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Based on observations, record reviews, and interviews, the hospital failed to ensure patients received care in a safe setting as evidenced by:

1) Failing to ensure the patient environment was free of safety and ligature risks during observations made on 09/05/17 at 9:55 a.m. through 10:50 a.m.
2) Failing to ensure patients were not allowed to be in common areas that had ligature and safety risks without staff present to observe the patients for 2 observations made on 09/05/17 at 10:03 a.m. and 10:20 a.m.
3) Failing to ensure patients were observed and documentation of the observations were kept current by MHTs for 2 (#1, R1) patients observed on 09/05/17 at 10:03 a.m. and 10:50 a.m. and for 5 (#1, R1, R3, R4, R5) patients' observation sheets reviewed on 09/05/17 at 10:25 a.m. and for 3 (#2, R1, R2) patients' observation sheets reviewed on 09/06/17 at 9:45 a.m.
Findings:

1) Failing to ensure the patient environment was free of ligature risks and safety risks:
Observation on 09/05/17 at 9:55 a.m. on the 5th floor of the hospital revealed the following:
a) The restroom used by patients outside Room "a" had a door knob that was not ligature proof. There was an approximate 6 inch protruding faucet to the bathtub that presented a ligature risk. The gooseneck shower nozzle presented a ligature risk. There were 2 protruding metal knobs on the shower wall in addition to the shower faucet knobs that were not ligature proof. The upper rail in the shower was loose, and the shower wall had 13 holes in the wall. The sink faucet and handles were not ligature proof. The covering over the light fixture had non-tamper-resistant screws and could be reached by the surveyor who was able to unscrew the screws. This presented a risk for safety of patients allowed to use the bathroom unattended by staff.
b) 12 wooden handrails in the hall had an approximate 2 inch space between the rail and the wall that presented a ligature risk.
c) The restroom used by patients next to the alcove near Room "b" had a sink faucet that was not ligature proof. The shower knobs and nozzle were not ligature proof. There were no handrails at the toilet or in the shower to provide safety.
d) The laundry hamper next to Room "b" had a plastic liner with another plastic liner tied to the outside of the hamper.
e) Beds in Rooms "c" "e", "f", "g", and "h" were metal-framed and had open metal springs where the mattress lies that presented a ligature risk. Beds in Rooms "f" and "h" (one of 2 beds) had hand cranks that could be used to raise and lower the bed that presented a ligature risk.
f) Room "c" had sheetrock to the right upper side of the window that had a hole with a face towel stuffed in the hole. During the observation Patient R6 indicated the sheetrock dust kept falling on him, so he placed the towel in the hole. This hole presented a risk for hiding contraband.
g) All mattresses in patient rooms had zippers that presented a risk for suffocation.

In an interview during the observation on 09/05/17 at 9:55 a.m., S3LPC confirmed the above findings.

2) Failing to ensure patients were not allowed to be in common areas that had ligature and safety risks without staff present to observe the patients:
Observation on 09/05/17 at 9:55 a.m. on the 5th floor of the hospital revealed Room "a", a common area room, had door hinges with space between each hinge that could present a ligature risk and had non-tamper-resistant screws. Hand sanitizer was mounted on the wall in the room next to the linen closet. A phone jack on the wall had 2 tamper-resistant screws protruding that presented a safety risk. The cords to the blinds on both windows were approximately 4 feet long and presented a ligature risk. The unlocked closet contained patients' toiletry items including combs, toothpaste, hair conditioner, and lotions. During the observation S3LPC indicated the door should be locked. The plexi-glass placed in front of the television had 9 non-tamper-resistant screws. There was a hole in the wall below the picture frame with an opening the size of a pencil and one about ½ inch in diameter that presented an opportunity for hiding contraband.

Observation on 09/05/17 at 10:03 a.m. revealed patient R1 walked into Room "a" unattended by staff, and no staff were in the room observing her. This observation was confirmed by S3LPC who was present with the surveyor at the time of the observation.

Observation on 09/05/17 at 10:20 a.m. revealed Patients R5, #2, R6, and R7 were observed seated in Room "a" that had multiple ligature and safety risks. No staff present during this observation to supervise the patients.

In an interview on 09/05/17 at 10:20 a.m., S3LPC confirmed no staff were present in Room "a" when the above listed patients were seated in the room.

3) Failing to ensure patients were observed and documentation of the observations were kept current by MHTs:
Observation of the MHT observation sheets documented by S4MHT on 09/05/17 at 10:20 a.m. revealed that observations of Patients #1, R1, R3, R4, and R5 had not been documented since 8:15 a.m. (2 hours and 5 minutes since the last documented observation). These patients were ordered to be on every 15 minutes observation.

Review of the policy titled "Patient Observation Record", presented as a current policy by S1ADM, revealed that the RN is responsible for MHT assignments regarding patient observation records. Further review revealed the observation with documented location and behavior must be documented and verified by the observer's initials at least every 15 minutes.

In an interview on 09/05/17 at 10:40 a.m., S4MHT indicated at 8:30 a.m. she was putting vital signs in the computer and at 9:15 a.m. she went down for breakfast with the patients. She confirmed S5MHT, the other MHT on the unit, also went to breakfast off the unit. She indicated that Patient #1 and Patient R1 didn't go down for breakfast. She indicated she got back from breakfast about 10:10 a.m. S4MHT indicated the nurse "keeps an eye on them" (patients left on the unit) while she's downstairs. She confirmed she documented Patient #1's observations during that time, even though she didn't make the observations. She said she leaves the observation sheets for all patients when she goes downstairs. She offered no explanation for the patients' observations sheets not having the above-listed patients' location and activity for 2 hours and 5 minutes.

In an interview on 09/05/17 at 10:50 a.m., S6RN indicated she wasn't aware she was supposed to make observations in the MHT's absence on the unit. She further indicated the MHT would have to hand her the observation sheets, if she's supposed to make observations. She indicated she could tell the MHT that the patient was fine when they returned, but she didn't document anything. When asked if she made q 15 minute observations while the MHTs were off the unit, S6RN indicated "I was mostly aware where they were."

Review of S11MHT's patient observation sheets while in the cafeteria on on 09/06/17 at 9:45 a.m. revealed 3 of the 6 patients' observation sheets were not current. Patient R1's and Patient #2's observation sheets were last documented completely at 7:30 a.m., and Patient R2's observation sheet was last documented at 8:00 a.m. S11MHT indicated while she was on the unit at these times, the patients were moving about, and she knows what each was doing. She further indicated she is supposed to observe and document q 15 minutes, but it's not an everyday practice to not document this way. She said the patients today needed more help. She confirmed she didn't document Patients' #2, R1, and R2 location and activity as listed above.

In an interview on 0-9/06/17 at 9:55 a.m., S3LPC confirmed there was a problem in the observation of patients and documentation of the observations by the MHTs. She indicated "it's black and white, I can't deny it."

In an interview on 09/06/17 at 10:00 a.m., S2DON confirmed the process of MHT's observation of patients is "broken." She indicated they are working to fix the problem.

Based on record reviews and interviews, the hospital failed to ensure a medical H&P was completed and documented for each patient no more than 30 days before or 24 hours after admission as evidenced by having incomplete written H&Ps with the dictated copy not being in the medical record within 24 hours after admission for 5 (#1, #2, #3, #4, #5) of 5 (#1 - #5) patient's medical records reviewed for a H&P from a total sample of 5 patients.
Findings:

Patient #1
The patient was a 31 year old male admitted on 9/03/17 as a voluntary admit. The patient had a history of anxiety disorder, asthma, epilepsy, substance abuse, suicide ideation, and seizures.

In an interview on 09/06/17 at 12:30 p.m. with S3LPC, in a review of the patient's medical record, there was no documented evidence of a completed H&P either on the paper medical record or in the EMR. She indicated that the H&P was probably performed and dictated on 09/05/17. A further review of the medical record on 09/06/17 revealed no documented evidence that a H&P was dictated on 09/05/17.

Patient #2
The patient was a 24 year old male admitted on 08/31/17 as a voluntary admit. The patient had no prior history of depression and was admitted for a suicide attempt and tried to overdose on pills. The patient had no prior medical conditions.

In an interview on 09/06/17 at 12:30 p.m. with S3LPC, in a review of the patient's medical record, there was no documented evidence of a completed H&P either on the paper medical record or in the EMR. The H&P was documented as being dictated on 09/01/17. She indicated that there was no documented evidence of a completed H&P in the medical record as of 09/06/17.

Patient #3
Review of Patient #3's H&P documented by S8NP on 07/12/17 at 8:00 a.m. revealed no documented evidence of a physician examination of the head, eyes, ears, nose, throat, neck, heart, lungs, abdomen, extremities, skin, an impression, diagnoses, and a plan.

Review of the dictated H&P that contained all of the above-listed examination revealed it was dictated on 07/13/17 at 8:31 a.m., 33 hours and 46 minutes after admission.

In an interview on 09/06/17 at 10:35 a.m., S2DON indicated it was her understanding that the H&P had to be done in 24 hours of admit. She didn't realize it had to be completed and physically on the chart in 24 hours of the patient's admission. When the surveyor reviewed with S2DON that the initial H&P did not have a documented physical examination of Patient #3 by S8NP, S2DON confirmed a complete H&P was not on the chart within 24 hours of admission.

Patient #4
The patient was a 28 year old female admitted on 09/01/17 as a voluntary admit. The patient had a history of depression with suicide ideation and bipolar disorder. She had a medical history of diabetes and seizures.

In an interview on 09/06/17 at 12:55 p.m. with S3LPC, in a review of the patient's medical record, there was no documented evidence of a completed H&P either on the paper medical record or in the EMR. The H&P was documented as being dictated on 09/01/17. She indicated that there was no documented evidence of a completed H&P in the medical record as of 09/06/17.

Patient #5
The patient was a 56 year old female admitted on 08/30/17 as a voluntary admit. The patient had a history of depression with suicide ideation, bipolar disorder, hypertension, congestive obstructive pulmonary disease.

In an interview on 09/06/17 at 2:30 p.m. with S3LPC, in a review of the patient's medical record, there was no documented evidence of a completed H&P either on the paper medical record or in the EMR. She indicated that the H&P was documented as being performed on 08/30/17 and then documented as being dictated on 09/03/17. She further indicated that there was no documented evidence of a completed H&P in the medical record as of 09/06/17.


30172

Based on observations, record reviews, and interviews, the hospital failed to ensure the RN supervised and evaluated the nursing care for each patient as evidenced by:
1) The RN failed to ensure patients were observed in accordance with physician orders as evidenced by having MHT's documentation of patient observations not kept current for 2 (#1, R1) patients observed on 09/05/17 at 10:03 a.m. and 10:50 a.m. and for 5 (#1, R1, R3, R4, R5) patients' observation sheets reviewed on 09/05/17 at 10:25 a.m. and for 3 (#2, R1, R2) patients' observation sheets reviewed on 09/06/17 at 9:45 a.m.
2) The RN failed to report a patient's elevated BP to the physician, treat with prn (as needed) medication ordered for withdrawals, and reassess the blood pressure for 1 (#3) of 1 patient record reviewed with elevated BP from a total sample of 5 (#1 - #5) patients.
Findings:

1) The RN failed to ensure patients were observed in accordance with physician orders:
Observation of the MHT observation sheets documented by S4MHT on 09/05/17at 10:20 a.m. revealed that observations of Patients #1, R1, R3, R4, and R5 had not been documented since 8:15 a.m. (2 hours and 5 minutes since the last documented observation). These patients were ordered to be on every 15 minutes observation, and Patient #1 was low risk suicide precautions.

Review of the policy titled "Patient Observation Record", presented as a current policy by S1ADM, revealed that the RN is responsible for MHT assignments regarding patient observation records. Further review revealed the observation with documented location and behavior must be documented and verified by the observer's initials at least every 15 minutes.

In an interview on 09/05/17 at 10:40 a.m., S4MHT indicated at 8:30 a.m. she was putting vital signs in the computer and at 9:15 a.m. she went down for breakfast with the patients. She confirmed S5MHT, the other MHT on the unit, also went to breakfast off the unit. She indicated that Patient #1 and Patient R1 didn't go down for breakfast. She indicated she got back from breakfast about 10:10 a.m. S4MHT indicated the nurse "keeps an eye on them" (patients left on the unit) while she's downstairs. She confirmed she documented Patient #1's observations during that time, even though she didn't make the observations. She said she leaves the observation sheets for all patients when she goes downstairs. She offered no explanation for the patients' observations sheets not having the above-listed patients' location and activity for 2 hours and 5 minutes.

In an interview on 09/05/17 at 10:50 a.m., S6RN indicated she wasn't aware she was supposed to make observations in the MHT's absence on the unit. She further indicated the MHT would have to hand her the observation sheets, if she's supposed to make observations. She indicated she could tell the MHT that the patient was fine when they returned, but she didn't document anything. When asked if she made q 15 minute observations while the MHTs were off the unit, S6RN indicated "I was mostly aware where they were."

Review of S11MHT's patient observation sheets while in the cafeteria on 09/06/17 at 9:45 a.m. revealed 3 of the 6 patients' observation sheets were not current. Patient R1's and Patient #2's observation sheets were last documented completely at 7:30 a.m., and Patient R2's observation sheet was last documented at 8:00 a.m. S11MHT indicated while she was on the unit at these times, the patients were moving about, and she knows what each was doing. She further indicated she is supposed to observe and document q 15 minutes, but it's not an everyday practice to not document this way. She said the patients today needed more help. She confirmed she didn't document Patients' #2, R1, and R2 location and activity as listed above.

In an interview on 0-9/06/17 at 9:55 a.m., S3LPC confirmed there was a problem in the observation of patients and documentation of the observations by the MHTs. She indicated "it's black and white, I can't deny it."

In an interview on 09/06/17 at 10:00 a.m., S2DON confirmed the process of MHT's observation of patients is "broken." She indicated they are working to fix the problem.

2) The RN failed to report a patient's elevated BP to the physician, treat with prn medication ordered for withdrawals, and reassess the blood pressure:
Review of the policy titled "Nursing Shift Assessment & (and) Nursing Daily Progress Note", presented as a current policy by S1ADM, revealed the content of nursing daily progress notes shall include documentation of all treatment rendered to the patient, descriptions of each change in the patient's condition, and descriptions of response of the patient to treatment and the outcome of treatment.

Review of Patient #3's nursing note documented by S10RN on 07/13/17 at 6:30 p.m. and the note documented by S9MHT on 07/13/17 (no time documented) revealed Patient #3's BP was 151/108, his pulse was 71, and his respirations were 21. There was no documented evidence that S10RN notified the physician or administered Librium 25 milligrams orally as ordered every 6 hours as needed for alcohol withdrawal. There was no documented evidence that Patient #3's BP was reassessed.

In an interview on 09/06/17 at 12:31 p.m., S2DON indicated she reviewed Patient #3's computerized medical record. She further indicated there was no documented evidence that the physician was notified of the elevated BP on 07/13/17 at 6:30 p.m., S10RN administered the patient's routine medications at at 3:00 p.m. but no Librium as ordered for alcohol withdrawal (which could result in an elevated BP), and there was no documented evidence that his BP was reassessed.

Based on record reviews and interview, the hospital failed to ensure the nursing staff developed and kept current a nursing care plan for each patient in accordance with hospital policy as evidenced by failure to include patient-specific problems identified through clinical assessments for 1 (#3) of 5 (#1 - #5) patient records reviewed for nursing care plans from a total of 5 sampled patients.
Findings:

Review of the policy titled "Master Treatment Plan/Weekly Update Treatment Plan", presented as a current policy by S1ADM, revealed that treatment plans will be individualized to address patient specific problems identified through clinical assessments. Each discipline is responsible for documenting specific short-term and long-term goals and interventions for each identified problem.

Review of Patient #3's medical record revealed his diagnoses included Alcoholisms, Suicidal Ideation, Anxiety, Bipolar Disorder, Chronic Obstructive Pulmonary Disease, Depression, Seizures, Substance Abuse, Chronic Pain, Gastroesophageal Reflux Disease, and Hepatitis C.

Review of Patient #3's "Physician Admit Orders" dated 07/11/17 at 10:45 p.m. revealed orders for suicide, assault,fall, and seizure precautions.

Review of Patient #3's "Treatment Plan" initiated on 07/12/17 at 1:27 a.m. revealed the problems identified with respective care plan, goals, and interventions developed included chronic medical problem of Hypertension and substance abuse. Patient #3 had orders for Protonix to be administered for Gastroesophageal Reflux Disease. There was no documented evidence that a care plan was developed that included goals and interventions for Suicidal Ideations, Assault, Seizures, Falls, Bipolar Disorder, Depression, Chronic pain, and hepatitis C.

In an interview on 09/06/17 at 1:20 p.m., S2DON confirmed the computerized medical record had no additional problems identified for the nursing care plan other than chronic medical problem of Hypertension and substance abuse. She confirmed the care plan should include the problems for which a patient is being treated.

Based on record reviews and interviews, the hospital failed to ensure the RN assigned the nursing care of each patient to other nursing personnel in accordance with the specialized qualifications and competence of the nursing staff as evidenced by failure to have documented evidence of evaluation of competency and/or current BLS certification for 4 (S4MHT, S11MHT, S12RN, S14MHT) of 7 (S2DON, S4MHT, S11MHT, S12RN, S14MHT, S15MHT, S16RN) personnel records reviewed for orientation, competency, and applicable licensure/certification.
Findings:

Review of the policy titled "Personnel Records", approved October 2017 (policy reviewed on 09/06/17) and presented as a current policy by S1ADM, revealed that the personnel record will contain orientation and training program records and performance evaluations. There was no documented evidence that the policy addressed a competency evaluation of staff prior to providing direct patient care.

Review of the policy titled "Staffing Plans And delivery Of Care", approved January 2017 and presented as a current policy by S1ADM, revealed that personnel assigned to patient care shall have completed competency documentation for that area or be under the supervision of a preceptor.

Review of the "Competency-Based Job Description" for Charge Nurse, RN, presented as a current job description by S1ADM, revealed that the education and/or experience/qualifications included successful completion of orientation and demonstration of competence.

Review of the "Competency-Based Job Description" for MHT, presented as a current job description by S1ADM, revealed that the education and/or experience/qualifications included successful completion of orientation and demonstration of competence and current BLS certificate. Further review revealed the hospital would ensure that the staff are trained and evaluated on their knowledge of and adherence to compliance policies and procedures specific to their jobs.

S4MHT
Review of S4MHT's personnel file revealed her BLS certification had expired on 07/31/17. There was no documented evidence of current BLS certification.

S11MHT
Review of S11MHT's personnel file revealed her competency evaluation dated 04/29/15 was not complete. Her performance evaluation signed by S11MHT on 07/23/15 revealed a score of 60% competence on vital signs and 73% on general MHT knowledge. No documented evidence was presented during the survey of re-education and re-evaluation of competency for S11MHT. There was no documented evidence that S4MHT had received a performance evaluation since 07/23/15.

S12RN
Review of S12's personnel file revealed the score on her annual RN competency test completed on 05/10/17 was 76%.

Review of an "Official Written Warning" dated and signed by S12RN and S2DON on 08/09/17 revealed S12RN had failed to complete nurse competency retesting for scoring less than 80%. Further review of her personnel file on 09/06/17 revealed no documented evidence that retraining and retesting had occurred for S12RN.

S14MHT
Review of S14MHT's "Employee Orientation Checklist", signed by S14MHT on 09/28/16, revealed no documented evidence of the signature of the person who provided the orientation. Further review of his personnel file revealed no documented evidence of an evaluation of competency.

In an interview on 09/06/17 at 1:40 p.m., S2DON indicated if a competency score of less than 80%, the employee has to be retrained and retested. She confirmed that S12RN had not yet received retraining and retraining since she scored 76% on her competency test on 05/10/17.

In an interview on 09/06/17 at 3:30 p.m., S13HRD confirmed there was no performance evaluation in S11MHT's personnel file since 07/23/15. She confirmed that S4MHT was not currently certified in BLS. S13HRD indicated she had failed to sign S14MHT's orientation documentation. She further indicated the hospital was not evaluating competency prior to staff providing direct patient care when S14MHT was hired on 10/11/16, and they were just doing an annual competency.