signed by the physician.

Patient #42's closed medical was reviewed on 4/25/2018 at 5:00 PM. Patient #42 was admitted on 2/25/2018 and discharged 2/27/2018. The Psychiatric Evaluation, and the Discharge Summary did not have a time they were signed by the physician.

Patient #43's closed medical was reviewed on 4/25/2018 at 5:35 PM. Patient #43 was admitted on 1/1/2018 and discharged 1/3/2018. The Psychiatric Evaluation, Discharge Summary, and the progress note dated 1/2/2018 did not have a time they were signed by the physician.

Patient #44's closed medical was reviewed on 4/25/2018 at 5:40 PM. Patient #44 was admitted on 2/2/2018 and discharged 2/21/2018. The Psychiatric Evaluation, Discharge Summary, and 17 progress notes dated between 2/4/2018-2/20/2018 did not have a time they were signed by the physician.


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Patient #17's closed medical record was reviewed on 4/25/2018 at 10:14 AM. Patient #17 was admitted on 2/26/2018 and discharged on 3/1/2018. The Psychiatric Evaluation, Discharge Summary and 1 progress note did not have a time they were signed by the physician.

Patient #18's closed medical record was reviewed on 4/25/2018 at 11:14 AM. Patient #18 was admitted on 3/1/2018 and discharged on 3/5/2018. The Psychiatric Evaluation, Discharge Summary and 3 progress notes dated between 3/2/2018-3/4/2018 did not have a time they were signed by the physician.

Patient #8's closed medical record was reviewed on 4/25/2018 at 12:51 PM. Patient #18 was admitted on 2/14/2018 and discharged on 3/5/2018. The Psychiatric Evaluation, Discharge Summary and 18 progress notes dated between 2/16/2018-3/4/2018 did not have a time they were signed by the physician.

Patient #19's closed medical record was reviewed on 4/25/2018 at 1:38 PM. Patient #19 was admitted on 2/27/2018 and discharged on 3/6/2018. The Psychiatric Evaluation, Discharge Summary and 5 progress notes dated between 3/1/2018-3/5/2018 did not have a time they were signed by the physician.

Patient #13's closed medical record was reviewed on 4/25/2018 at 2:20 PM. Patient #13 was admitted on 3/8/2018 and discharged on 3/12/2018. The Psychiatric Evaluation, Discharge Summary and 2 progress notes dated 3/10/2018 and 3/11/2018 did not have a time they were signed by the physician.

Patient #20's closed medical record was reviewed on 4/25/2018 at 2:34 PM. Patient #20 was admitted on 3/12/2018 and discharged on 3/15/2018. The Psychiatric Evaluation, Discharge Summary and 1 progress note dated 3/14/2018 did not have a time they were signed by the physician.

Patient #10's closed medical record was reviewed on 4/25/2018 at 2:50 PM. Patient #10 was admitted on 2/22/2018 and discharged on 3/20/2018. The Psychiatric Evaluation, Discharge Summary and 22 progress notes dated between 2/25/2018-3/18/2018 did not have a time they were signed by the physician.

Patient #21's closed medical record was reviewed on 4/25/2018 at 3:35 PM. Patient #21 was admitted on 3/8/2018 and discharged on 3/21/2018. The Psychiatric Evaluation, Discharge Summary and 10 progress notes dated between 3/10/2018-3/20/2018 did not have a time they were signed by the physician.

Patient #22's closed medical record was reviewed on 4/25/2018 at 4:06 PM. Patient #22 was admitted on 2/18/2018 and discharged on 3/22/2018. The Psychiatric Evaluation, Discharge Summary and 31 progress notes dated between 2/19/2018-3/21/2018 did not have a time they were signed by the physician.

Patient #23's closed medical record was reviewed on 4/25/2018 at 4:18 PM. Patient #23 was admitted on 3/29/2018 and discharged on 3/30/2018. The Psychiatric Evaluation, Discharge Summary did not have a time they were signed by the physician.

Patient #24's closed medical record was reviewed on 4/25/2018 at 6:00 PM. Patient #24 was admitted and discharged on 2/1/2018 The Psychiatric Evaluation/Discharge Summary did not have a time it was signed by the physician.

Patient #25's closed medical record was reviewed on 4/25/2018 at 6:10 PM. Patient #25 was admitted on 2/2/2018 and discharged 2/3/2018. The Psychiatric Evaluation, Discharge Summary did not have a time they were signed by the physician.

Patient #26's closed medical record was reviewed on 4/25/2018 at 6:30 PM. Patient #26 was admitted on 1/31/2018 and discharged on 2/6/2018. The Psychiatric Evaluation, Discharge Summary and 4 progress notes dated between 2/2/2018-2/4/2018 did not have a time they were signed by the physician.

Patient #27's closed medical record was reviewed on 4/25/2018 at 7:00 PM. Patient #27 was admitted on 1/23/2018 and discharged on 2/6/2018. The Psychiatric Evaluation, Discharge Summary and 13 progress notes dated between 1/26/2018-2/5/2018 did not have a time they were signed by the physician.

Findings were shared with Health Information Management Manager F on 4/25/2018 at 5:45 PM, Health Information Management Manager F stated in an interview, "All entries into the medical record should include a signature, date, and time."

Based on record review and interview, staff failed to ensure that physician order policies are current and updated, and failed to ensure that physicians are properly authenticating orders with time, date, and or signature in 29 out of 32 medical records reviewed (Patient #17, 18, 8, 19, 20, 10, 21, 22, 23, 24, 25, 26, 27, 3, 4, 5, 36, 28, 31, 32, 33, 34, 37, 38, 39, 40, 41, 43, and 44).

Findings include:

Per review on 4/25/2018 at 1:15 PM of policy titled, Health Information Standards and Management, dated 4/25/2017 revealed, "IV. All Handwritten entries into the medical record, or documents requiring a provider's signature, must be signed, dated, and times to be considered a complete and legal document".

An interview regarding nursing services was conducted on 4/24/2018 at 9:55 AM with Head Nurse D. Regarding verbal orders Nurse D stated, "We do take them [verbal and telephone orders]. The physician is to co-sign them within 24 hours give or take a few hours depending on when they were written and when the next physician is doing rounds. It might not be exactly 24 hours."

An interview regarding pharmacy services was conducted on 4/24/2018 at 3:55 PM with Director of Nursing C. Regarding verbal orders Director C stated, "The nurse writes them. The doctor has 24 hours to sign them. Night shift nurses go through and check."

The facility policy titled, "Physician Orders," dated May 13, 2011, was reviewed on 4/25/2018 at 1:45 PM. The policy revealed in part, "Physician Sign and date verbal order/telephone order in timely manner. Signature will be secured in a 48 hour period for acute unit orders."

Patient #17's closed medical record was reviewed on 4/25/2018 at 10:14 AM. Patient #17 was admitted on 2/26/2018 and discharged on 3/1/2018. There was 2 telephone orders from 2/26/2018 and a verbal order from 3/1/2018 that did not have a date and time they were signed by the physician.

Patient #18's closed medical record was reviewed on 4/25/2018 at 11:14 AM. Patient #18 was admitted on 3/1/2018 and discharged on 3/5/2018. There was a telephone order and 2 verbal orders from 3/1/2018 that did not have a date and time they were signed by the physician. There was a verbal order from 3/1/2018 that is still not signed by the physician and 3 verbal orders from 3/1/2018 that were signed on 3/5/2018 (more than 48 hours) and do not include the time they were signed by the physician. There is 2 verbal order from 3/5/2018 that does not include the date and time the physician signed the order.

Patient #8's closed medical record was reviewed on 4/25/2018 at 12:51 PM. Patient #8 was admitted on 2/14/2018 and discharged on 3/5/2018. There was a verbal order from 2/14/2018 and a verbal order from 3/5/2018 that did not have a date or time the physician signed the orders.

Patient #19's closed medical record was reviewed on 4/25/2018 at 1:38 PM. Patient #19 was admitted on 2/27/2018 and discharged on 3/6/2018. There was a verbal order from 2/27/2018 that did not have a date or time the physician signed the order and a verbal order from 3/3/2018 that did not have the time the physician signed the order.

Patient #20's closed medical record was reviewed on 4/25/2018 at 2:34 PM. Patient #20 was admitted on 3/12/2018 and discharged on 3/15/2018. There were 2 verbal orders from 3/12/2018 that did not have the date or time they were signed by the physician and 2 verbal orders from 3/14/2018 that did not have the date or time they were signed by the physician.

Patient #10's closed medical record was reviewed on 4/25/2018 at 2:50 PM. Patient #10 was admitted on 2/22/2018 and discharged on 3/20/2018. There was 1 verbal order on 2/22/2018 and 1 verbal order from 3/1/2018 that did not have dates or times the physician signed them. There was one physician order that did not include the date or time the physician wrote the order on 3/5/2018.

Patient #21's closed medical record was reviewed on 4/25/2018 at 3:35 PM. Patient #21 was admitted on 3/8/2018 and discharged on 3/21/2018. There was a verbal order on 3/8/2018, a verbal order on 3/14/2018, and 2 verbal orders from 3/21/2018 that did not have dates or times they were signed by the physician.

Patient #22's closed medical record was reviewed on 4/25/2018 at 4:06 PM. Patient #22 was admitted on 2/18/2018 and discharged on 3/22/2018. On 2/18/2018 there were 2 verbal orders that did not have a date or time the physician signed them and 1 that did not have the time it was signed. On 2/22/2018, 2/26/2018, 3/13/2018 and 3/14/2018 there was a verbal order from each date that did not have a date or time the physician signed the orders. Alcohol withdrawal pre-printed standing orders dated 2/18/2018 were initiated as a verbal order and did not include a time the physician signed them.

Patient #23's closed medical record was reviewed on 4/25/2018 at 4:18 PM. Patient #23 was admitted on 3/29/2018 and discharged on 3/30/2018. There is a telephone order from 3/29/2018 that did not include a date or time the physician signed it and one physician order that did not include the time the physician wrote the order.

Patient #24's closed medical record was reviewed on 4/25/2018 at 6:00 PM. Patient #24 was admitted and discharged on 2/1/2018. There are 2 telephone orders and a verbal order from 2/1/2018 that did not include a date or time the physician signed them.

Patient #25's closed medical record was reviewed on 4/25/2018 at 6:10 PM. Patient #25 was admitted on 2/2/2018 and discharged 2/3/2018. On 2/2/2018 there were 3 verbal orders that did not include a date or time the physician signed them and 2 telephone orders that did not include the time they were signed by the physician. There were 2 verbal orders from 2/3/2018 that did not include the time they were signed by the physician. One of the verbal orders from 2/3/2018 was not signed by the physician until 2/10/2018, which was more than 48 hours.

Patient #26's closed medical record was reviewed on 4/25/2018 at 6:30 PM. Patient #26 was admitted on 1/31/2018 and discharged on 2/6/2018. There was a verbal order from 2/1/2018, a verbal order from 2/6/2018 and a telephone order from 1/31/2018 that did not have a date or time the physician signed them.

Patient #27's closed medical record was reviewed on 4/25/2018 at 7:00 PM. Patient #27 was admitted on 1/23/2018 and discharged on 2/6/2018. There was a verbal order from 1/23/2018 and a verbal order from 2/6/2018 that did not have a date or time the physician signed them. A physician written order from 1/30/2018 and 1/31/2018 did not include the time the physician wrote them. A nurse practitioner order from 2/5/2018 did not include a time it was written.


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Patient # 3's open medical record was reviewed on 4/25/2018 at 2:50 PM. Patient #3 was admitted 4/23/2018. There was 2 physician orders written on 4/24/2018 that did not include a time when the orders were written, and a telephone order from 4/23/2018 that did not have a date and time they were signed by the physician.

Patient #4's open medical record was reviewed on 4/25/2018 at 3:00 PM. Patient #4 was admitted 4/17/2018. There was 2 physician orders written on 4/24/2018, 4/22/2018, and 4/19/2018, did not include a time when the orders were written. There was a telephone order from 4/17/2018 that is not signed by the physician, and a telephone order from 4/17/2018 that did not have a date and time the orders were signed by the physician.

Patient #5's open medical record was reviewed on 4/25/2018 at 3:15 PM. Patient #5 was admitted 3/29/2018. There was a verbal from 4/12/2018, and 3/30/2018 that did not have a date and time the orders were signed by the physician. There was an order written on 3/30/2018 that did not include a time when the order was written.

Patient #36's closed medical record was reviewed on 4/25/2018 at 3:30 PM. Patient #36 was admitted 3/21/2018. There was a telephone order written from 3/20/2018, 3/22/2018, 3/23/2018, and 2 verbal orders written on 3/28/2018 that did not have the date and time the orders were signed by the physician. There was an order written on 3/24/2018 and 3/25/2018 that did not have a time documented as to when the order was written.

Patient #28's closed medical record was reviewed on 4/25/2018 at 5:30 PM. Patient #28 was admitted on 2/6/2018. There were telephone orders written on 2/5/2018, 2/6/2018, and 2/9/2018 that did not include a date and time the order was signed by the physician. There was an order written on 2/8/2018, and 2/6/2018 that did not include a time the order was written by the physician.

Patient #31's closed medical record was reviewed on 4/25/2018 at 12:00 PM. Patient #31 was admitted on 2/7/2018. There were 2 telephone orders written on 2/7/2018, and on 2/9/2018 that did not have a dated and time the order was signed by the physician. There was an order written on 2/8/2018, and 2/7/2018 that did not include a time when the physician wrote the orders.

Patient #32's closed medical record was reviewed on 4/25/2018 at 1:15 PM. Patient #32 was admitted on 2/6/2018. There were 3 telephone orders written on 2/6/2018, 2/7/2018, and 2/9/2018 that did not include a date and time the order was signed by the physician. There was an order written on 2/7/2018, and 2/8/2018 that did not include a time the order was written by the physician.

Patient #33's closed medical record was reviewed on 4/25/2018 at 1:40 PM. Patient #33 was admitted on 3/30/2018. There were 3 telephone orders written on 3/30/2018, and 4/2/2018 that did not include a date and time the order was signed by the physician. There was an order written on 3/31/2018, and 4/1/2018 that did not include a time the order was written by the physician.

Patient #34's closed medical record was reviewed on 4/25/2018 at 2:00 PM. Patient #34 was admitted on 10/6/2017. There were telephone orders written on 10/6/2018, 3 orders written on 10/8/2018, and 10/9/2018 that did not include a date and time the order was signed by the physician.

Patient #37's closed medical record was reviewed on 4/25/2018 at 4:00 PM. Patient #37 was admitted on 2/26/2018. There was a telephone order written on 2/26/2018 that does not have a date and time the order was signed by the physician. There were 3 orders written on 2/27/2018, that did not include a time when the physician wrote the order.

Patient #38's closed medical record was reviewed on 4/25/2018 at 4:15 PM. Patient #38 was admitted on 1/1/2018. There was a telephone orders written on 1/1/2018 that did not include a time the order was signed by the physician.

Patient #39's closed medical record was reviewed on 4/25/2018 at 4:30 PM. Patient #39 was admitted on 12/10/2017. There were telephone orders written on 12/10/2017, 1/3/2018, and 1/12/2018 that did not include a date and time the order was signed by the physician. There were orders written on 12/14/2017, 12/17/2017, 12/20/2017, 12/22/2017, 12/23/2017, and 12/25/2017 that did not include a time the order was written by the physician.

Patient #40's closed medical record was reviewed on 4/25/2018 at 4:45 PM. Patient #40 was admitted on 1/16/2018. There were 2 telephone orders written on 1/25/2018, 1/20/2018, and 1/16/2018 that do not include a date and time the order was signed by the physician. There was an order written on 1/20/2018 that did not include a time the order was written by the physician.

Patient #41's closed medical record was reviewed on 4/25/2018 at 5:15 PM. Patient #41 was admitted on 2/3/2018. There was a telephone orders written on 2/3/2018 that did not include a time the order was signed by the physician. There was an order written on 2/5/2018, 2/7/2018, and 2/12/2018 that did not include a time the order was written by the physician.

Patient #43's closed medical record was reviewed on 4/25/2018 at 5:35 PM. Patient #43 was admitted on 2/20/2018. There were telephone orders written on 2/20/2018 and 2/23/2018 that did not include a date and time the order was signed by the physician.

Patient #44's closed medical record was reviewed on 4/25/2018 at 5:40 PM. Patient #44 was admitted on 2/2/2018. There were telephone orders written on 2/3/2018 and 2/20/2018 that did not include a date and time the order was signed by the physician. There was an order written on 2/5/2018 that did not include a time the order was written by the physician.

Findings were shared with Health Information Management Manager F on 4/25/2018 at 5:45 PM, Health Information Management Manager F stated, "All physician orders should include a signature, date, and time."

Based on observation and interview, staff failed to remove medications that were either out dated and/or ordered for patients who were discharged in 1 of 1 medication refrigerator involving 2 of 2 stored patient medications (Patient #29 and 30).

Findings include:

Observations in the medication room behind the nurses station on the inpatient unit was conducted on 4/24/2018 at 9:35 AM accompanied by Head Nurse D who confirmed the following observations:

In the medication refrigerator a multi-dose pen of Bydureon (injectable medication that helps stimulate the pancreas to produce more insulin) 2 milligrams ordered for Patient #29 was observed. Patient #29 was not a current patient. A review of Patient #29's medical record on 4/25/2018 at 4:30 PM revealed that Patient #29 was discharged on 12/8/2017.

Also in the medication refrigerator were 3 pre-filled syringes of Invega Sustenna (an antipsychotic medication for Schizophrenia) 117 milligrams ordered for Patient #30. Patient #30 was not a current patient on the inpatient unit. The pharmacy medication label on the box for the medication revealed that Patient #30's name was blacked out with black marker. Per interview with Nurse D on 4/24/2018 at 9:40 AM regarding why the name would be blacked out but the medication still remained on the unit, Nurse D stated, "I don't know."

Also, on the medication box, the storage recommendations revealed, "Store at room temperature (77 degrees). Temperatures between 59 degrees and 86 degrees are permitted." The temperature log for the refrigerator, reviewed on 4/24/2018 at 9:40 AM, revealed the temperature is maintained between 37 degrees and 41 degrees. Per interview with Nurse D on 4/24/2018 at 9:45 AM regarding the storage of this medication, Nurse D responded, "So really it shouldn't even be in the refrigerator."

A review of Patient #30's medical record on 4/25/2018 at 4:45 PM revealed that Patient #30 was discharged from the inpatient unit on 7/19/2017 and is still a patient on one of the long-term care floors in this facility.

Per interview with Nurse D on 4/24/2018 at 9:45 AM regarding why the medications still remained on the unit if the patients were no longer there, Nurse D responded, "I don't know."

An observation of the medical emergency cart was made on 4/24/2018 at 11:00 AM. The epinephrine pen in the cart expired on 4/20/2018. Per interview with Nurse D on 4/24/2018 at 11:00 AM regarding the expired medication, Nurse D responded, "Oh! And it just expired!"

Based on record review and interview, staff failed to ensure that a qualified dietician is providing policy oversight and dietary counseling to patients identified as needing this service and failed to obtain a dietary consult in 1 of 1 medical record out of a total of 32 medical records reviewed (Patient #21).

Findings include:

An interview with Food Service Supervisor/Certified Dietary Manager H was conducted on 4/24/2018 at 12:00 PM. Manager H stated that the dietician is contracted and comes for the inpatient program one time per month. Manager H stated that the dietitian does not develop policies or provide oversight of the policies for the dietary program for the inpatients.

During the interview Manager H stated that during the admission process nursing staff fill out a dietary questionnaire to screen for problems/issues with nutrition. If a patient answers yes the form is forwarded to Manager H in the dietary department. In response to who is providing dietary counseling if this is needed, Manager H responded, "I do."

The facility's policy titled, "Nutrition Intervention," dated November 20, 2014, was reviewed on 4/24/2018 at 1:16 PM. The policy revealed in part, "Nutrition Assessments...Dietician Review nutrition assessments and advise Food Services Supervisor of recommendations." Per interview with Manager H on 4/24/2018 at 1:30 PM regarding how often the dietician is reviewing nutrition assessments for inpatients, Manager H responded, "Not happening often."

Patient #21's medical record was reviewed on 4/25/2018 at 3:35 PM. The "Admission Nutrition Questionnaire" completed by nursing staff on 3/8/2018 revealed that Patient #21 had been, "Eating poorly because of a decreased appetite for more than 5 days." The directions on the bottom of the form revealed, "If the patient answers YES to any of the above questions, please send sheet to [Manager H], Dietary Manager for a consult." There is no documentation to indicate that Manager H or a dietician completed a dietary consult for Patient #21.

This finding was discussed with and confirmed per interview by Head Nurse D on 4/25/2018 at 3:55 PM. Nurse D stated, "If there is a yes answer then they send that form to [Manager H] for a consult." Nurse D was unable to find the consult in the medical record.

Based on observation, record reviews and staff interviews, the facility failed to construct, install and maintain the building systems to ensure compliance with Physical Environment. The cumulative effects of the deficiencies result in the hospital's inability to ensure a safe environment for all patients and staff.

Findings include:

The facility was found to contain the following deficiencies. Refer to the full description at the cited K-tags:

K-0353 - Sprinkler System - Maintenance And Testing
K-0374 - Subdivision of Building Space
K- 0521 - HVAC

Based on observation, record reviews and staff interviews, the facility failed to construct, install and maintain the building systems to ensure life safety from fire. The cumulative effects of the deficiencies result in the hospital's inability to ensure a safe environment for all patients and staff.

Findings include:

The facility was found to contain the following deficiencies. Refer to the full description at the cited K-tags:

K-0353 - Sprinkler System - Maintenance And Testing
K-0374 - Subdivision of Building Space
K- 0521 - HVAC

Based on observation, record review and interview, staff failed to maintain an environment that is clean and free from potential contamination in 1 out 1 units observed (inpatient unit) and failed to prevent possible contamination with hand hygiene during 1 of 2 staff (Mental Health Technician I) observations completed.

Findings include:

Per review on 2/25/2018 at 12:12 PM of policy titled, Hand washing, dated 12/20/2017 revealed "Hands will be sanitized before applying and after removal of gloves".

A tour of the inpatient psychiatric unit was conducted on 4/24/2018 at 9:00 AM accompanied by Head Nurse D. The following breaches in infection control were observed and confirmed by Nurse D:

In the locked bathroom between the restraint room and the seclusion room several personal toiletry items were observed on top of the paper towel dispenser (hair spray, perfume, mouthwash, saline solution for contacts, and tooth paste). There was also trash in the trash can and a magazine observed to be on a cloth covered chair that was also in the bathroom. Per interview with Head Nurse D on 4/24/2018 at 9:05 AM regarding these items and if staff were using this bathroom for personal use, Nurse D replied, "I can't say for sure, but it would appear so."

In unoccupied/cleaned room 218 there was debris on the floor and the mattress on bed 2 had cracks in the vinyl rendering it un-cleanable.
In the clean linen room down the "women's pod" on the floor, large dust balls were observed.
In the tub room toilet area there was toilet paper in the toilet, an unused tampon in its protective outer-wrap on top of the toilet paper holder, and debris on the floor. Per interview with Nurse D on 4/24/2018 at 9:30 AM regarding the tub room, Nurse D stated that it is not used much for patients and should be clean. Nurse D stated, "Obviously the staff are using this restroom as well, it would appear." Nurse D stated that staff do have their own bathroom off of the nurses station.
A red vinyl couch at the end of the "women's pod" has tears/cracks in the vinyl rendering it un-cleanable.


29963


Per observation on 4/25/2018 at 11:35 AM of Mental Health Technician I checking a blood sugar on patient #5, Mental Health Technician I removed gloves after completing the procedure and threw away garbage and put on a new glove on the right hand without completing hand hygiene.

Findings were confirmed with Director of Nursing C on 4/25/2018 at 5:30 PM, Director of Nursing C stated that staff should be completing hand hygiene every time gloves are taken off, and before gloves are reapplied."

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

I. Provide thorough and comprehensive social work assessments for 6 of 6 active sample patients (1, 2, 3, 4, 5, and 6). Social work assessments failed to include interviews with family members and other significant collateral sources to obtain a current and factual clinical history. The social work assessment also failed to include a social evaluation of strength/deficits and high-risk psychosocial issues, conclusions, recommendations of the anticipated necessary steps for discharge to occur, and specific community resources/support systems for utilization in discharge planning. In addition, the anticipated social work role in treatment was not identified in assessments. As a result, the treatment team did not have necessary social information and evaluation of social functioning level to utilize in developing treatment goals and interventions. (Refer to B108)

II. Ensure that 6 of 6 active sample patients (1, 2, 3, 4, 5, and 6) received a Psychiatric Evaluation containing sufficient information to justify diagnoses and planned treatment. This failure results in a lack of patient information necessary for the treatment team to formulate an appropriate master treatment plan. (Refer to B110)

III. Adequately develop treatment plans with individualized treatment interventions based on the needs of 6 of 6 active sample patients (1, 2, 3, 4, 5 and 6). This deficiency resulted in a failure to provide a basis for accurate implementation, evaluation of treatment provided, and to plan revisions based on individual patient changes. (Refer to B122)

IV. Ensure the assessment and treatment of adolescents based on their age-specific psychiatric needs for 6 of 6 discharged Patients (7, 12, 13, 14, 15, and 16) reviewed for treatment. This failure resulted in patients being hospitalized without age-specific assessments and treatments being provided in a timely fashion and potentially delaying improvement. (Refer to B125 Part I)

V. Provide sufficient numbers of structured therapeutic groups/activities to meet the needs of the patient population. In addition, some of the scheduled groups were cancelled. This failure hinders patient's participation in active treatment and results in patients roaming the unit, sleeping in their bedrooms, and idly sitting around on the unit. (Refer to B125 Part II)

VI. Ensure that staff were sufficiently trained to manage and care for patients who present physical violence in the clinical area. By facility policy, staff may call the local city police for assistance in managing and caring for patients with aggressive behaviors. In addition, while on the patient care unit the police may be armed with weapons such as guns and Tasers. This practice results in a) a conflict between treatment and law enforcement actions and b) a potential breach in the patient's right that care and interventions be delivered by health care professionals in a therapeutic treatment environment. In addition, the presence of weapons on the patient care unit results in a safety risk for all patients and staff. (Refer to B125 Part III)

VII. Ensure that Adolescent patients are safe during hospitalization. Adolescent patients are admitted to the facility on "emergency involuntary detention" for up to 72 hours (excluding week-ends and holidays) and are transferred to an adolescent facility or discharged after their "probable cause" hearing is held. The adolescent patients are housed on the 16-bed certified general psychiatric co-ed unit for adults. This results in a safety risk for all adolescent patients. (Refer to B125 Part IV)

VIII. Provide a discharge summary for each patient who had been discharged that included a recapitulation of the patient's hospitalization including assessments, treatments, and a synopsis of accomplishments achieved as reflected through the treatment plan for 5 of 5 discharged patients (7, 8, 9,10, and 11). This deficiency results in a failure to communicate, in a timely manner, psychiatric assessments, treatments, and discharge plans with providers providing follow-up care. (Refer to B133)

Based on record review and interview, the facility failed to provide thorough and comprehensive social work Assessments for six (6) of six (6) active sample patients (Patients 1, 2, 3, 4, 5, and 6). Social work Assessments failed to include interviews with family members and other significant collateral sources to obtain a current and factual clinical history. The social work Assessment also failed to include a social evaluation of strength/deficits and high-risk psychosocial issues, conclusions, recommendations of the anticipated necessary steps for discharge to occur, and specific community resources/support systems for utilization in discharge planning. In addition, the anticipated social work role in treatment was not identified in the psychosocial Assessments. As a result, the treatment team did not have necessary social information and evaluation of social functioning level to utilize in developing treatment goals and interventions.

Findings include:

A. Record Review

The following Psychosocial Assessments (dates in parentheses) failed to include interviews with family members or other collateral sources, an evaluation of psychosocial issues, conclusions and recommendations, or a description of the social work staff's role in treatment and discharge planning. Patients 1 (4/23/18), 2 (4/20/18), 3 (4/24/18), 4 (4/17/18), 5 (3/20/18), and 6 (4/14/18).

B. Staff Interview

During an interview with the Director of Social Work on 4/25/18 at 11:45 a.m., she acknowledged that the Psychosocial Assessments for Patients 1, 2, 3, 4, 5, and 6 lacked an evaluation of the psychosocial issues, conclusions and recommendations, or a description of the social work role in treatment. Also, there was no documentation that either family or collateral sources were used to gather the information.

Based on record review and interview, the facility failed to ensure that five (5) of six (6) active sample patients (Patients 1, 2, 4, 5, and 6) received a Psychiatric Evaluation that contained sufficient information to justify diagnoses and planned treatment. This failure results in a lack of patient information necessary for the treatment team to formulate an appropriate Master Treatment Plan.

Findings include:

1. The Psychiatric Evaluation for Patient 1, dated 4/23/18, listed the diagnoses as "Major Depression, Recurrent" and "Adjustment Disorder with Mixed Features." The Psychiatric Evaluation did not document sufficient information in the psychiatric history and mental status examination to justify these diagnoses according to the DSM-5 or ICD-10 criteria for "Major Depression, Recurrent" and "Adjustment Disorder with Mixed Features."

2. The Psychiatric Evaluation for Patient 2, dated 4/21/18, listed the diagnoses as "Major Depression, Recurrent, NOS with Self-Injurious Behaviors," and "Marijuana Dependence," "Cluster B Personality Disorder, Also Cluster C Traits." The Psychiatric Evaluation did not document sufficient information in the psychiatric history and mental status examination to justify the diagnosis of "Major Depression, Recurrent" according to the DSM-5 or ICD-10 criteria. The qualifier of "NOS with Self-Injurious Behavior" does not have criteria in the DSM-5 or ICD-10. The Psychiatric Evaluation did not document sufficient information in the psychiatric history and mental status examination to justify the diagnosis of "Marijuana Dependence," "Cluster B Personality Disorder," or "Cluster C Traits" according to DSM-5 or ICD-10 criteria.

3. The Psychiatric Evaluation for Patient 4, dated 4/17/18, listed the diagnoses as "Pain Disorder With Medical and Psychological Factors," "Major Depression, Recurrent, Moderate," and "Cluster B Personality Traits." The Psychiatric Evaluation did not document sufficient information in the psychiatric history and mental status examination to justify the diagnoses of "Major Depression, Recurrent, Moderate" and "Cluster B Personality Traits" according to the DSM-5 or ICD-10 criteria. "Pain Disorder With Medical and Psychological Factors" does not have criteria in the DSM-5 or ICD-10. The Psychiatric Evaluation did not document sufficient information in the psychiatric history and mental status examination to justify the diagnoses of somatic symptom disorder with persistent pain according to the DSM-5 or ICD-10 criteria.

4. The Psychiatric Evaluation for Patient 5, dated 4/2/18, listed the diagnosis as "Bipolar Disorder." The Psychiatric Evaluation did not document sufficient information in the psychiatric history and mental status examination to justify the diagnosis of bipolar disorder according to the DSM-5 or ICD-10 criteria.

5. The Psychiatric Evaluation for Patient 6, dated 4/14/18, listed the diagnoses as "Schizophrenia" and "Methamphetamine Use Disorder - Severe." The Psychiatric Evaluation did not document sufficient information in the psychiatric history and mental status examination to justify the diagnoses of "Schizophrenia" and "Methamphetamine Use Disorder" according to the DSM-5 or ICD-10 criteria.

B. Interview

During an interview with the Medical Director on 4/25/18 at 3:30 p.m., the Medical Director acknowledged that the Psychiatric Evaluations for the Patients 1, 2, 4, 5, and 6 failed to contain sufficient information to justify diagnoses and planned treatment.

Based on record review and interview, the facility failed to ensure that the Psychiatric Evaluation for one (1) of six (6) active sample patients (5) was completed within 60 hours of admission. This failure delays the availability of the Psychiatric Evaluation and a substantiated diagnosis for use in the development of the Treatment Plan.

Findings include:

A. Record Review:

Patient 5 was admitted on 3/29/18 at 9:00 p.m. The Psychiatric Evaluation was not dictated until 4/2/18 at 9:58 p.m. and made available to the other treatment team members when it was typed on 4/3/18 at 11:55 a.m.

B. Staff Interview:

During an interview on 4/25/18 at 3:30 p.m., the Medical Director acknowledged that the Psychiatric Evaluation for Patient 5 was not completed within 60 hours of the admission of Patient 5 to the facility.

Based on record review and interview, the facility failed to ensure that Psychiatric Evaluations included an estimate of memory functioning in measurable, behavioral terms for 6 of 6 sample patients (1, 2, 3, 4, 5, and 6). This failure results in the absence of cognitive impairment data for use in diagnosis and treatment and does not allow for the assessment of changes in cognitive impairment during treatment or at the time of possible future hospitalizations.

Findings include:

A. Record Review

The initial Psychiatric Evaluations (dates in parentheses) had no descriptive data regarding the degree of impairment in memory as follows:

Patient 1 (4/23/18): "Cognition: Appears within normal limits but was not formally tested."

Patient 2 (4/21/18): "Cognition: Appears intact."

Patient 3 (4/24/18): "Recent memory appears within normal limits as estimated by [her/his] history and communication."

Patient 4 (4/17/18): "Memory: Intact."

Patient 5 (4/2/18): "Recent and remote memory are impaired based on [her/his] history and communication."

Patient 6 (4/14/18): "Memory: Intact for immediate recall and short-term and long-term memory."

B. Staff Interview

During an interview on 4/25/18 at 3:30 p.m., the Medical Director acknowledged that the Psychiatric Evaluations for Patients 1, 2, 3, 4, 5, and 6 did not document specific estimates of memory functioning in measurable, behavioral terms.

Based on record review and interview, the facility failed to ensure that the Psychiatric Evaluations for four (4) of six (6) active sample patients (Patients 1, 2, 4, and 5) included an inventory of descriptive patient assets that might be used in treatment planning. Failure to identify patient assets impairs the ability of the treatment team to develop interventions using the individual strengths of each patient.

A. Record Review

1. The Psychiatric Evaluation for Patient 1, dated 4/23/18, did not document any patient assets.

2. The Psychiatric Evaluations (dates in parentheses) for the following patients did not document specific patient assets:

a. Patient 2 (4/21/18): "Knows community resources, wants to find a job and tolerating medications."

b. Patient 4 (4/17/18): "[S/he] is verbal."

c. Patient 5 (4/2/18): "[S/he] is grandiose and feels that others should tend to [her/his] needs."

B. Staff Interview:

During an interview on 4/25/18 at 3:30 p.m., the Medical Director acknowledged that the Psychiatric Evaluations for Patients 1, 2, 4, 5 did not document specific patient assets that could be utilized for treatment planning.

Based on interview and record review, the facility failed to develop Treatment Plans with individualized treatment interventions based on the needs of six (6) of six (6) active sample patients (Patients 1, 2, 3, 4, 5 and 6). This deficiency resulted in a failure to provide a basis for accurate implementation, evaluation of treatment provided, and plan revisions based on individual patient changes.

Findings include:

A. Record Review:

1. Patient 1 (Initial Treatment Plan dated 4/22/18):

a. For the Problem, "Ineffective coping R/T [related to] wanting to kill [himself/herself] due to a break up with [his/her] [boyfriend/girlfriend," there were no physician interventions on this initial plan of care.

A generic nursing intervention was stated as "Assess if ineffective coping endangers the resident and/or others." There were no specific safety interventions to direct nursing personnel addressing this patient's suicidal behaviors.

b. For the Problem, "Has risk for injury to self manifested by having a plan to stab [himself/herself] in the stomach." Other than safety monitoring checks, there were no specific safety interventions to direct nursing personnel to address this patient's suicidal behaviors.

c. For the Problem: "Will need an effective discharge plan and after care for a successful transition home," generic social work interventions were listed as "Arrange for discharge planning conference. Set up court proceedings [sic] as needs with county of responsibility. Review with patient legal status and expectations of hospital stay in collaboration with psychiatry," "Define roles and expectations of discharge with the patient and support person. Allow patient to verbalize preference for discharge," and "Provide written instructions for care and resources to use in case of emergency in the form of an individual aftercare plan. Patient will be provided a discharge safety plan specific to patients needs."

2. Patient 2 (MTP dated 4/19/18):

a. For the Problem, "Had a plan to overdose on medication in a suicide attempt," a nursing intervention was stated as "Nursing will assess [Patient] for suicidal thoughts everyday related to [his/her] plan to overdose. Nursing will provide 1:1 time and inform the doctor. Nurse will adjust safety level accordingly." There were no additional nursing interventions to direct nursing personnel in monitoring and care for this patient based on suicidal thoughts/behaviors.

b. For the Problem, "Has been cutting himself/herself more frequently," there were no safety interventions identified by nursing to address this behavior in the clinical area.

3. Patient 3 (Initial treatment plan dated 4/23/18):

a. For the Problem, "Has multiple mental breakdowns with multiple psychiatric hospitalizations related to past hx [history] of depression and traumatic past," there were no physician interventions.

Generic nursing interventions were stated as "Encourage [Patient] to become involved with activities: Group discussion and activities with other peers," "Encourage physical activity to maximal potential," and "Provide comfortable environment to promote sleep (e.g. clean bedding, comfortable bed clothing, incontinence care, comfortable temperature, ventilation, etc."

b. For the Problem, "Will need an effective discharge plan and after care for a successful transition home," generic social work interventions were listed as "Arrange for discharge planning conference. Set up court proceedings [sic] as needs with county of responsibility ...," "Define roles and expectations of discharge with the patient and support person. Allow [Patient] to verbalize preference for discharge," and "Provide written instructions for care and resources to use in case of emergency in the form of an individual aftercare plan. [Patient] will be provided a discharge safety plan specific to patients needs."

4. Patient 4 (MTP dated 4/17/19):

a. For the Problem, "Reported suicidal thoughts," other than the usual generic discipline function, assessment, and level of safety checks required, there were no safety interventions to direct nursing personnel in the care of this patient in the clinical area.

b. For the Problem, "Verbal and physical aggression," the only nursing intervention listed was "Assess whether the behavior endangers [Patient] and or others. Intervene if necessary." There were no additional safety interventions to direct nursing personnel in the care of this patient in the clinical area.

5. Patient 5 (MTP dated 4/1/18):

a. For the Problem, "Suicidal ideation of just wanting to be dead," the only nursing safety intervention was "Nursing will assess daily for statements of suicide related to stating his goal is to be dead, Nursing will offer 1:1 if necessary." There were no additional interventions to address safety in the clinical area.

b. For the Problem, "Inability to engage in rational/reality based conversation," nursing intervention was listed as "Nursing will monitor [Patient] for any negative behavior such as agitation, anxiety or verbally aggression related to delusional behavior and off PRNs if necessary." There were no interventions to direct nursing personnel in their response to the delusional comments.

6. Patient 6 (MTP dated 4/13/18):

For the Problem, "Admitted to hearing voices and seeing things that others cannot see ...
Admits to being depressed ...," nursing intervention was stated as "Nursing will encourage [Patient] to come to staff if the voices are getting worse related to [him/her] stating that the voices are louder at night. Nursing will notify the doctor and provide a quiet area for [Patient] if indicated." There were no interventions to direct nursing personnel in methods to assist the patient to deal with his/her hallucinations, instead the patient was sent to an area alone to deal with these symptoms.

B. Interview:

1. During interview that included a review of social work interventions, on 4/25/18 at 11:40 a.m., with the Director of Social Work, the Director verified that social work interventions should be more individualized on Treatment Plans.

2. During interview on 4/25/18 at 2:15 p.m., the Director of Nursing agreed that nursing interventions need to be more individualized.

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

I. Ensure the assessment and treatment of adolescents based on their age-specific psychiatric needs for 6 of 6 discharged Patients (7, 12, 13, 14, 15, and 16) reviewed for treatment. This failure resulted in patients being hospitalized without age-specific assessments and treatments being provided in a timely fashion and potentially delaying improvement.

II. Provide sufficient numbers of structured therapeutic groups/activities to meet the needs of the patient population. In addition, some of the scheduled groups were cancelled. This failure hinders patient's participation in active treatment and results in patients roaming the unit, sleeping in their bedrooms, and idly sitting around on the unit.

III. Ensure that staff were sufficiently trained to manage and care for patients who present physical violence in the clinical area. By facility policy, staff may call the local city police for assistance in managing and caring for patients with aggressive behaviors. In addition, while on the patient care unit the police may be armed with weapons such as guns and Tasers. This practice results in a) a conflict between treatment and law enforcement actions and b) a potential breach in the patient's right that care and interventions be delivered by health care professionals in a therapeutic treatment environment. In addition, the presence of weapons on the patient care unit results in a safety risk for all patients and staff.

IV. Ensure that Adolescent patients are safe during hospitalization. Adolescent patients are admitted to the facility on "emergency involuntary detention" for up to 72 hours (excluding week-ends and holidays) and are transferred to an adolescent facility or discharged after their "probable cause" hearing is held. The adolescent patients are housed on the 16-bed certified general psychiatric co-ed unit for adults. This results in a safety risk for all adolescent patients.

Findings include:

I. Assessment and treatment of adolescents

A. Record Review

1. Patient 7

The Discharge Summary dated 3/5/18 stated that Patient 7 was a 14 year-old admitted 2/28/18 because of "severe suicidal statements with a plan to hang [her/himself], take pills, or shoot [her/himself]." The Discharge Summary stated "[s/he] was accepted at [another hospital] - Adolescent Psychiatric Unit. . . Over the weekend, [s/he] had a lot of difficulty and was upset that [s/he] was not transferred, writing a suicide note indicating that [s/he] wanted to get shot by a police officer. [S/he] also acted out at times and on one occasion cut [her/himself] superficially in the arm with a paperclip. Today, [s/he] was accepted by [another hospital] - Adolescent Unit . . . When the patient heard that [s/he] would be going, [s/he] felt much better." The Psychiatric Progress Note dated 3/3/18 at 1:15 p.m. stated "[S/he] looks forward to adolescent programming at the other facility. . . [S/he] needs transfer to a psychiatric facility specializing in the care of adolescents. . . Plan: . . . Transfer to an adolescent facility as soon as possible." The Psychiatric Progress Note dated 3/4/18 at 12:01 p.m. stated "[S/he] hopes that [her/his] behaviors will not prevent [her/him] from being transferred to an adolescent facility. . . Assessment: . . . [S/he] needs transfer to an adolescent unit for safety. . . Plan: . . . Transfer to an adolescent facility as soon as possible for inpatient stabilization" The Discharge Summary dated 3/5/18 stated that Patient 7 was discharged on 3/5/18 to be admitted to an adolescent psychiatric inpatient unit. There was no documentation that Patient 7 received an evaluation or treatment during this hospitalization based on age-specific psychiatric needs.

2. Patient 12

The Discharge Summary dated 3/8/18 stated that Patient 12 was a 17 year-old admitted 3/6/18 after Patient 12 "tried to overdose with prescriptions. Today, [s/he] tried to electrify [her/himself] in a bathtube [sic] half full of water. [S/he] had first tried a hair straightener and then a four-slice toaster. [S/he] fault [sic] the shocks but not strong. [S/he] then wanted to drown in a local lake." The Discharge Summary stated "When I asked [her/him] if [s/he] would consider antidepressants, especially if they would improve [her/his] depression as well as [her/his] motivation, [s/he] was open to the idea. I told [her/him] that I would not be able to start [her/him] on antidepressants as [s/he] soon will be transferred to an appropriate adolescent unit." The Discharge Summary dated 3/8/18 stated that Patient 12 was discharged on 3/8/18 to be admitted to an adolescent psychiatric inpatient unit. There was no documentation that Patient 12 received an evaluation or treatment during this hospitalization based on age-specific psychiatric needs.

3. Patient 13

The Discharge Summary dated 3/12/18 stated that Patient 13 was a 14 year-old admitted 3/8/18 and found to have "a suicidal plan with intent." The Discharge Summary stated "[S/he] understands that [s/he] is in our facility waiting to be transferred to an appropriate adolescent psychiatric unit. . . The patient was not started on any antidepressant mediations since I felt that [s/he] would be transferred to an adolescent unit and be evaluated by an adolescent psychiatrist who would start [her/him] on the most appropriate medications." The Psychiatric Progress Note dated 3/10/18 at 11:19 a.m. stated "Assessment: [S/he] is struggling with severe chronic depression and can benefit from evaluation by a child and adolescent psychiatrist. [S/he] needs transfer to an adolescent facility as soon as possible." The Psychiatric Progress Note dated 3/11/18 at 11:45 a.m. stated "Assessment: Patient is struggling with some family strain. It is difficult to determine the story. I suspect there may be some difficulties at home. This should be evaluated by a child and adolescent specialist who can work with the family to determine the best plan for the patient. [S/he] had severe depression with serious suicidal ideation and can likely benefit from ongoing treatment initiated in hospital. [S/he] should transfer to an adolescent facility as soon as possible. . . Plan: Transfer to adolescent psychiatric facility as soon as possible. . ." The Discharge Summary dated 3/8/18 stated that Patient 13 was discharged on 3/12/18 to be admitted to an adolescent psychiatric inpatient unit. There was no documentation that Patient 13 received an evaluation or treatment during this hospitalization based on age-specific psychiatric needs.

4. Patient 14

The Discharge Summary dated 3/14/18 stated that Patient 14 was a 17 year-old admitted 3/11/18 because of "concern about depression and having thoughts of suicide." The Discharge Summary stated "I did inform the patient that even though [s/he] was not expressing thoughts of suicide, I still feel uncomfortable discharging [her/him] from an inpatient unit without the benefit of an opinion from an adolescent psychiatrist." The Psychiatric Progress Noted dated 3/12/18 (no time) stated "Recommendations: . . . Transfer the patient to an appropriate adolescent psychiatric unit." The Psychiatric Progress Note dated 3/13/18 (no time) stated "I testified today that I felt [s/he] continued to need inpatient treatment and to be evaluated by an adolescent psychiatrist to determine [her/his] overall care and further management." The Discharge Summary dated 3/14/18 stated that Patient 14 was discharged on 3/14/18 to be admitted to an adolescent psychiatric inpatient unit. There was no documentation that Patient 14 received an evaluation or treatment during this hospitalization based on age-specific psychiatric needs.

5. Patient 15

The Discharge Summary dated 3/23/18 stated that Patient 15 was a 15 year-old admitted 3/21/18 because of "suicidal threats." The Discharge Summary stated "[S/he] was informed that I am not an adolescent psychiatrist and that [s/he] is on our unit pending transfer to an adolescent psychiatric unit. [S/he] has been refusing to see staff members." The Discharge Summary dated 3/23/18 stated that Patient 15 was discharged on 3/23/18 to be admitted to an adolescent psychiatric inpatient unit. There was no documentation that Patient 15 received an evaluation or treatment during this hospitalization based on age-specific psychiatric needs.

6. Patient 16

The Discharge Summary dated 3/14/18 stated that Patient 16 was a 17 year-old admitted 3/12/18 "after [s/he] attempted to commit suicide by cutting [her/himself] and hanging [her/himself]." The Discharge Summary stated "No adolescent beds were available and [s/he] was admitted to [the facility] with the assumption that [s/he] would be transferred to an adolescent unit for further treatment." The Discharge Summary dated 3/14/18 stated that Patient 16 was discharged on 3/14/18 to be admitted to an adolescent psychiatric inpatient unit. There was no documentation that Patient 16 received an evaluation or treatment during this hospitalization based on age-specific psychiatric needs.

B. Document Review

1. An email from the DON to the CEO and the Nurse Manager dated 3/15/18 at 2:56 p.m. regarding adolescent inpatients stated ". . . We are not a treatment facility just a detention facility so they [adolescent patients] receive no active treatment. . . We no longer have an adolescent psychologist on staff. And we don't have an adolescent psychiatrist."

2. An email from the Medical Director to the CEO dated 4/10/18 at 12:56 p.m. stated "It is difficult to have both adults and adolescents on the same unit. They require different programming. They cannot be on the same unit as adult Sex offenders. Also, they should be seen by C and A [child and adolescent] Psychiatrists with respect to treatment and disposition and the training is different for both specialties. Even if I was double boarded, I would still have to send kids to hospitals or units that treat kids."

C. Staff Interview

1. During interview on 4/25/18 at 11:20 a.m., COTA 1 reported that there may be as many as 3 adolescents hospitalized for a short period of time, but there were usually 1-2 adolescent patients at any given time. COTA 1 reported that "adolescent patients come to the regular groups (with the adult patients)." She stated that if she were to conduct groups for adolescents without adults, she would design the content and methods differently than the current programming. COTA 1 stated that she did not conduct adolescent-specific groups since the adolescents attend the adult groups and activities.

2. During interview on 4/25/18 at 11:45 a.m. the Director of Social Work stated, "It would be better if the adolescent patients went directly to an adolescent facility. They need different services than adult patients." She verified that the adolescent patients attended groups and activities with adult patients.

3. During an interview on 4/25/17 at 2:10 p.m., the Director of Nursing stated that she had "concerns" about admitting adolescent patients to a unit with adult patients. She stated that separate units for adolescents and adults were "overall better for the safety of all the patients (adults and adolescents)." She stated that she presented a list of her concerns about mixing adolescent and adult patients to the CEO for presentation to the county Health and Human Services Committee.

4. During interview on 4/25/18 at 3:30 p.m., when asked about the admission of adolescent and adult patients to the same unit, the Medical Director stated, "We are addressing that issue. We are going to suggest to the Department of Health and Human Services that we no longer admit adolescents here." He stated "They [adolescent patients] are here in a holding area pending disposition." He stated "In another place [where he was employed], we would rely on adolescent psychiatrists. I am not certified in Child and Adolescent. This is a high risk group. It would be nice if we had a child and adolescent psychiatrist to do assessments. We do not have this luxury."

II. Active Treatment

A. Unit Description

The certified patient care unit was a 16-bed unit with patients from ages 12 and older. Patients had varied levels of acuity and needs/problems including suicide, psychosis, drug disorders, adjustment disorders, anxiety, etc. Due to this wide range of age groups and treatment needs, a greater number and varied options of structured groups/activities were required to meet the patient needs.

B. Group Schedule

A review of the group/activity schedule for the patient care unit revealed only 3 structured groups daily scheduled 45 minutes to 1 hour each 7 days/week. There were no additional groups/activities scheduled other than goal groups conducted by the mental health technicians and "leisure time." There were no formal groups after 3:15 p.m.

C. Observation

During the time of the scheduled social work group, "Emotion Regulation," on 4/24/18 at 12:45 p.m., no group was being conducted. Patient 3 was observed sitting alone in the dayroom coloring. Patient 5 was observed lying in his bed.

D. Staff Interview

1. During interview on 4/25/18 at 11:20 a.m., COTA 1 (Certified Occupational Therapy Assistant) reported that there were only 3 scheduled groups/activities daily for the patients. Two of these daily groups were conducted by a COTA staff member. She verified that some of the groups were cancelled. She added that when this occurs, the staff spend time with each patient.

2. During interview on 4/25/18 at 11:40 a.m., the Director of Social Work verified that one patient group was conducted by social work staff each day. She stated that they were trying to provide more scheduled groups by social work staff. She verified that no scheduled groups were held after 3:00 p.m. each day.

3. During interview on 4/25/18 at 2:15 p.m. the DON verified that formal groups were not offered by RNs, only medication education on an individual basis.

III. Management and care for patients who present with physical violence

A. Policy Review:

1. Facility policy, "Security on Admissions Unit (3/29/18)" states: "Law enforcement support: a. There may be an occasion when law enforcement may be called to support and assist with an extremely violent patient ... b. Staff needs to clearly communicate to law enforcement the internet of why they are being asked to assist (i.e.: help with a violent patient to administer an injection, conduct and investigation of disorderly conduct on the unit, or address a criminal act on grounds. c. Although we can ask law enforcement to leave their weapons in their vehicle under Wisconsin Chapter 941.235, it is the policy that law enforcement are permitted to enter Norwood Health Center with their weapons in the line of duty."

2. Review of policy, "Weapons Management At Norwood (5/31/17)," stated "The presence of weapons are not allowed on the hospital unit. The use of weapons is not considered a safe healthcare intervention and is not to be used as a means of subduing a patient in order to place the patient in restraints or seclusion on the unit. Weapons are not permited [sic] to be in the building unless in control of law enforcement for the course of their work duty ...Firearms are not to be used within the building, or on the grounds, unless there is a reasonable indication as determined by Law Enforcement. Although it is the expectation that no guns or weapons will be brought on the unit, Norwood recognizes the rights of Law Enforcement to not have to relinquish their weapons while on duty. Law enforcement will need to use their professional judgement [sic] based on training and experience ...Law enforcement have [sic] specific reasons to be present on or around the unit. a. Dropping off patients. This will occur in the ancillary area located at the back of the unit. It is preferred, unless the clinical indication is there, that the police do not enter the unit with the patient. Law enforcement should be searching all patients prior to admission. Staff on the hospital unit will conduct a second search, and if the patient is not cooperative, law enforcement may need to assist ...c. Rare incidents. Law enforcement personnel may be called upon to respond to situation that are beyond the control of the psychiatric staff ...If law enforcement is called on those rare incidences beyond our control, Administration may request charges be made against that individual."

B. Interview:

1. During interview on 4/24/18 at 2:45 p.m., RN 1 reported that when 911 was called in emergency situations, the local police come (to the facility). She stated, "In my history when patients are dropped off at the unit by the police and the patient is not cooperative, the police may assist (staff) with the body search."

2. During interview on 4/25/18 at 8:10 a.m., the Director of Nursing (DON) reported that the RN on the unit decides when to call the police for assistance with a patient. When asked what the police do to assist staff, she responded "We expect the police to help out, support staff and help to move the patient to the seclusion room if needed." The DON reported that she was not sure what weapons the police carry, and added, "I think they carry a Taser and handcuffs." She stated, "If the patient is very agitated (when they are dropped off at the unit by police) sometimes the police bring patients onto the ward or take a patient to the seclusion room (located on the locked patient care unit) and uncuff them there." The DON verified that some patients have reacted to the police in uniform.

IV. Safety of adolescents admitted to the general psychiatric co-ed unit for adults

A. Policy Review

Facility policy, "Security on Admissions Unit (3/29/18)" states: "Adolescents will be roomed in the main pod in the main nursing area for better visibility to staff. Nurses will be responsible for the room placement of all adolescents on the unit."

B. Patient Unit Overview

Observation of the patient care unit on 4/24/18 and 4/25/18 revealed a 16-bed unit with 2 patient wings with a large dayroom and nursing station between the wings. Additional patient rooms are along the side of the center dayroom. Male adult patients were assigned to one wing and female adult patients to the opposite wing. Adolescents were assigned to the rooms off of the central dayroom. The patient rooms could not be seen from the central dayroom.

A review of admissions to the facility provided by administration revealed that 11 of 39 (28 %) patient admissions during the month of March 2018 were adolescent patients.

C. Interview and Observation

1. During interview with observations of the patient care unit layout and location of bedrooms on 4/25/28 at 10:30 a.m., RN 1 verified the assignment of rooms as described above in section B. She reported that on the night shift when there were only 3 nursing personnel on duty, one Mental Health Technician (MHT) was assigned the 5 or 15-minute monitoring checks for all patients on the unit. The second technician completes paperwork or light unit cleaning duties (wiping furniture, sweeping the floor, etc.). RN 1 verified that a patient could go on in "an area of the unit where they were not supposed to go" since all areas and patient doors cannot be seen from the central dayroom in front of the nursing station.

2. During interview on 4/25/18 at 2:15 p.m., the DON reported that hospital administration had prepared data to support a request to the Department of Health and Services to support that adolescents no longer be admitted to the Norwood facility.
A review of this report provided by the Director of Nursing revealed the following statements: "It is difficult to have both adults and adolescents on the same unit. They require different programming. They cannot be on the same unit as adult Sex Offenders." "It is not safe for the adolescents when we have really sick adults patients [sic] on the same unit." "It is not safe ...with more and more violent patient's [sic] being referred to the unit to have a 12 year-old or above on a psychiatric unit with sex offenders, psychotic adults, or patients who are grossly intoxicated."

3. During interview on 4/25/18 at 3:30 p.m., when asked about the admission of adolescent patients to the adult unit the Medical Director stated, "We are addressing that issue. We are going to suggest to the Department of Health and Human Services that we no longer admit adolescents here." He reported, "We have had a situation where an adult patient on the unit was a sexual predator. We didn't know he had a class 4 felony charge against him. We had to rapidly move the adolescent patient off of the unit." When the Medical Director was asked whether he thought that safety issues are present when adolescents and adults are placed on the same patient unit, he stated, "Yes, absolutely."

Based on interview and record review, the facility failed to provide a Discharge Summary for each patient who had been discharged that included a recapitulation of the patient's hospitalization including assessments, treatments, and synopsis of accomplishments achieved as reflected through the treatment plan for five (5) of five (5) discharged patients (Patients 7, 8, 9, 10, and 11). This deficiency results in a failure to communicate, in a timely manner, psychiatric assessments, treatments, and discharge plans with providers providing follow-up care.

Findings include:

A. Record review

The Discharge Summaries (dates in parentheses) failed to include a recapitulation of the patients' hospitalization as follows:

1. For Patient 7, the Discharge Summary (3/5/18) stated "The patient was treated on the inpatient psychiatric unit (Admissions Unit) with individual therapy, group therapy, activities therapy, milieu therapy, as well as medication restabilization. By the time of discharge, [s/he] was receiving all the medications that were ordered on 03-02-2018 and probable cause was found . . . Over the weekend, [s/he] had a lot of difficulty and was upset that [s/he] was not transferred, writing a suicide note indicating that [s/he] wanted to get shot by a police officer. [S/he] also acted out at times and on one occasion cut [her/himself] superficially in the arm with a paperclip. . . When the patient heard that [s/he] would be going, [s/he] felt much better, although [s/he] still had some passive suicidal thoughts but was able to contract for [her/his] safety. Because of the letter, [s/he] was on a 1:1 at night." This Discharge Summary did not contain further documentation of assessments, treatments, or synopsis of accomplishments achieved as reflected through the Treatment Plan.

2. For Patient 8, the Discharge Summary (3/5/18) stated "The patient was treated on the inpatient psychiatric unit (Admissions Unit) with individual therapy, group therapy, activities therapy, milieu therapy, as well as medication restabilization. By the time of discharge, [s/he] was receiving Abilify, 15 mg per day; [s/he] tolerated this well without side-effects. [S/he] was able to slowly reintegrate. [Her/his] psychotic symptoms completely went away and [s/he] was in good reality contact. [Her/his] family visited [her/him] and [s/he] was able to reconcile with partner/ex-[wife/husband] and [her/his] children." This Discharge Summary did not contain further documentation of assessments, treatments, or synopsis of accomplishments achieved as reflected through the Treatment Plan.

3. For Patient 9, the Discharge Summary (3/19/18) stated "The patient was treated on the inpatient psychiatric unit (Admissions Unit) with individual therapy, group therapy, activities therapy, milieu therapy, as well as medication restabilization. By the time of discharge, the patient was receiving Seroquel, Lamictal, and Lorazepam prn; no side-effects were noted. [S/he] was able to reintegrate fairly well and felt stable at the time of discharge." This Discharge Summary did not contain further documentation of assessments, treatments, or synopsis of accomplishments achieved as reflected through the Treatment Plan.

4. For Patient 10, the Discharge Summary (3/20/18) stated "The patient was treated on the inpatient psychiatric unit (Admissions Unit) with individual therapy, group therapy, activities therapy, milieu therapy, as well as medication restabilization. By the time of discharge, [s/he] was receiving Olanzapine, 30 mg per day. For the greater part of [her/his] hospitalization, [s/he] remained quite psychotic and was selectively mute. However towards the end of the hospitalization when we began to consider discharge to [county health center], the patient finally began to talk coherently. . ." This Discharge Summary did not contain further documentation of assessments, treatments, or synopsis of accomplishments achieved as reflected through the Treatment Plan.

5. For Patient 11, the Discharge Summary (3/20/18) stated "The patient was treated on the inpatient psychiatric unit (Admissions Unit) with individual therapy, group therapy, activities therapy, milieu therapy, as well as medication restabilization. By the time of discharge, [s/he] was receiving Risperdal, 1 mg in the evening. [S/he] tolerated the medications well without side-effects. Overall, [s/he] had a good hospital stay. [S/he] opened up after the Risperdal was initiated. [S/he] participated in groups and activities. [S/he] was willing to follow up with the after-care plans arranged by Social Services." This Discharge Summary did not contain further documentation of assessments, treatments, or synopsis of accomplishments achieved as reflected through the Treatment Plan.

B. Interview:

During interview with the Medical Director on 4/25/18 at 3:30 p.m., he acknowledged that the medical record for Patients 7, 8, 9, 10, and 11 did not contain a Discharge Summary that contained a recapitulation of the patient's hospitalization including assessments, treatments, and a synopsis of accomplishments achieved as reflected through the Treatment Plan.

Based on observation, interview, and document review, the Medical Director and the Director of Nursing failed to monitor active treatment and take corrective actions. Specifically, there was failure to:


I. Ensure the assessment and treatment of adolescents based on their age-specific psychiatric needs for 6 of 6 discharged Patients (7, 12, 13, 14, 15, and 16) reviewed for treatment. This failure resulted in patients being hospitalized without age-specific assessments and treatments being provided in a timely fashion and potentially delaying improvement. (Refer to B144 Part V)

II. Provide sufficient numbers of structured therapeutic groups/activities to meet the needs of the patient population. In addition, some of the scheduled groups were cancelled. This failure hinders patient's participation in active treatment and results in patients roaming the unit, sleeping in their bedrooms, and idly sitting around on the unit. (Refer to B144 Part VI and B148 Part I)

III. Ensure that staff were sufficiently trained to manage and care for patients who present physical violence in the clinical area. By facility policy, staff may call the local city police for assistance in managing and caring for patients with aggressive behaviors. In addition, while on the patient care unit the police may be armed with weapons such as guns and Tasers. This practice results in a) a conflict between treatment and law enforcement actions and b) a potential breach in the patient's right that care and interventions be delivered by health care professionals in a therapeutic treatment environment. In addition, the presence of weapons on the patient care unit results in a safety risk for all patients and staff. (Refer to B144 Part VII and B148 Part II)

IV. Ensure that Adolescent patients were safe during hospitalization. Adolescent patients were admitted to the facility on "emergency involuntary detention" for up to 72 hours (excluding week-ends and holidays) and are transferred to an adolescent facility or discharged after their "probable cause" hearing is held. The adolescent patients were housed on the 16-bed certified general psychiatric co-ed unit for adults. This results in a safety risk for all adolescent patients. (Refer to B144 Part VIII and B148 Part III)

Based on observation, record review, and interview, the Medical Director failed to:

I. Ensure that 6 of 6 active sample patients (1, 2, 3, 4, 5, and 6) received a Psychiatric Evaluation containing sufficient information to justify diagnoses and planned treatment. This failure results in a lack of patient information necessary for the treatment team to formulate an appropriate master treatment plan. (Refer to B110)

II. Ensure that the Psychiatric Evaluation for 1 of 6 active sample patients (5) was completed within 60 hours of admission. This failure delays the availability of the Psychiatric Evaluation and a substantiated diagnosis for use in the development of the treatment plan. (Refer to B111)

III. Ensure that Psychiatric Evaluations included an estimate of memory functioning in measurable, behavioral terms for 6 of 6 sample patients (1, 2, 3, 4, 5, and 6). This failure results in the absence of cognitive impairment data for use in diagnosis and treatment and does not allow for the assessment of changes in cognitive impairment during treatment or at the time of possible future hospitalizations. (Refer to B116)

IV. Ensure that the Psychiatric Evaluations for 4 of 6 active sample patients (1, 2, 4, and 5) included an inventory of descriptive patient assets that could be used in treatment planning. Failure to identify patient assets impairs the ability of the treatment team to develop interventions using the individual strengths of each patient. (Refer to B117)

V. Ensure the assessment and treatment of adolescents based on their age-specific psychiatric needs for 6 of 6 discharged Patients (7, 12, 13, 14, 15, and 16) reviewed for treatment. This failure resulted in patients being hospitalized without age-specific assessments and treatments being provided in a timely fashion and potentially delaying improvement. (Refer to B125 Part I)

VI. Provide sufficient numbers of structured therapeutic groups/activities to meet the needs of the patient population. In addition, some of the scheduled groups were cancelled. This failure hinders patient's participation in active treatment and results in patients roaming the unit, sleeping in their bedrooms, and idly sitting around on the unit. (Refer to B125 Part II)

VII. Ensure that staff were sufficiently trained to manage and care for patients who present physical violence in the clinical area. By facility policy, staff may call the local city police for assistance in managing and caring for patients with aggressive behaviors. In addition, while on the patient care unit the police may be armed with weapons such as guns and Tasers. This practice results in a) a conflict between treatment and law enforcement actions and b) a potential breach in the patient's right that care and interventions be delivered by health care professionals in a therapeutic treatment environment. In addition, the presence of weapons on the patient care unit results in a safety risk for all patients and staff. (Refer to B125 Part III)

VIII. Ensure that Adolescent patients are safe during hospitalization. Adolescent patients are admitted to the facility on "emergency involuntary detention" for up to 72 hours (excluding week-ends and holidays) and are transferred to an adolescent facility or discharged after their "probable cause" hearing is held. The adolescent patients are housed on the 16-bed certified general psychiatric co-ed unit for adults. This results in a safety risk for all adolescent patients. (Refer to B125 Part IV)

IX. Provide a discharge summary for each patient who had been discharged that included a recapitulation of the patient's hospitalization including assessments, treatments, and a synopsis of accomplishments achieved as reflected through the treatment plan for 5 of 5 discharged patients (7, 8, 9,10, and 11). This deficiency results in a failure to communicate, in a timely manner, psychiatric assessments, treatments, and discharge plans with providers providing follow-up care. (Refer to B133)

Staff Interview

During an interview with the Medical Director on 4/25/18 at 3:30 p.m., the Medical Director acknowledged that the only monitoring of documentation and treatment provided by physicians was through the medical records department and through informal observations. He acknowledged that he conducted no formalized and documented qualitative monitoring of physician services.

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

I. Provide sufficient numbers of structured therapeutic groups/activities to meet the needs of the patient population. In addition, some of the scheduled groups were cancelled. This failure hinders patient's participation in active treatment and results in patients roaming the unit, sleeping in their bedrooms, and idly sitting around on the unit. (Refer to B125, Part II)

II. Ensure that staff were sufficiently trained to manage and care for patients who present physical violence in the clinical area. By facility policy, staff may call the local city police for assistance in managing and caring for patients with aggressive behaviors. In addition, while on the patient care unit the police may be armed with weapons such as guns and Tasers. This practice results in a) a conflict between treatment and law enforcement actions and b) a potential breach in the patient's right that care and interventions be delivered by health care professionals in a therapeutic treatment environment. In addition, the presence of weapons on the patient care unit results in a safety risk for all patients and staff. (Refer to B125 Part III)

III. Ensure that Adolescent patients are safe during hospitalization. Adolescent patients are admitted to the facility on "emergency involuntary detention" for up to 72 hours (excluding week-ends and holidays) and are transferred to an adolescent facility or discharged after their "probable cause" hearing is held. The adolescent patients are housed on the 16-bed certified general psychiatric co-ed unit for adults. This results in a safety risk for all adolescent patients. (Refer to B125 Part IV)

IV. Ensure that specific interventions to guide personnel in the provision of nursing care were documented on the treatment plans of 6 of 6 active sample patients (1, 2, 3, 4, 5 and 6). This resulted in the absence of interventions to guide nursing personnel in the implementation and evaluation of the care, especially for patients with violence toward self and/or others.

Findings include:

A. Record Review:

1. Patient 1 (Initial treatment plan dated 4/22/18-MTP not due until 4/26/18):

a. For the problem, "Ineffective coping R/T [related to] wanting to kill [himself/herself] due to a break up with [his/her] [boyfriend/girlfriend," a generic nursing intervention was stated as "Assess if ineffective coping endangers the resident and/or others." There were no specific safety interventions to direct nursing personnel addressing this patient's suicidal behaviors.

b. For the problem, "Has risk for injury to self manifested by having a plan to stab [himself/herself] in the stomach," other than safety monitoring checks there were no specific safety interventions to direct nursing personnel addressing this patient's suicidal behaviors.

2. Patient 2 (MTP dated 4/19/18):

a. For the problem, "Had a plan to overdose on medication in a suicide attempt," a nursing intervention was stated as "Nursing will assess [Patient] for suicidal thoughts everyday related to [his/her] plan to overdose. Nursing will provide 1:1 time and inform the doctor. Nurse will adjust safety level accordingly." There were no additional nursing interventions to direct nursing personnel in monitoring and care for this patient based on suicidal thoughts/behaviors.

b. For the problem, "Has been cutting himself/herself more frequently," there were no safety interventions identified by nursing to address this behavior in the clinical area.

3. Patient 3 (Initial treatment plan dated 4/23/18-MTP not due until 4/27/18):

For the problem, "Has multiple mental breakdowns with multiple psychiatric hospitalizations related to past hx [history] of depression and traumatic past," generic nursing interventions were stated as "Encourage [Patient] to become involved with activities: Group discussion and activities with other peers," "Encourage physical activity to maximal potential," and "Provide comfortable environment to promote sleep (e.g. clean bedding, comfortable bed clothing, incontinence care, comfortable temperature, ventilation, etc."

4. Patient 4 (MTP dated 4/17/19):

a. For the problem, "Reported suicidal thoughts," other than the usual role function, assessment, and level of safety checks required, there were no safety interventions to direct nursing personnel in the care of this patient in the clinical area.

b. For the problem, "Verbal and physical aggression," the only nursing intervention listed was "Assess whether the behavior endangers [Patient] and or others. Intervene if necessary." There were no additional safety interventions to direct nursing personnel in the care of this patient in the clinical area

5. Patient 5 (MTP dated 4/1/18):

a. For the problem, "Suicidal ideation of just wanting to be dead," the only nursing safety intervention was "Nursing will assess daily for statements of suicide related to stating his goal is to be dead, Nursing will offer 1:1 if necessary." There were no additional interventions to address safety in the clinical area.

b. For the problem, "Inability to engage in rational/reality based conversation," a nursing intervention was listed as "Nursing will monitor [Patient] for any negative behavior such as agitation, anxiety or verbally aggression related to delusional behavior and off PRNs if necessary." There were no interventions to direct nursing personnel in their response to the delusional comments.

6. Patient 6 (MTP dated 4/13/18):

For the problem, "Admitted to hearing voices and seeing things that others cannot see ...
Admits to being depressed ...," a nursing intervention was stated as "Nursing will encourage [Patient] to come to staff if the voices are getting worse related to [him/her] stating that the voices are louder at night. Nursing will notify the doctor and provide a quiet area for [Patient] if indicated." There were no interventions to direct nursing personnel in methods to assist the patient to deal with his/her hallucinations, instead the patient was sent to an area alone to deal with these symptoms.

B. During interview on 4/25/18 at 2:15 p.m., the DON stated agreed that some nursing interventions need to be more individualized.

Based on record review and staff interview, the Director of Social Work failed to ensure the provision of thorough and comprehensive social work Assessments for six (6) of six (6) active sample patients (Patients 1, 2, 3, 4, 5, and 6). Social work Assessments failed to include interviews with family members and other significant collateral sources to obtain a current and factual clinical history. The social work Assessment also failed to include a social evaluation of strength/deficits and high-risk psychosocial issues, conclusions, recommendations of the anticipated necessary steps for discharge to occur, and specific community resources/support systems for utilization in discharge planning. In addition, the anticipated social work role in treatment was not identified in Assessments. As a result, the treatment team did not have necessary social information and evaluation of social functioning level to utilize in developing treatment goals and interventions. (Refer to B108)

Staff Interview

During an interview with the Director of Social Work on 4/25/18 at 11:45 a.m., she stated that she did not monitor the quality of social work services including the Psychosocial Assessments.