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Based on review of the Unit Dose Packaging policy, review of the Unit Dose Packaging log, and interviews, the pharmacy personnel failed to ensure expiration dates assigned to repackaged medications did not exceed manufacturer expiration dates for five of five repackaged medications (Cymbalta 60 milligrams (mg), Lexapro 5 mg, Fenfofibrate 160 mg, Mucinex ER 600 mg, Ceftin 250 mg), which was not in accordance with hospital policy. The potential existed for the repackaged medications to be dispensed to patients in which physician orders had been written.


Findings:


A. The Unit Dose Packaging policy was reviewed on 12/09/15 at 0945. The policy stated "In the absence of stability data for the drug product in the repackaged container, the beyond-use dating period is one year or the time remaining of the expiration date, whichever is shorter. If current stability data are available for the drug product in the repackaged container, the length of time established by the stability study may be used to establish the beyond-use date but must not exceed the manufacturer's expiration date."


B. The Unit Dose Packaging log was reviewed on 12/09/15 at 0955. Five repackaged medication entries were selected for review in which less than one year dating would be required to be assigned as an expiration date to the medications. Five of five entries reflected expiration dates exceeding the manufacturer's expiration date. Findings:

1) Cymbalta 60 mg was assigned an expiration date of 11/27/16 while the manufacturer expiration date was 04/30/16;

2) Lexapro 5 mg was assigned an expiration date of 11/25/16 while the manufacturer expiration date was 06/30/16;

3) Fenfofibrate 160 mg was assigned an expiration date of 11/27/16 while the manufacturer expiration date was 05/30/16;

4) Mucinex ER 600 mg was assigned an expiration date of 11/27/16 while the manufacturer expiration date was 07/31/16; and

5) Ceftin 250 mg was assigned an expiration date of 11/20/16 while the manufacturer expiration date was 10/31/16.


C. During interview on 12/09/15, at 1030, the Director of Pharmacy verified the expiration dates had been assigned to repackaged medications exceeding manufacturer expiration dates.

Based on observations, interviews, review of environmental rounding documents, electronic mails, and policy and procedure review, it was determined that the facility was aware in January, February, and October 2015, of identified concerns for the cleanliness of the facility. Based on surveyor observations from 12/07/15 through12/10/15, it was determined that the facility failed to develop and implement a plan of action to ensure the facility was clean and sanitary (dusty, soiled floors and patient furniture, bathrooms, trash in floor, etc.) in all patient care areas. Failure to ensure the facility maintained a clean and sanitary environment had the potential to allow proliferation of bacterial and viral illnesses, disease and illness cross contamination between patients, staff and visitors. The failed practice also had the potential of hindering the recovery of patients per its policy and procedure titled "Infection Control Guidelines: Environmental Services". See CMS A-0748 and A-0749.

Based on interview, it was determined that the Infection Control Nurse failed to develop policies and procedures relevant to construction, renovation, maintenance, demolition and repair. The failed practice did not allow the facility to be assured that no transmission of illnesses, bacterial or viral infections could occur. The failed process had the potential to affect any patient, staff or visitor during a construction process.


Findings:


During an interview with the Infection Control Nurse at 1020 on 12/09/15, she stated there were no policies or procedures addressing Infection Control processes during construction, renovation, maintenance, demolition or repairs made in the facility.



Based on interview and review of Employee Health Orientation packet, it was determined that the facility failed to develop and implement well-defined policies and procedures defining when sick employees were able to work. The failed practice had the potential to allow transmission of illnesses to patients, staff and visitors. The failed practice affected all employees and patients. Findings:


A. During an interview with the Infection Control Nurse at 1410 on 12/08/15, she stated the facility did not have a policy or procedure addressing when potentially infectious personnel were able to work and provide direct patient care.

B. Review of the Employee Health Orientation packet revealed the following on page 2 under "Employee Illness: 1. May not work if infectious." During the above interview the findings were verified by the Infection Control Nurse.



Based on review of policies and procedures, and interview, it was determined that the Infection Control Officer failed to ensure the Infection Control Committee approved all disinfectants used at the facility. The failed practice did not ensure disinfectants utilized in the facility were effective against any potential infectious agent. The failed practice affected all patients, visitors and staff. Findings:


A. Review of the policy and procedure titled "Medical Equipment Cleaning" received from the Infection Control Nurse at 0840 on 12/08/15, revealed the following: "...III: The Infection Control Committee must approve all disinfectants used at the hospital ..."

B. During an interview with the Chief Nursing Officer and Director of Risk Management at 1020 on 12/10/15, they stated the cleaning agents utilized in the facility had not been approved by the Infection Control Committee.

Based on observations, policy and procedure review, and interview, it was determined that the facility failed to ensure the environment was clean and sanitary (dusty, soiled floors and patient furniture, etc.) for 5 of 5 Units (Intake/Emergency, Geropsyche, Women's, and Adult and Adolescent) and one of two clean linen rooms. Failure to ensure the facility was clean and sanitary had the potential for the transmission and cross-contamination of bacteria and viruses to patients, staff and visitors. The failed practice affected all in-patients on 12/10/15. Findings:


A. The following observations were made by Surveyor #1 during her initial tour on 12/07/15, from 1300 to 1530, and confirmed by the Director of Clinical Services and the Chief Nursing Officer during the tour:

1) Intake/Emergency Areas:

a) Assessment Room #1 - desk chair arms peeling off which were uncleanable, three soiled cloth chairs.

b) Assessment Room #2 - three soiled cloth chairs.

c) Assessment Room #3 - Desk chair arms peeling off which were uncleanable, two soiled cloth chairs, Dinamap with heavy accumulation of dust over the base surface.


2) Geropsyche Unit:

a) Laundry Room - three wheelchairs and one bariatric chair all with dust accumulation, cracks and torn areas in the vinyl seat and back which were not cleanable and five walkers all with dust accumulation.

b) Time out room - toilet paper roll on the bathroom floor.

c) Room 103 - bathroom shower stool dusty, top of cabinets on A and B sides with thick dust accumulation and two soiled cloth chairs.

d) Room 102 - Top of cabinets on A and B sides with thick dust accumulation and two soiled cloth chairs.

e) Quiet Room - two tan vinyl chairs with rips on back and one cloth chair with rips which were not cleanable, soiled Merry Walker with soiled Velcro strap, and Hoyer lift/scale with lift pads hanging over the lift and touching the floor.

f) Family Room - floor soiled with unknown substance/stains.

h) Group Room - Detecto wheelchair scale soiled and with dust accumulation, Linen cart containing towels and gowns with multiple rips in the vinyl cover, O2 (oxygen) concentrator dusty and the floor carpet was soiled with unknown substance/stains.


3)Adult Unit:

a) Laundry Room - floor dusty.

b) Seclusion Room - mattress soiled, cloth-type house shoe found under the mattress, floor with dust and trash, clear observation door window soiled and smeared. Soiled cloth chair in the bathroom.

c) Group Room - 3 of 18 cloth chairs with rips on seat and back which were uncleanable. There was trash on the floor and soiled with unknown substance/stains.

d) Room 112 - (empty and ready for occupancy per the Director of Clinical Services at 1430), top of cabinets on A and B sides with thick dust accumulation, two soiled cloth chairs, 2 1/2 by 1 inch cracker on the wood ledge behind the C-pap container mounted at the bedside between the A and B beds, and bathroom shower curtain soiled.

e) Room 114 - (empty and ready for occupancy per the Director of Clinical Services at 1435) top of cabinets on A and B sides with dust accumulation, and two soiled cloth chairs.


4) Adolescent Unit

a) Observation Room - was reported not to have been used in several weeks but a cracker wrapper, used band-aid, paper and dust were observed on the floor.

b) Room 203 - (clean and ready for use per Director of Clinical Services) floor soiled with scuff marks and dust. The tops of cabinets A and B had dust accumulation and two soiled cloth chairs.

c) Room 207- (clean and ready for use per Director of Clinical Services) Top of cabinets A and B had thick dust accumulation and two soiled cloth chairs.


5) Women s Unit

a) Time out/seclusion Room - dust in floor, soiled cloth chair in the bathroom at 1502.

b) Day Room - four of seven cloth chairs soiled.

c) Group Room - five plastic molded chairs with soiled cloth inserts, three soiled cloth chairs, and three soiled bean bag chairs

d) Room 211-- (clean and ready for use per Director of Clinical Services at 1508), Top of cabinets A and B had dust accumulation and two soiled cloth chairs; C-pap box unlocked for inspection - floor of box with an accumulation of plastic shavings, paper and dust. Bathroom shower was soiled as well as shower curtain. Toilet bowl cracked.

e) Room 213 - (clean and ready for use per Director of Clinical Services), Top of cabinets A and B had dust accumulation and three soiled cloth chairs.


B. The following observations were made by Surveyor #2 during her initial tour on 12/07/15, from 1530 to 1615 with Registered Nurse (RN) #3. All observations were verified by RN #3 during the tour:

Geropsyche Unit

1) A dead bug was observed in the tray of the ice machine in the Day Room.


2) Room 100 - dirt observed in the bathroom floor, silver tabs off shampoo bottles and toothpaste caps were observed in the floors of the bathroom and shower; splatter was observed on the bathroom mirror; a large area of a sticky pink substance was observed on the mattress and side rail of the B bed, multiple scuff marks, unknown substance/stains and dirt were observed on the floor at 1600.


3) Room 108 - dirt, unknown substance/stains and scuff marks were observed on the floor and dirt was observed in the bathroom floor.


C. The following observations were made by Surveyor #2 from 0900 to 1045 on 12/08/15 with the Infection Control Nurse. All observations were verified by the Infection Control Nurse during the tour:

1) Geropsyche Unit

a) Isolation Room - dirt in the vestibule floor and bunched up toilet paper in the floor by the head of the B bed.

b) Therapy Room #1 - pillowcase in the floor, pillow case lying on the shower chair, oxygen cannula and trash on the floor.

c) Time Out Room (consists of two rooms) - trash as well as unknown substance/stains were observed on the floor of the restraint room; the seclusion room floor was scuffed and soiled with unknown substance/stains.


2) Adult Unit

a) Laundry Room - there was a dryer sheet, lint, and dust bunnies on the floor soiled with unknown substance/stains. There was a thick accumulation of lint in the right dryer door.

b) Time Out Room - soiled cloth chair which was observed in the bathroom and restraint room floors were soiled with unknown substance/stains.

c) Day Room - six of seven cloth chairs stained. One plastic base chair with blue vinyl inset had a thick accumulation of dust, hair, crumbs and dirt along either side of the seat.

d) Day Room Alcove - trash in the floor and floor was soiled with unknown substance/stains.

e) Quiet Room - 1 inch black blob on threshold of door, trash in the floor; 2 of 19 cloth chairs had ripped and torn seats and were badly stained; 15 of the cloth chairs were badly stained. Floor with numerous scuff marks and soiled with unknown substance/stains.


3) Adolescent Unit

a) Exam Room - trash and dust in the floor

b) Room 204 - silver tabs from shampoo bottles in the floor, dust bunnies and trash on the floor, two cloth chairs with dust on the backs of chairs and stains on the seats.



D. During an interview with RN #2 at 1005 on 12/08/15, she stated she sees housekeeping on the Adolescent Unit 2 to 3 times weekly. RN #2 worked straights days Monday through Friday.


E. During an interview with Environmental Services Employee (EVS) #1 at 1025, she stated she tried to get to each unit everyday but was not always able to. EVS #1 stated she splits duties with EVS #2. EVS #1 stated she splits the weekends with EVS #2 cleaning all four patient units on one day and cleaning the rest of the facility the other day.


F. The following observations were made by Surveyor #2 from 0900 to 1045 on 12/08/15 with the Infection Control Nurse. All observations were verified by the Infection Control Nurse during the tour:

1) Women's Unit

a) Day Room - three of eight gold cloth chairs with numerous stains, five plastic base chairs all with dirt, dust, hair, and crumbs along either side of the seat.

b) Alcove - books for reading were observed on the scuffed and floor soiled with unknown substance/stains. Trash was observed on the floor soiled with unknown substance/stains in front of the sink.

c) Group Room - five plastic base chairs were observed to have dust, hair, crumbs and dirt along either side of the seat; floor soiled with unknown substance/stains, scuffed and trash observed on the floor.

d) Hallway between patient rooms was observed to have black spots, dust bunnies and scuff marks along the hall to the exit door.

e) Medication Room - blue cloth chair with beige Coban on the ends of the arms which were not cleanable.


G. During an interview with the Maintenance Director at 1430 on 12/08/15, he stated there were no cleaning schedules because he only had one EVS and one maintenance employee. The Maintenance Director stated "I am basically re-building EVS."


H. Observation of the second floor Clean utility Room, where clean linen carts were stored, at 1045 on 12/08/15, revealed the first and second level ceiling panels were missing from the ceiling allowing exposure to the attic space for two levels up. The above findings were verified by the Infection Control Nurse at 1045 on 12/08/15.


I. During an interview with EVS #2 at 1345 on 12/09/15, he stated in addition to maintenance duties he assisted with housekeeping when he could, he "wands" (checking for metal objects) all visitors during visitation hours, made badges and delivered supplies to the units. EVS #2 stated he alternated weekends with EVS #1. On Saturdays he focused on cleaning units and Sundays he focused on the front of the building. EVS #2 stated discharged rooms were usually cleaned late in the evenings. EVS #2 was asked if the scrubber and buffer worked and he stated "Yes I used to work 2 to 10:30 pm (post meridian) and I used the buffer and scrubber then. Now that I'm on days I have no time to work on the floors." EVS #2 was asked if there was a dedicated schedule for cleaning and he stated no. EVS #2 stated there was only one EVS employee scheduled to work Friday through Monday and two were scheduled Tuesday through Thursday.


J. During an interview with the Maintenance Director at 1530 on 12/09/15, he stated patient rooms were cleaned daily. During the interview, Surveyor #2 showed the Maintenance Director a blank housekeeping schedule (identified the days of the week and tasks to perform each day) that was received from the Director of Risk Management at 0820 on 12/08/15. The Maintenance Director stated the schedule did not work well with a two person rotation and the primary focus was on discharged rooms. Review of the blank housekeeping schedule did not reveal in-patient rooms were in the rotation of daily duties.


K. During an interview with RN #4 at 0905 on 12/10/15, he stated the Mental Health Technicians on each unit should help pick up trash in patient rooms.


L. The following observations were made by Surveyor #2 from 0910 to 1015 on 12/10/15 with the Maintenance Director and all observations were verified by the Maintenance Director during the tour:

1) Women's Unit

a) Day room - three gold cloth chairs, one with ripped seat and all three badly stained. During an interview with the Maintenance Director at 0910 he was asked what the chairs should be cleaned with; the Maintenance Director stated "The cloth chairs are not cleanable and if they were cleaned I guess it would be with some type of carpet cleaner." Eight plastic base chairs were observed to have dirt, lint, hair, crumbs and dust along both sides of the seat cushion.

b) Hallway - the Maintenance Director stated in an interview the halls should be wet mopped in sections every day and then dry mopped. The Maintenance Director stated he did not know when the last time the hallway on this unit was cleaned.


2) Adolescent Unit

a) The floors were heavily soiled with unknown substance/stains, trash, and dust bunnies were observed on the hallway between patient rooms.

b) Room 201 - floor was observed to have scuff marks and was soiled with unknown substance/stains on the floor between the A desk and A bed; dust on the back of the A chair; both cloth chairs in the room had stains on the back rests, the top of the A and B cabinets were noted to have a thick accumulation of dust. A one inch hole in the wall was observed next to the A cabinet. The shower curtain in the bathroom was observed to have a large rust colored stain at the bottom.

c) During an interview with RNs #1 and #2 at 0930 they were asked if patient rooms were cleaned every day and both stated no. RNs #1 and #2 were asked how often the hallway was cleaned and both stated every other day if (NAMED) was here. RN #1 stated she saw the housekeeper on this unit 3 times a week.


3) Geropsyche Unit

a) Isolation Room - dirt still on floor of vestibule.

b) Day Room - banding missing from sink counter, ice machine counter and desk counter.
Time Out Room (consists of two rooms) restraint bed room floor heavily soiled with unknown substance/stains; time out room floor soiled with unknown dark substance/stains.


M. Review of the policy and procedure titled Medical Equipment Cleaning received from the Infection Control Nurse at 0840 on 12/08/15 revealed the following under "VI. SPECIFIC ENVIRONMENT AND EQUIPMENT CLEANING:

Common Areas: (restrooms, countertops, elevators, furniture, televisions, telephones, office equipment, surfaces, meeting rooms and lounges) Cleaned daily and PRN (as needed) by EVS.

Nursing Stations: cleaned daily by EVS

Patient Equipment/items from home: Clean upon arrival and when visibly soiled by Nursing.
Patient Rooms/Other Patient Care Areas: (restrooms, televisions, telephones, bedding, furniture, countertops & surfaces) daily and PRN promptly clean spills of blood and body fluids ASAP (as soon as possible) by EVS.

Beds/patient room/countertops: Clean daily as above by EVS ... "


N. Review of the policy and procedure titled Dayroom Cleaning received from the Director of Risk Management at 0815 on 12/10/15 revealed the following under " POLICY: The dayrooms are normally one of the most frequently used areas of the hospital, usually functioning on a twenty-four hour basis. Because of this, it is also one of the most difficult areas to keep clean and neat. In order to keep these areas within acceptable standards at all times, the upkeep of these areas will be a team effort. The following intra-departmental procedures have been developed to reach this goal.

PROCEDURE:

HOUSEKEEPING

1. Empty trash receptacles into the large barrel located outside each nursing unit on a daily basis.

2. Using a damp-dust detergent, damp wipe all furniture, tables, chairs, couches, televisions, etc. Also use this method on windowsills, ledges, doors, doorknobs, light switches, counters, etc. Use a hand duster for ledges and items above normal reach. After areas are wiped down with the treated detergents, they will be wiped dry with a dry cloth.

3. Windows should be spot cleaned daily and washed as scheduled.

4. Tiled areas should be damp mopped daily and mopped weekly with soapy water.

5. Carpeted areas should be vacuumed daily. Wet vac (vacuum) when needed. ...


MAINTENANCE

1. Maintenance will spray buff or extract dayroom carpets as scheduled or as needed on a monthly basis. "


O. Review of the policy and procedure titled Housekeeper's Patient Room Cleaning Schedule and Duties received from the Director of Risk Management at 0815 on 12/10/15 revealed the following:

"1. All Patient rooms will be cleaned daily.

2. All patient bathrooms will be cleaned and vacuumed daily.

3. Bathroom floors and shower floors of patients diagnosed with Tinea Pedis (athlete ' s foot) will be mopped daily with disinfectant."


During an interview with the Maintenance Director at 1000 on 12/10/15, he stated the above was not being performed.


P. Review of the policy and procedure titled Infection Control Guidelines: Environmental Services revealed the following:

" PURPOSE:

Nosocomial infections may occur as the result of exposure to contaminated surfaces, equipment, air dust and other inanimate objects. The Environmental Service Department's responsibility is to maintain a thoroughly clean environment throughout the hospital. Reducing the pathogens on the many fomites in the hospital helps protect visitors, medical staff, patients, and hospital employees. Moreover, aesthetically pleasing surroundings can improve mental attitudes and speed patient's recoveries. The maintenance of a complete hospital-wide cleaning program increases the awareness of other employees of the necessity of good sanitary practices, as well.

1. RESPONSIBILITIES

1. Environmental Services Director

a. Supervise all activities pertaining to housekeeping.

b. Evaluate products used in Environmental Service and submit information to Infection Control Committee for approval.

c. Member of the Infection Control Committee ...

d. Established and reviews procedures in housekeeping.

e. Provide educational programs for each new employee and to all employees periodically. ...


2. Infection Control Nurse/Coordinator

a. Assist Environmental Service Director in evaluating products, procedures and policies pertaining to infection control.

b. Assist in programs on the role of Environmental Service in infection control

c. Accompany Director on rounds periodically to observe whether proper techniques are being used.


3. Infection Control Committee

a. Establish and review infection control standards for Environmental Services.

Evaluate and approve cleaning products. "


Q. Review of the following Environmental/Infection Control Rounding Concerns for January, February, and October 2015, revealed identified concerns for facility cleanliness but as evidenced by surveyor observations from 12/07/15 through 12/10/15, the facility failed to develop and implement a plan to correct the identified problems. The following are the facility observations for January, February and October 2015:

January 2015

Adult Unit:

Dust in elevated places

Shower floor dirty in select rooms

Dust behind washer/dryer

Laundry room floor dirty ...


Geriatric Unit

Dust behind washer/dryer

Shower floors dirty in select rooms

Dust in elevated places


ADOL Unit

Red clay/wad on ceiling in dayroom. - Still there from November

Dust in elevated places.

Spit/paper towel/paint wads on ceiling in dayroom and bathroom

Shower floors dirty in select rooms

Dust behind washer/dryer

Laundry room floor dirty

Door scuff from previous rounds ...



February 2015

Adult Unit:

Dust in elevated places

Laundry room floor dirty

Shower floors dirty in select rooms

Biohazard and sharps ¾ full ...


Geriatric Unit

Dust in elevated places

Ants by sink in dayroom/hallway

Biohazard and sharps ¾ full


ADOL UNIT

Red clay/wad on ceiling in dayroom - Still there from November

Dust in elevated places

Shower floors dirty in select rooms

Biohazard and sharps ¾ full

Laundry room floor dirty


Women ' s Unit


October 19, 2015 environmental rounds made by Infection Control Nurse
The following was found during IC (infection control) rounds today.
Lobby

Several chairs are stained

3 ceiling tile are stained

Bathroom floor is dirty

Bugs in light fixture

Wall dirty


Outpatient

Need gowns, masks, a spill kit, and one red bag trashcan

12 ceiling tiles stained


Exam Rooms

1st floor

Trash on floor

Floor dirty

Trash needs emptied


2nd floor

Chair is stained

Floor dirty

Trash on floor


Common Areas (hallways)

1st floor

6 stained ceiling tiles

Floor is dirty

Rugs need vacuumed

Bugs in light fixture

Elevators need cleaned top to bottom


2nd floor

Vent is dusty


Dietary

Trash on floor of pantry

Stack of empty boxes in pantry

Housekeeping door is dirty

Sink with burn kit needs cleaned

Boxes and trash on floor of freezer

Stuff on floor of trash room

Based on medical record review and staff interview it was determined that the Psychosocial Assessment of eight (8) of eight (8) active sample patients failed to describe what efforts the social work staff would be providing during hospitalization and for discharge planning. This failure results in the treatment team not having information about what anticipated psychsocial issues had been identified and what efforts for dischare planning would be pursued. (Patients A1, A2, A3, A4, B1, B2, B3, and B4). The findings include----

I. Medical Record Review:

1. Patient A1: The Psychosocial Assessment dated 11/24/2015 had for the role of the social work staff "Pt.(patient) needs to increase coping skills and decrease S.I.(suicide ideation) and S.I. w/plans (suicide ideation with plans)."

2.Patient A2: The Psychosocial Assessment dated 11/24/2015 had as the role of the social work staff "Pt. needs to increase coping skills and absence of command hallucinations."

3. Patient A3: The Psychosocial Assessment dated 11/23/2015 had as the role for the social work staff "Improve mood, deny any S.I., stop responding to internal stimuli, staff and med(medicine) compliance, and sleep 6-8 hours per night."

4. Patient A4: The Psychosocial Assessment dated 11/24/2015 had as the role of the social work staff "Improve mood and mental state, compliance with staff and medications, and sleep 6-8 hours per night."

5. Patient B1: The Psycosocial Assessment dated 9/9/2015 had as the role of the social work staff "Increase coping skills, eliminate S.I. and cutting, work on communication skills." The Addendum dated 12/01/2015 had no description of what focus the social servive staff were going to pursue in treatment and discharge planning during this rehospitalization that began 12/01/2015. There was no information as to why the previous discharge plans were unsuccessful and what alternatives for this hospitalization would be pursued.

6. Patient B2: The Psychosocial Assessment dated 12/04/2015 had as the role of the social service staff "Pt. will report improved mood & deny hallucinations for 3 days prior to d/c(discharge). Pt. will not respond to internal stimuli for 3 days prior to d/c. Pt. will follow up with O.G.C. (Ozark Guidance Center) for outpatient therapy & med management upon d/c."

7. Patient B3: The Psychosocial Assessment dated 12/02/2015 had as the role of the social work staff "Eliminate S.I., Increase coping skills."

8. Patient B4: The Psychosocial Assessment dated 12/06/2015 had as the role of the social work staff "Process stressors, ID coping skills, deny S.I."

II. Staff Interview:

On 12/08/2015 at 11:45 AM the Director of Social Services was interviewed. The findings described in Section I. were discussed. She concurred that these types of statements did not describe the efforts the social work staff would be pursing in treatment and discharge planning.

Based on record review and staff interview, the hospital failed to identify the names of specific treatment team members responsible for the modalities selected for seven of eight active patients (A1, A2, A4, B1, B2, B3, and B4). The treatment plans listed only the disciplines of those staff members responsible for selected treatment modalities. This has the potential to create an inability to determine which staff member is responsible for ensuring compliance with the various aspects of treatment. The findings include--

I. RECORD REVIEW

1. Patient A1's treatment plan dated 11/25/15 did not identify the specific staff member responsible for the treatment modalities selected.

2. Patient A2's treatment plan dated 11/25/15 did not identify the specific staff member responsible for the treatment modalities selected.

3. Patient A4's treatment plan dated 11/24/15 did not identify the specific staff member responsible for the treatment modalities selected.

4. Patient B1's treatment plan dated 12/2/15 did not identify the specific staff member responsible for the treatment modalities selected.

5. Patient B2's treatment plan dated 12/7/15 did not identify the specific staff member responsible for the treatment modalities selected.

6. Patient B3's treatment plan dated 12/3/15 did not identify the specific staff member responsible for the treatment modalities selected.

7. Patient B4's treatment plan dated 12/7/15 did not identify the specific staff member responsible for the treatment modalities selected.


INTERVIEWS

In an interview on 12/8/15 at 10:15 AM, the Director of Clinical Services concurred that the treatment plans did not indicate the specific staff member responsible for implementing the specific modalities selected.

Based on interview and review of personnel file, it was determined that the Director of Nursing (DON) failed to meet the educational and/or psychiatric nursing experience necessary for the position of Director of Nursing within the facility. A review of the personnel file for the Director of Nursing revealed that she obtained a Bachelor of Science in Nursing from Oklahoma Wesleyan University in 2009, a Master of Science in Leadership and Ethics from John Brown University in 2002, an Associate of Science in Nursing from Northwest Arkansas Community College in 1995 and a Bachelor of Science in Communication/Journalism from John Brown University in 1991. A review of the DON's personnel file indicated an employment history which did not include any direct psychiatric nursing experience.

An interview was conducted by the nurse surveyor with the DON on 12/08/15 at 1:00 PM. The DON confirmed that she has no work history that includes direct care psychiatric nursing experience.






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