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Based on medical record review, facility policy and document review and staff interview, it was determined that the hospital failed to obtain consent from the patient, or the patient representative, prior to the administration of a psychotropic medication (refer to A 117); failed to provide the patient with written notice of its decision that contains the steps taken on behalf of the patient to investigate the grievance and the results of the grievance process (refer to A 123); failed to document the patient's advacne directve status (refer to A 132); failed to provide care in a safe setting by not observing patients as ordered by the physician (refer to A 144); faild to keep patients free from abuse (refer to 145); and failed to appropriately document the use of restraints (refer to A 154). The cumulative effect of these deficient practices resulted in the hospital's inability to protect patient rights and ensure that patients would be free from abuse from both other patients and facility staff. As a result of the facility failure to act to prevent the reoccurrence of abuse, Chief Executive Officer A, Division President A, Director of Risk Management A and Nurse #5 were notified that an Immediate Jeopardy began on 1/7/22 at 4:45 PM. The facility submitted an "Immediate Jeopardy Abatement Plan" which was approved on 1/7/22 at 8:50 PM.

The "Immediate Jeopardy Abatement Plan" included reeducating all staff policies and topics related to abuse. All employees were required to complete the training program, and pass a competency test, prior to returning to work at the facility. In addition, rounding by facility leadership was increased on all units to monitor quality of patient observations, supervision by the Charge Nurse, and to monitor for signs of abuse.

On 1/19/22, the survey team conducted interviews with various staff members regarding the reeducation on abuse. All staff were able to relay the process to identify and mitigate potential abusive situations.

After staff interviews and confirmation of staff reeducation, the IJ was lifted on 1/19/22 at 4:50 PM.

Based on medical record review, facility policy review, and staff interview, it was determined that for 2 of 19 patients (Patients #'s 9 and 16) in the sample, the facility failed to obtain consent from the patient, or the patient representative, prior to the administration of a psychotropic medication. Findings include:

The hospital policy titled "Consent for Treatment with Psychiatric Medication" stated, "...procedures for obtaining consent for treatment with psychopharmaceutical agents...obtain...informed consent from the patient, parent (legal guardian)...prior to the onset and or changes of such treatment...consent form is filed in...the medical chart..."

Medical record review revealed:

A. Patient # 9 (Admission Date: 7/26/21)

1. "Practitioner Order Sheet"
a. 7/28/21 at 4:00 PM, included orders for:
- Haldol (anti-psychotic medication) 5mg (milligrams) to be administered at bedtime each day.
- Zoloft (an antidepressant medication) 50 mg daily
b. 7/30/21 at 11:20 AM included orders for:
- Haldol 10 mg to be administered at bedtime each day

2. The "Medication Consent - Psychotropics":
- stated, "...I...hereby authorize the professional staff of this facility to administer treatment, limited to the psychotropic medications indicated...Haldol ...Zoloft...patient shall always be asked to sign this authorization form...if the patient...is incompetent to consent to treatment, the consent of his or her legal representative shall be obtained."

3. Medication administration record documented that Patient #9 was given:
a. Haldol as follows:
7/28 to 7/30/21 at 9:00 PM (3 days)
8/1 to 8/5/21 at 9:00 PM (5 days)
b. Zoloft as follows:
7/29 to 8/5/21 at 9:00 AM (8 days)

4. There was no documentation in the consents or in medical record to support that the patient or legal representative was offered or declined to sign the consent for the administration of Haldol or Zoloft.

This finding was confirmed with ADON A during an interview on 1/26/22 between 2:30 PM and 4:15 PM.

B. Patient #16 (Adolescent patient, Admission Date: 1/15/22)
1. "Practitioner Order Sheet"
a. 1/15/22 at 10:30 PM, included orders for:
- Lexapro (an antidepressant medication) 5 mg at bedtime each day

2. The "Medication Consent - Psychotropics":
- Stated, "...I...hereby authorize the professional staff of this facility to administer treatment, limited to the psychotropic medications indicated...Lexapro...patient shall always be asked to sign this authorization form...if the patient...is incompetent to consent to treatment, the consent of his or her legal representative shall be obtained..."
- Documentation on "Signature of Patient or Legal Representative" line dated 1/16/22 at 2:10 PM stated "Mom gave verbal (consent) via phone"

3. Medication administration record documented that Patient #16 was given Lexapro 1/16/22 at 9:00 AM (5 hours prior to obtaining consent from legal guardian).

4. There was no documentation in the consents or in medical record to support that the patient or legal representative was offered or declined to sign the consent prior to the administration Lexapro.

This finding was confirmed with ADON A during an interview on 2/1/22 at 1:40 PM.

Based on policy and document review, it was determined that for 2 of 2 patients (Patient #'s 1 and 4) in the sample that filed a grievance, the hospital failed to provide the patient with written notice of its decision that contains the steps taken on behalf of the patient to investigate the grievance and the results of the grievance process. Findings include:

The hospital policy titled "Grievance, Patient" stated, "...Report to the patient should contain...steps taken on behalf of the patient to investigate the grievance, results of the grievance..."

Patient#1 (Admission 11/17/21)

A. Hospital document review revealed:

1. "MeadowWood Behavioral Health System Response to Patient or Family Grievance or Privacy Concern" revealed:

a. Letter from MeadowWood Behavioral Health System dated 11/25/21 to the patient stated, "Unfortunately, due to the privacy laws, I cannot disclose any further information about this matter..."

b. No documentation to support that Patient #1 received written notice of the grievance decision that contained the steps taken on behalf of the patient to investigate the grievance and the results of the grievance process.

Findings were confirmed with Compliance Nurse #3 on 2/9/22 4:30 PM.

Patient #4 (Admission 11/26/21)

A. Hospital document review revealed:

1. "MeadowWood Behavioral Health System Response to Patient or Family Grievance or Privacy Concern" revealed:

a. Letter from MeadowWood Behavioral Health System dated 12/6/21 to the parent(s) of Patient #4 stated, "...I have completed my investigation and found that Patient #4 was discharged on 12/5/21, against medical advice. At this time, I consider this grievance resolved. Unfortunately, due to the privacy laws, I cannot disclose any further information about this matter..."

b. No documentation to support that Patient #4 or the parents of Patient #4 received written notice of the grievance decision that contained the steps taken on behalf of the patient to investigate the grievance and the results of the grievance process.

Findings were confirmed with Compliance Nurse #2 on 2/9/22 4:30 PM.

Based on medical record review and document review, it was determined that for 1 out of 19 patients in the sample (Patient #9), the agency did not document the patient's advance directive status. Findings include:

The hospital policy titled "Advance Directive" stated: "...Admission staff will complete the Advance Directive and Organ Donation Form to determine if a patient has executed an Advance Directive and/or desires information related to the process of formulating an Advance Directive..."

A. Review of Patient #9's (Admission Date: 7/26/21) medical record revealed:
1. The document titled "Organ Donation/Advance Directives" was not completed.
2. No evidence of the patient's advance directive status.

This finding was confirmed during an interview with the Assistant Director of Nursing A on 1/26/22 from 2:30 PM to 4:15 PM.

Based on medical record review, policy and document review, and staff interview, it was determined that the hospital failed to provide care in a safe setting for 5 of the 19 patients in the sample (Patient #'s 6, 9, 10, 14, 16) by failing to conduct patient observations at the time intervals ordered by the patient's physician or at the time intervals consistent with facility policy. This failure has the potential to negatively impact all patients admitted to this facility. Findings include:

The hospital policy titled "Routine Observation of Inpatients" stated, "...staff...documents routine safety rounds on patients in accordance with the level of observation ordered by the practitioner...RN (registered nurse) may increase the level of observation if the patient's condition changes...practitioner will be contacted soon as possible for notification of the change in condition and to obtain and order for the observation level...Each entry is to include the following...location...behavior...activity...staff initial and signature...Documentation of the observation is to be completed once the patient has been observed...All patients are monitored at minimum once in every 15 minute block of time, regardless of level of supervision...Remain vigilant for specific risks for patients on Special Precautions...and potential ways the patient can elope from the facility..."

Medical record review revealed:

A. Patient #10 (Admission 6/17/21)

1. Admission orders dated 6/17/21, included orders for staff to observe the patient every 5 minutes.

2. "Patient Observation Record"
a. No evidence that observations were conducted every 5 minutes during the following time frame:
- 6/20/21 6:20 PM to 6/21/21 8:25 AM (114 observations not documented)

These findings were confirmed with Assistant Director of Nursing (ADON) A on 1/11/22 between 3:02 PM and 3:06 PM.

B. Patient #14 (Admission 11/20/21 at 12:31 AM)

1. Progress Note dated 1/13/22 at 9:30 PM reported that Patient #14 attacked a staff member, punched staff in the face, and destroyed the staff's cell phone.

2. Practitioner Orders:
- 1/13/22 at 8:15 PM: (after the incident) for "assault precautions".
- 1/14/22 at 10:45 AM: "Discharge 1/14/22...call police to transfer to ED."
- 1/15/22 at 8:00 AM: "Cancel discharge."

3. Nursing reassessment note on 1/14/22 at 10:00 PM stated, "Patient returned to this facility, discharge was cancelled. Pt arrived on the unit around 7:15 PM..."

4. "Patient Observation Record"
- Documentation ceased at 2:00 PM, stating Patient #14 was discharged.
- No evidence of observations performed every 15 minutes in accordance with facility policy for Patient #14 from 1/14/22 at 7:15 PM to 1/15/22 at 7:00 AM (47 observations not documented).

These findings were confirmed during an interview with ADON A on 1/24/22 between 11:00 and 11:23 AM.

C. Patient #16 (Admission 1/15/22 at 9:45 PM)

1. Admission diagnosis of "Major Depressive Disorder - Severe" after an overdose of medication.

2. Practitioner Orders
- Admission orders dated 1/15/22 at 10:30 PM, included orders for staff to observe the patient every 5 minutes.
- The frequency of observation order was revised on 1/20/22 at 10:30 AM to every 15 minutes.

3. "Patient Observation Record"
a. No evidence observations were completed every 5 minutes during the following timeframe:
- 1/17/22 5:45 AM to 7:10 AM (10 observations not documented)
b. No evidence observations were completed every 15 minutes during the following timeframe:
- 1/25/22 2:00 AM to 5:45 AM (14 observations not documented)

These findings were confirmed during an interview with ADON A on 2/1/22 between 1:40 and 1:55 PM.

D. Patient #6 (Admission 6/11/21)

1. "Patient Observation Record" revealed no evidence observations were completed between 6/19/21 at 7:00 AM and 6/20/21 at 6:55 AM (96 missing observations).

Observations were not completed every 15 minutes in accordance with facility policy. This finding was confirmed during an interview with ADON A on 1/12/22 between 10:50 AM and 3:15 PM.

E. Patient #9 (Admissions on 7/26/21 and 8/7/21)

1. 7/26/21 Admission
a. Practitioner Orders
- 7/26/21 at 5:40 PM: staff to observe the patient every 5 minutes.
- 7/30/21 at 1:55 PM: observation orders were changed to every 15 minutes.
- 7/30/21 at 8:24 PM: observation orders were changed to every 5 minutes.
- 8/5/21 at 6:15 PM: observation orders were changed to every 15 minutes.

b. "Patient Observation Record"
- Observations were documented every 15 minutes, rather than the observations ordered every 5 minutes between 5:40 PM until 11:30 PM on 7/26/21 (46 missing observations).
- Observations were not documented on 7/27/21 at 11:05 PM and 11:10 PM (2 missing observations).
- Observations were documented every 15 minutes, rather than the observations ordered every 5 minutes, between 11:15PM on 7/30/21 until 7:00 AM on 8/2/21 (445 missing observations).
- Observation at 5:55 PM on 8/2/21 were incomplete: missing behavior, activity, and staff initial.
- Observation at 7:10 PM on 8/2/21 were incomplete: missing activity and staff initial.
- Observations were documented every 15 minutes, rather than the observations ordered every 5 minutes on 8/2/22 between 8:00 PM and 11:15 PM (26 missing observations).
- Observations were not documented on 8/4/21 at 5:35 AM and 5:40 AM (2 missing observations).
- Observations were documented every 15 minutes, rather than the observations ordered every 5 minutes on 8/4/22 between 7:45 PM and 11:30 PM (30 missing observations).

2. 8/7/21 Admission
a. Practitioner Orders
- 8/7/21 at 12:20 PM staff to observe the patient every 15 minutes

b. "Patient Observation Record"
- No evidence of patient observations between 8/7/21 at 12:20 PM and 7:00 AM on 8/8/21 (74 missing observations).

These findings were confirmed during an interview with ADON A on 1/26/22 between 2:30 PM and 4:15 PM and 1/28/22 between 10:02 AM and 12:30 PM.

Based on medical record review, policy and document review and staff interview, it was determined that for 2 of 19 patients (Patient #'s 1 and 2) in the sample, the hospital failed to keep patients free from abuse resulting in an Immediate Jeopardy (IJ). Findings include:

The hospital failed to ensure that patients would be free from abuse from both other patients and facility staff. As a result, the facility failed to act to prevent the reoccurrence of abuse. Chief Executive Officer A, Division President A, Director of Risk Management A and Nurse #5 were notified that an IJ began on 1/7/22 at 4:45 PM. The facility submitted an "Immediate Jeopardy Abatement Plan" which was approved on 1/7/22 at 8:50 PM.

The "Immediate Jeopardy Abatement Plan" included reeducating all staff policies and topics related to abuse. All employees were required to complete the training program, and pass a competency test, prior to returning to work at the facility. In addition, rounding by facility leadership was increased on all units to monitor quality of patient observations, supervision by the Charge Nurse, and to monitor for signs of abuse.

On 1/19/22, the survey team conducted interviews with various staff members regarding the reeducation on abuse. All staff were able to relay the process to identify and mitigate potential abusive situations.

After staff interviews and confirmation of staff reeducation, the IJ was lifted on 1/19/22 at 4:50 PM.

The hospital policy titled "Inpatient Precautions - Sexual Acting Out Precautions" stated, "...Sexual activity between patients while in the hospital, whether consensual or not, is prohibited. Patients are assessed...to identify if they are at risk for sexual aggression or sexual victimization...Sexual contact between patients while in the hospital, is against hospital policy...Staff members will take reasonable steps to prevent the opportunity for sexual contact between patients by...Reminding patients of the 'Boundaries' section of the patient handbook...observing and redirecting patients engaging in touching of a sexual or romantic nature..."

The hospital policy titled "Patient Neglect, Abuse, Exploitation By Staff" stated, "...'zero tolerance' does not condone any action that can be construed as neglect, abuse and/or exploitation. Established procedures for the identification, reporting, and resolution of situations involving alleged neglect and/or abuse shall be strictly followed..."

The hospital policy titled "Patient Neglect, Abuse, Exploitation by Staff" stated, "...Any employee who hears from a patient...or observes a potential situation of patient neglect and/or abuse is required to register a complaint immediately with their supervisor...Any employee who fails to report an incident of patient neglect and/or abuse is subject to disciplinary action up to and including immediate termination...Any supervisor who receives information, written or oral, of an alleged patient neglect and/or abuse and fails to follow the described procedure is subject to disciplinary action...Abuse: Any mental/psychological - acts that inflict emotional harm, invoke fear and/or humiliate, intimidate, degrade, demean or otherwise negatively impact the mental health or safety of an individual...Sexual Abuse - acts of sexual nature between patients and staff...Any patient...who believes a patient has been...abused...in any way, including sexually...has the right to initiate the Grievance Procedure..."

The hospital policy titled "Grievance, Patient" stated, "...Any reported grievance by patients, families, staff and/or visitors that directly related to patient neglect or abuse will be forwarded to the Administrator On-Call immediately for review...All verbal or written complaints regarding abuse...are considered grievances..."

The hospital documentation titled "Adult Program Handbook" stated, "...Patients are not permitted to touch nor express physical affection to their peers at any time..."

I. Incident between patient (Patient #2) and patient (Patient #19)

A. Review of Patient #2's medical record revealed:
1. The Progress Note" dated 12/18/21 at 8:45 PM contained the following documentation:
- At 4:00 PM, Patient #2 "told staff that s/he was rape (sic.) by (Patient #19)"
- Patient #19 was removed from Unit D East and transferred to D West
- Police were called, arrived at facility and took statements from Patient #2 and Patient #19
- Patient #2 sent to Hospital B emergency room for rape kit

B. Review of the facility documents on 1/7/22 revealed:

1. The "Incident Report Form" dated 12/18/21 at 6:00 PM, for Patient #19, completed by Nurse #11 contained the following documentation:
- At approximately 4:00 PM on 12/18/21, "Found (Patient #19) disrobed in room with (Patient #2) who stated that s/he (Patient #2) was sodomized...stated that s/he (Patient #19) had oral sex with (Patient #2)."

2. The "Incident Report Form" dated 12/18/21 at 6:00 PM, for Patient #2, completed by Nurse #11 contained the following documentation:
- At approximately 4:00 PM on 12/18/21, Patient #2 stated that s/he "was sodomized by (Patient #19) who was found disrobed in room".
- State police notified and interviewed Patient #2
- Facility Supervisor was notified verbally at 4:00 PM
- Physician was notified at 6:00 PM.
- Transferred to Hospital B for evaluation
- Reviewed by Supervisor A on 12/27/21 at 9:30 AM.
- Reviewed by Director of Risk Management A on 12/28/21

3. Patient #19 was moved to another unit after report of incident. No further evidence was provided by facility to demonstrate identification of deficient practices that contributed to event, implementation of corrective action to prevent re-occurrence of abuse, or to explain nine day delay between incident and initiation of review of incident by management team.

B. Interviews
1. During an interview with BHA (Behavioral Health Associate) #5 on 1/13/22 at 1:28 PM, the following was reported:
- BHA #3 reported to BHA#5 that Patient# 19 was discovered "naked" in Room 30 (a shared bedroom) with roommate, Patient #2, present
- BHA #5 went to the Room 30 and instructed Patient #19 to "get clothes on" and continued rounds
- BHA #5 returned to Room 30 15 minutes later
- Patient #19 was found with "pants down and Patient #2 standing in corner of room"
- BHA #5 removed Patient #2 from Room 30 to the Day Room
- BHA #5 returned to the Room 30 to speak with Patient #19, who stated "nothing happened."
- BHA #5 left Room 30 and spoke to Patient #2 who stated s/he had been "raped."
- BHA #5 reported incident to Nurse #11

2. During an interview with BHA #3 on 1/13/22 at 3:30 PM, the following was reported:
- On the date of incident, BHA #3 discovered Patient #19 in Room 30 (a shared bedroom) without clothes on.
- BHA #3 told Patient#19 to put clothes on and then went out of Room 30 to tell BHA #5 about Patient #19.
- BHA #3 and BHA #5 returned to Room 30, Patient #19 was instructed to put clothes on again and Patient #2 stated s/he was "okay".
- Both BHA #3 and BHA#5 left Room 30 and BHA#3 continued to complete rounds.
- Upon returning to the Room 30 about 20 minutes later, BHA#3 and BHA #5 found Patient #19 "completely naked" and Patient #2 "fully clothed lying on the bed".
- BHA #5 took Patient #2 out of Room 30.
- Patient #19 was instructed to get dressed, and incident was reported the nurse.

3. During an interview on 2/1/22 at 10:48 AM, Director of Risk Management:
- Confirmed these findings.
- Reported that Patient #19 and Patient #2 were not separated when initially discovered in Room 30 and Patient #19 was found naked.

II. Incident between patient (Patient #1) and employee (BHA#1)

A. Review of Patient #1 Medical record revealed:
1. The "Intake Assessment" dated 11/17/21, contained documentation that the patient had a history of sexual abuse.

B. Review of the facility documents on 1/6/22 revealed:

1. "Incident Report Form" dated 11/22/21 at 3:30 PM contained the following documentation:
a. "Facts Summary of Event" section: on 11/22/21 at approximately 3:00 PM, BHA #12 reported to Nurse #8 that BHA #1 went into Patient #1's room and massaged the patient's legs.
b. "Optional Facility Risk manager follow-up notes": "The patient also reported that the staff member (BHA #1) came in her bedroom, shut the door, and started to rub her back. Then he pulled down her pants and touched her butt and private area."
c. "Nursing Assessment documented on the incident report states, "Pt is A&O [alert and oriented] x 3. Pt is agitated, screaming at staff, uncooperative. Constantly demanding to give him/her extra valium."
d. "Physician/Practitioner Notified as applicable" section is marked as "N/A".
- Interview with Assistant Director of Nursing on 1/6/22 from 12:20 PM - 2:38 PM confirmed that the provider should have been notified.
- Interview with Provider #2 on 1/21/22 from 1:15 PM - 2:00 PM confirmed that in an instance of a patient who experienced abuse the attending or on-call provider should be notified.
e. The following notifications were made:
- Facility supervisor on 11/22/21 at 4:00 PM
- Director of Nursing on 11/23/21 at 4:50 PM
- Facility Administrator on 11/23/21 at 4:50 PM
f. Patient #1 refused to have family notified of the incident.
g. Signed by the nursing supervisor on 11/23/21 at 4:50 PM
h. Signed by Director of Risk Management on 11/29/21

2. The "Incident Data Analysis" signed by the Director of Risk Management A on 12/14/2021 contained the following documentation:
a. Date of Incident: 11/21/21
b. Location of Incident: Unit T - Patient/Resident Bedroom
c. Date Started & Completed Data Collection: November 21, 2021 - December 14, 2021
d. "Time Line of Event":
7:00 AM: Patient #1 is in the dayroom talking to a staff member
7:04 AM - 7:07 AM: BHA #1 is in the nursing station
7:08 AM: BHA #1 exits nursing station and can be seen talking to Patient #1 while pointing at his/her knee/leg
7:09 AM - 7:15 AM: BHA #1 and Patient #1 are in Room 75 (Patient #1's bedroom) with a closed door
7:15 AM: BHA #1 can be seen opening Room 75's door, peaking his head out to look in the dayroom for a brief moment and closing the door again. Both BHA #1 and Patient #1 remain in Room 75 with a closed door.
7:19 AM: BHA #1 exits Room 75 while Patient #1 remains in the room.
7:20 AM: Patient #1 exits Room 75

3. The "Witness Statement" completed by BHA #9, dated 11/21/21, contained the following documentation:
a. On 11/21/21 at 12:30 PM, Patient #1 reported the following incident to BHA #9:
- At approximately 10:30 AM, Patient #1 was awoken by BHA #1 massaging her shoulders over clothing while lying in bed.
- BHA #1 touched Patient #1's "rear end" over clothes.
b. On 11/21/21 at approximately 12:35 PM, BHA #9 reported this incident to Nurse #1.
No facility documentation explaining the discrepancy in timing between witness statements was provided.

4. There is no evidence of Nurse #1 taking any further action after being made aware of the incident on 11/21/21 at 12:35 PM.
a. Interview with the Director of Risk Management on 1/31/22 at 11:24 AM indicated:
- Nurse #1 would have delegated documentation of the incident to the unit charge nurse (Nurse #8).
- Nurse #1 did not take action to separate BHA #1 and Patient #1.

5. The "Incident Investigation Report" signed by the Director of Risk Management on 12/14/2021 (23 days after the incident) contained the following documentation:
a. Date of Incident: 11/21/21
b. The "Outcome of Investigation" section stated, "...it was determined that the boundary violation/sexual allegation of abuse by staff member (BHA#1) is substantiated as evidenced by the video review..."

6. Leadership meeting minutes from 11/29/2021 indicate:
-A plan for all nursing staff to be educated by 12/7/21 on maintaining appropriate boundaries and how to appropriately assist a patient in their room.
-Interview with Assistant Director of Nursing A on 1/20/22 confirmed that the focus of this meeting was the adolescent unit, not the entire facility.

7. The facility failed to provide evidence to demonstrate that corrective action was implemented to prevent the re-occurrence of abuse throughout the facility.

Based on medical record review, policy review, and staff interview, it was determined that for 1 out of 19 patients (Patient #14) in the sample, the hospital failed to appropriately document the use of restraints. Findings include:

Hospital policy titled "Seclusion and Restraint" states, "...Holding a patient in a manner that restricts the patient's movement against the patient's will is considered a restraint...restraint is used only after alternative, less restrictive approaches...have been attempted and proven unsuccessful...non-physical interventions are preferred...the use of seclusion or restraint requires a physician's order...1:1 observation will be maintained on the flow sheet..."

A. Review of Patient #14's medical record revealed:
1. 1/13/22 at 8:15 PM:
a. "Progress Note": Patient #14 attacked a staff member, punched staff in the face, and destroyed the staff's cell phone.
b. Physician's Order: "assault precautions" after the incident.

2. 1/14/22:
a. 10:45 AM Physician's Order: "Discharge 1/14/22 ...call police to transfer to ED (acute care hospital)."
b. 2:00 PM: "Patient Observation Record": documentation ceased stating Patient #14 "discharged."
c. 10:00 PM "Nursing Reassessment": stated "Patient returned to this facility, discharge was cancelled, patient arrived on the unit around 7:15 PM, patient attempted to attack a peer at 7:30 PM. Staff physically restrained patient..."
d. 11:00 PM "Progress Notes": stated "Patient arrived on the unit at 7:15 PM, and at 7:30 PM, tried to attack a peer. Pt (patient) was physically restrained, removed from the situation and was verbally deescalated."

3. Medical record review revealed no evidence of documentation of physician's order to physically restrain patient, of attempts of least restrictive measures, or of patient behavior/condition during physical restraint on 1/14/22.

Findings confirmed during interview with Assistant Director of Nursing A on 1/24/22 between 11:00 AM and 11:23 AM.

Based on review of medical records, policies, bylaws and other hospital documentation and staff interview, it was determined that the medical staff failed to ensure that the physician adhered to facility policies and procedures in the care and treatment of patients as required by medical staff bylaws. The cumulative effect of these deficient practices resulted in the hospital's failure to provide services in a safe setting.

Based on review of medical records, policies, bylaws, staff interviews, and other hospital documentation, it was determined that for 7 out of 19 patients (Patient #1, 5, 6, 7, 8, 9, 16) in the sample, the medical staff failed to ensure that the provider adhered to the facility's medical staff rules and regulations, policies and procedures as required by the medical staff bylaws. Findings include:

The hospital document titled "Medical Staff Bylaws" stated, "...each applicant by applying for or being granted any category of membership or Clinical Privileges, obligates himself to...provide his patients with continuous care of a professionally accepted level of quality and efficiency in the community and as established by the Medical Staff and the Governing Board...abide by the Medical Staff Bylaws, Rules and Regulations and by all other policies, procedures, and rules of the Facility and the Governing Board as they may exist now or in the future

The hospital document titled "Rules and Regulations of the Medical Staff of Meadowwood Hospital" stated, "...The Attending Physician has the ultimate responsibility for providing a diagnostic impression of each patient as required hereunder and for supervising the care of the patient in the facility...Each practitioner will adhere to all written facility policies, procedures, protocol, and guidelines...a complete progress note is to be documented for each visit... All entries to the medical record must be accurate, legibly written, dated, times, and authenticated/signed...All orders for medication and/or treatment for patients admitted to the Facility shall be in documented in the medical record. Orders must be complete, including the name of the Practitioner given the order and the date, time, and justification for the order...Orders that are illegibly or improperly written will not be carried out until rewritten and understood by the duly authorized person. The usage of "renew," "resume," and "continue" without identification of the medication, dosage, frequency, and route of administration will not be accepted...Pertinent progress notes related to diagnosis and to treatment plan goals and objectives, sufficient to permit continuity of care, shall be recorded on the date of each visit. Each of the patient's clinical problems should be clearly identified in the progress note and correlated with specific orders, as well as results of tests and treatments Any additional information related to the visit that is added after the date of the visit shall be identified as a late entry. Each Progress Note shall include...Interval History: Chief complaint in patient's own words; History of Present Illness with summary of symptoms content, theme since last visit and explanation of abnormal findings and critical test values and changes to family or social history. Examination: with mental status examination. Assessment and Medical Decision Making: Diagnosis/Impressions; Plan and Medication changes/indications; Response to treatments; Estimated date of discharge and Reason for continued Hospitalization...In general, the standards or practice of psychiatry and medicine in the Facility will be governed by the standards of practice prevailing within the community. The Governing Board, however, holds the Medical Director and the Medical Staff accountable for the quality of practice within the Facility...The Attending Physician or designee will see each of his patients 7/week..."

I. No evidence abnormal blood glucose levels were addressed.

The hospital policy titled "Change in Condition" stated "...The process for recognizing and responding as soon as a patient's condition appears to be worsening...based on the established criteria ...Glucose levels below 60 or above 400 ..."

The hospital policy "Diabetic Monitoring" stated "...in general, the medical somatic health consultant is called if blood sugar is confirmed as below 50 or above 400..."

The hospital document titled "Insulin Sliding Scale - Insulin Standing Order MAR" stated " ...Blood sugar > 400 [give 15 units and call medical]..."

Medical record review revealed:

A. Patient #9
7/26/21 Admission

a. The Medication Administration Record (MAR) contained documentation of the following blood glucose testing results:

7/29/21
7:00 AM: 406
11:00 AM: "HI"
4:30 PM: 514
9:00 PM: 524

8/3/21
4:30 PM: 536
9:00 PM: 506

8/4/21
9:00 PM 456

b. Review of "Psychiatry Progress Notes" revealed no evidence that the abnormal blood glucose results were addressed.

8/7/21 Admission

a. The MAR contained documentation of the following blood glucose testing results:

8/8/21
4:30 PM: 598

8/9/21
12:30 PM: 518

8/23/21
4:30 PM: 557

b. Review of "Psychiatry Progress Notes" revealed no evidence the abnormal blood glucose results were addressed.

These findings were confirmed with Assistant Director of Nursing (ADON) A on 1/26/22 from 2:30 PM - 4:15 PM and 1/28/22 from 10:02 AM - 12:30 PM.

II. No evidence a complete progress note was documented for each visit as required by the "Rules and Regulations of the Medical Staff of Meadowwood Hospital".

Medical record review revealed:

A. Patient #9

1. Admission 7/26/21
a. Review of "Psychiatry Progress Notes" revealed no evidence of a complete progress note for the visit conducted 7/21/21.

2. Admission 8/7/21
a. Review of "Psychiatry Progress Notes" revealed no evidence of a complete progress note for each visit conducted between 8/9 - 8/24/21.

These findings were confirmed with ADON A on 1/26/22 from 2:30 PM - 4:15 PM and 1/28/22 from 10:02 AM - 12:30 PM.

IV. The practitioner failed to assess and monitor: medical condition, symptoms, and compliance with treatment.

The hospital policy titled, "Treatment Planning" stated, "...Each clinical discipline develops the specific interventions that they will utilize to support and assist the patient in achieving the objective by which the patient will advance toward a successful discharge and return to the community..."

Medical record review revealed:

A. Patient #6 (Admission 6/11/21)
1. 6/11/21:
a. "Interdisciplinary Treatment Plan - Medical Problem Sheet "for altered tissue perfusion (Cardiovascular/Peripheral Vascular Disease):
- "Practitioner to assess and monitor: medical condition, symptoms, and compliance with treatment".
b. Practitioner order: Metoprolol 25 mg (milligrams) by mouth twice a day. Hold for systolic blood pressure less than 100, diastolic blood pressure less than 60 or heart rate less than 50.

2. "Graphic Sheet" documentation of heart rate:
- 6/12/21 at 8:00 PM: 112
- 6/14/21 at 8:00 AM: 111

3. 6/18/21 at 10:52 AM: "Consultation Report" stated "...Patient had syncopal episode yesterday ...has a history of orthostatic hypotension..." (a form of low blood pressure that happens when standing after sitting or lying down).

4. 6/18/21 at 10:53 AM: Practitioner Order for orthostatic blood pressure (Obtained by having the patient lie down for 5 minutes, measuring blood pressure and pulse rate, having the patient stand, repeat blood pressure and pulse rate measurements after standing 1 and 3 minutes) daily in the morning for 3 days.

5. No evidence the following were completed as ordered:
- The metoprolol was administered between 6/11 and 6/21/21.
- The orthostatic blood pressures

This finding was confirmed by ADON A on 1/12/21 between 10:50 AM and 2:02 PM.

During an interview on 1/21/22 between 1:15 PM and 2:00 PM, Provider #2 confirmed that it is the responsibility of the provider to ensure orders have been carried out and to follow up on any concerns presented by the patient.

B. Patient #8 (Admission 3/11/21)

1. Transfer documents from Nursing Home A reported that Patient #8 had a medical history of hearing loss, lumbago, sciatica, chronic kidney disease, hypercalcemia, hypertension, iron deficiency anemia, history of cardiac arrhythmia, history of peptic ulcer disease, high cholesterol, and dementia. Ambulatory status is documented as ambulatory without the assistance of medical devices.

2. "Nursing Assessment" dated 3/11/21 at 6:40 PM stated: "Resistant to enter the facility or to walk down hall to unit. Three staff members were able to direct patient to unit. Alert to person, confused."

3. "Nursing Note Post Patient Fall" dated 3/12/21 at 3:35 AM reported Patient #8:
- Fell at 2:15 AM.
- Was sent to the local emergency department (ED) for examination.

4. "History and Physical Examination" dated 3/12/21 at 9:15 AM:
- Completed by Provider #4 after Patient #8's return from emergency department.
- Addressed the computed tomography (CT) of the head which was completed at the ED, stating it, "was negative for any bleed [and] that showed ethmoid mucosal thickening and retention cysts."

5. "Psychiatric Progress Notes" dated 3/13/21 and 3/14/21, documented Patient #8 was "in geri chair" (a large, padded chair that is designed to help seniors with limited mobility); however, contained no evidence of a psychomotor assessment.

6. "Psychiatry Progress Notes" dated 3/16/21 stated, "Patient not eating, holding food in mouth...patient not drinking, spitting fluid out..."

7. Practitioner orders dated 3/16/21:
- Ensure 8 ounces by mouth three times a day for decreased eating/drinking.
- Consultations for physical therapy and occupational therapy.

8. "Psychiatry Progress Notes" dated 3/17/21 stated, "patient sedated...not eating...having to force fluids...speech slurred and mumbling."

9. "Psychiatry Progress Notes" dated 3/18/21 stated, "Slurred speech...not eating/drinking..."

10. Occupational Therapy evaluation dated 3/18/21 reported the following about Patient #8:
- Level of assist needed for all activities was "dependent".
- Sitting balance: poor
- Standing: unable
- Endurance: poor
- Mobility: unable

11. Practitioner Order dated 3/18/21 at 10:30 AM for STAT (immediate) blood work including a CBC (complete blood count) with differential and BMP (basic metabolic panel).

12. Lab results from STAT bloodwork resulted in several abnormal values.

13. Practitioner Order dated 3/18/21 at 6:15 PM: "Send to ED".

14. "Narrative Daily Progress Note" stated "patient to be admitted" to local acute care hospital.

Facility was unable to provide evidence that medical staff performed reassessment of patient's neurological condition in presence of changes in patient's motor ability, speech, and appetite, in a timely manner. There is no evidence of clinical justification regarding delay in patient referral to ED after change in presentation.

These findings were confirmed during an interview with ADON A on 1/31/22 from 2:35 to 2:53 PM.

V. Medical record entries were illegible and/or did not contain all required information.

Medical Record review revealed:

A. Patient #1 (Admission 11/17/21)
1. Progress notes illegible on the following dates:
- 11/18/21 - 11/21/21

2. Medication orders were incomplete or illegible include:
- 11/17/21 at 11:40 AM - Unable to read all medication names, indications, doses including units, routes and frequency of administration.
- 11/18/21 at 10:40 AM - Medication order was missing units: "Seroquel 200 PO (by mouth) qhs (every bedtime)"
- 11/19/21 at 9:00 AM - Unable to read all medication names, doses including units, indications, or frequency of administration.
- 11/19/21 at 1:00 PM - Medication order was missing units: "Valium 10 PO at 3 PM"
- 11/21/21 at 10:00 AM - Medication order was missing a route of administration: "Valium 10 mg (milligrams) now as extra dose"
- 11/21/21 at 12:00 PM - Telephone/verbal order missing provider signature, date, and time.
- 11/21/21 at 9:10 PM - Telephone/verbal order missing provider signature, date, and time.
- 11/22/21 at 8:00 AM - Unable to read orders.

These findings were confirmed by Compliance Nurse #3 on 2/1/21 at 9:51 AM.

B. Patient# 6 (Admission 6/11/21):

1. Progress notes illegible on the following dates:
- 6/13/21- 6/20/21

2. Consult notes dated 6/15 and 6/19/21 were illegible.
- On 1/11/22 between 3:20 PM and 5:00 PM, Nurses #5, 12, and 13 attempted to read the consult notes and none were able to do so.

3. Orders were incomplete or illegible include:
- 6/13/21 at 7:30 AM - Order to send the patient to the ED was missing an indication.
- 6/14/21 at 9:40 AM - Missing indication for patient transfer Unit B.
- 6/15/21 at 10:00 AM - No indication given for wrist brace or vital signs to be done every shift for 24 hours.
- 6/16/21 at 1:45 PM - Provider did not date and time signature.

These findings were confirmed with ADON A on 1/11/22 between 3:20 PM and 5:00 PM.

Based on medical record review, staff interview and review of policies and other hospital documents, it was determined that the hospital failed to: ensure adequate numbers of nursing staff (refer to A 392); ensure the registered nurse supervised and evaluated the nursing care (refer to A 395); document interventions in the care plan to reflect current needs (refer to A 396). The cumulative effect of these systemic problems resulted in the hospital nursing service's inability to provide quality patient care.

Based on hospital document review and staff interview it was determined that the hospital failed to ensure adequate numbers of nursing staff for 3 (Unit A, B and T) of 7 patient care units. Findings include:

The hospital policy titled "Staffing Plan for Nursing Services" stated, "...Core coverage includes ensuring there is 1 RN (registered nurse) on each unit at all times and that there is at minimum 2 staff on each unit at all times...An RN must always be in the unit. Neither an RN House Supervisor nor an LPN (licensed practical nurse) can serve as the RN in the unit..."

The hospital policy titled "Twenty Four Hour Staffing Coverage" stated, "...There will be at least 1 Registered Nurse and 1 other licensed person on each unit for day shift, evening shift. There will be at least 1 RN covering each unit on the night shift..."

Review of the hospital staffing records from 1/9/22 to 1/22/22 revealed there was not an RN on each unit as follows:
1/15/22 7:00 PM to 11:00 PM: Unit A
1/17/22 7:00 PM to11:00 PM: Unit B
1/19/22 6:30 AM to 7:00 AM: Unit B
1/20/22 7:00 AM to 11:00 AM: Unit A
1/20/22 11:00 PM to 7:00 AM: Unit T
1/22/22 12:00 PM to 3:00 PM: Unit T

These findings were confirmed with Assistant Director of Nursing A on 2/1/22 between 2:00 PM and 3:00 PM.

Based on medical record review, policy review and staff interview, it was determined that the registered nurse (RN) failed to supervise and evaluate the nursing care for 4 of 19 patients in the sample (Patient #'s 1, 4, 5 and 9). Findings include:

I. The hospital policy titled "Detoxification" stated, "...Patients...experiencing significant medical withdrawal from addictive substances are admitted to an inpatient program and managed safely following established detoxification protocols...The patients are prescribed treatment and management of withdrawal symptoms based upon adopted guidelines of clinical Institute of Withdrawal Assessment and the facility established Diazepam Detoxification Protocol for Benzodiazepines & Alcohol dependence or the Buprenorphine Detoxification Protocol for Opiate...Protocol for Alcohol Withdrawal...CIWA (Clinical Institute of Withdrawal Assessment) is to be done only by the RN (registered nurse) or LPN (licensed practical nurse). Document medications given on Medication Administration record...assessment and score prior to any schedule Diazepam administration...Protocol for Opiate Withdrawal...COWS (Clinical Opiate Withdrawal Scale) to be done only by RN or LPN...Vital signs & COWS assessment to be completed prior to Diazepam...administration..."

A. Patient #1
1. Admitted 11/17/21 with diagnoses of depression with dependence to alcohol, opioids via intravenous route, and cocaine via smoking, and a history of seizures.

2. Practitioner orders
a. Admission orders dated 11/17/21 included orders:
- Place patient on a Clinical Withdrawal Assessment for Opiates (COWS) and Alcohol (CIWA) until discontinued by MD (medical doctor).
- Withdrawal medications: Day 1 (11/17/21) Diazepam 10 milligrams (mg) at 6:00 AM, 12:00 PM
b. Orders dated 11/18/21:
- Day 1 (11/17/21): Diazepam 20 mg at 6:00 PM and 12:00 AM
- Day 2 (11/18/21): Diazepam 20 mg at 6:00 AM, 12:00 PM, 6:00 PM and 12:00 AM
- Day 3 and 4 (11/19 and 11/20/21): Diazepam 10 mg at 6:00 AM, 12:00 PM, 6:00 PM and Diazepam 20 mg 12:00 AM
- Day 5 and 6 (11/21 and 11/22/21): Diazepam 10 mg at 12:00 PM and 12:00 AM

3. The "Medication Administration Record" revealed that Diazepam was administered in accordance with the practitioner orders between 11/17/21 and 11/22/21.

4. The COWS assessment form revealed no evidence assessments were completed prior to Diazepam administration on the following dates/times:
11/17/21: 12:00 PM and 6:00 PM
11/18/21: 12:00 AM, 6:00 AM, 12:00 PM and 6:00 PM
11/19/21: 12:00 AM, 6:00 AM, 12:00 PM and 6:00 PM
11/20/21: 12:00 AM, 6:00 AM, 12:00 PM and 6:00 PM
11/21/21: 12:00 AM

5. The CIWA assessment form revealed no evidence assessments were completed prior to Diazepam administration on the following dates/times:
11/20/21: 6:00 AM and 6:00 PM
11/21/21: 12:00 AM and 12:00 PM
11/22/21: 12:00 AM

Interview with Assistant Director of Nursing (ADON) A on 1/13/22 between 2:20 PM and 3:00 PM, confirmed these findings and that nursing failed to complete the detoxification monitoring in accordance with facility policy.

II. The hospital policy titled "Vital Signs and Pain Re-Assessment" stated, "...the nursing staff is responsible for initiating and monitoring vital signs for all patients...physician...orders an appropriate frequency of vital signs monitoring...When the physician orders non-routine vital signs, the specific frequency of monitoring is noted both on the medication administration record...and the non-medication kardex...'Routine vital signs' ...Following admission, temperature, blood pressure, pulse and respirations are obtained from inpatients at least once a day in the morning and recorded on the vital sign sheet...the RN (registered nurse) is responsible for vital sign monitoring on the program..."

Medical record review revealed:
A. Patient #4
1. Admission orders dated 11/26/21, include orders for daily vital signs.

2. No evidence of vital signs on 12/4/21 and 12/5/21.

This finding was confirmed with Assistant Director of Nursing (ADON) A on 1/10/22 between 3:14 and 3:26 PM.

B. Patient #5
1. Admission orders dated 8/19/21, including orders for routine vital signs.

2. No evidence of vital signs on 9/10, 9/11, 9/12, 9/14, 9/17, 9/18, and 9/20/21.

3. Practitioner orders dated 10/13/21, included order for vital signs to be completed once a shift (day/evening/night).

4. No evidence of vital signs as follows:
Day shift (7:00 AM - 3:00 PM): 11/3, 11/12, 11/21, 11/24, and 11/25/21
Evening shift (3:00 PM - 11:00 PM): 10/16, 10/17, 10/22-10/26, 10/28, 10/31, 11/2, 11/5-11/9, 11/12, 11/13, 11/15, 11/18, 11/20, 11/21, and 11/25/21
Night shift (11:00 PM - 7:00 AM): 10/14, 10/17, 10/23-10/26, 10/30, 11/1-11/3, 11/7-11/9, 11/11-11/14, 11/16, 11/22, 11/26, and 11/27/21.

This finding was confirmed with Assistant Director of Nursing (ADON) A on 1/31/22 between 12:16 PM and 12:35 PM.

C. Patient # 9
1. Admission orders dated 7/26/21, included orders for routine vital signs.

2. No evidence of vital signs on 7/28-7/30, 8/2 and 8/4/22.

3. Admission orders dated 8/7/21, included orders for routine vital signs.

4. No evidence of vital signs on 8/17, 8/18, 8/21, and 8/22/21.

These findings were confirmed with ADON A on 1/26/22 from 2:30 PM - 4:15 PM and 1/28/22 from 10:02 AM - 12:30 PM.

Based on policy review, medical record review, and staff interview it is determined that for 1 of 1 patients that fell during the hospitalization (Patients #8), the facility failed to document interventions in the care plan to reflect current needs.

The hospital policy titled "Treatment Planning" stated, "...policy to develop...a Multidisciplinary treatment plan for each patient...will be individualized and identify the specific needs...and specific interventions to be conducted by staff..."

Medical record review revealed:

A. Patient #8 (Admitted 3/11/21)
1. "Nursing Assessment" dated 3/11/21 at 6:00 PM contained the following documentation:
- "Morse Fall Assessment" score of 70
- High level of risk is a score greater than 45
- Moderate to high risk requires the implementation of the "Potential for Injury related to Falls Problem Sheet"

2. "Nursing Note Post Patient Fall" documented that Patient #8 fell on 3/12/21 at 2:15 AM.

3. "Interdisciplinary Treatment Plan" dated 3/12/21:
- Problem: "Potential Injury related to Fall"
- Level of Risk: High Morse Falls Score
- No interventions documented to prevent falls on treatment plan.

These findings were confirmed during an interview with Assistant Director of Nursing A on 1/31/22 between 2:35 PM and 2:53 PM.

Based on medical record review, policy and document review and staff interview, it was determined that for 6 of 19 patients (Patient #'s 1, 2, 5, 6, 7 and 9) in the sample, nursing staff failed to administer medications in accordance with the practitioner orders and approved medical staff policies and procedures. Findings include:

The hospital policy titled "Medication Order Transcription and Administration" states, "...The nurse follows all guidelines for the...medication administration...Each nurse is responsible for signing her/his first initial, last name, title and initials in the space provided on the M.A.R. (medication administration record)...Standard Times for Medication Administration...daily 0900 ...b.i.d. (twice a day) 0900 - 2100...t.i.d. (three times a day) 0900 - 1600 - 2100...q.6h. (every 6 hours) 0600 - 1200 - 1800 - 2400...q. 12h. (every 12 hours) 0900 - 2100...exceptions to the times...must be stated in...order...immediately upon administering a medication, the nurse administering it records her/his first and last initials in the appropriate time box on the M.A.R. to indicate that the patient has taken the respective medication...The patient's physician must be notified when the patient refuses prescribed medication or in any circumstance in which patient's receipt of medication varies from what has been ordered by the medical staff...Prior to administering any...insulin the Medication Nurse must have a second licensed nurse review and confirm that the correct medication, dosage, time and route has been prepared for the administration to the patient. The second is to co-sign the M.A.R. to indicate that she/he has confirmed that the correct medication, dosage, route and time have been ensured..."

The hospital policy titled "Diabetic monitoring Policy" stated, "...Documentation...On the MAR...Injection Site..."

The hospital policy titled "Nursing Accountability" stated, "Registered Nurse (RN)...responsible for...primary responsibility for the overall safety...of individual patients...careful execution of all applicable physician or treatment orders for patients on the program..."

Medical record review revealed the following:

A. Patient #1 (Admission 11/17/21)

1. Practitioner orders
- 11/17/21 Cephalexin 500 mg by mouth q.6h. for 7 days.
- 11/17/21 Clonidine 0.1mg by mouth every 2 hours as needed for any of the following: SBP (systolic blood pressure define) greater than 140, heart rate greater than 100

2. M.A.R. revealed no evidence the following medications were administered in accordance with practitioner orders, or that the patient refused the medication, or that the physician was notified that the patient's receipt of medication varied from what was ordered:

a. Cephalexin 500 mg q.6h.
- 11/19/21 at 1:00 PM (only 3 doses given)

b. Clonidine 0.1 mg as needed based on symptoms

1. Heart Rate greater than 100
11/18/21 at 6:00 PM - HR 103
11/19/21 at 4:00 PM - HR 112
11/19/21 at 6:40 PM - HR 105
11/20/21 at 1:00 AM - HR 105
11/20/21 at 9:00 AM - HR 101
11/20/21 at 12:00 PM- HR 110
11/21/21 at 9:00PM - HR 106

2. SBP greater than 140
11/17/21 at 3:00 AM - 155/64
11/21/21 at 9:00 AM - 142/82

These findings were confirmed with Assistant Director of Nursing (ADON) A on 1/13/22 between 2:20 PM and 3:14 PM.

B. Patient #2 (Admission 12/7/21)

1. Practitioner Orders
- 12/7/21 at 6:30 PM Ducusate Sodium (Colace) 100 mg by mouth b.i.d.
- 12/7/21 at 6:30 PM Lithium Carbonate 300 mg by mouth t.i.d.
- 12/19/21 at 9:53 AM Truvada 200 mg - 300 mg by mouth daily for 27 days
- 12/19/21 at 9:53AM Isentress 400 mg by mouth b.i.d. for 30 days

2. "Documentation of Medications Not Administered" record revealed the following medications were not administered and the reason the medication was not administered; however, there was no evidence the physician was notified when the medication administration varied from what was ordered by the medical staff:
- Truvada 200/300 mg at 9:00 AM on 12/22 - 12/24, 12/28 - 12/31/21 and 1/2/22
- Insentress 400 mg at 9:00 AM on 12/23, 12/24, 12/26, 12/28 - 12/31/21, 01/2/22 and at 8:00 PM on 12/30/21
- Colace 100 mg on 12/26/21 at 9:00 PM and 12/28 - 12/30/21 at 9:00 AM
- Lithium Carbonate 300 mg at 4:00 PM on 12/30/21

These findings were confirmed with ADON A on 1/25/22 at 12:02 PM.

C. Patient #5 (Admission 8/19/21)

1. Practitioner Orders:
- 8/19/21 Tegretol 400mg by mouth b.i.d.
- 8/19/21 Clobazam 30mg by mouth b.i.d.
- 8/19/21 Topamaz 200mg by mouth b.i.d.
- 8/20/21 Nystatin Powder 100,000 grams b.i.d. to inframammary folds for 10 doses

2. M.A.R. revealed no evidence the following medications were administered, or that the patient refused the medication:

a. Tegretol 400 mg b.i.d.
- 8/21/21 at 9:00 PM
- 9/23/21 at 9:00 PM
- 12/2/21 at 9:00 AM

b. Clobazam 20 mg b.i.d.
- 8/21/21 at 9:00 PM
- 9/23/21 at 9:00 PM
- 12/2/21 at 9:00 AM

c. Topamaz 200 mg b.i.d.
- 8/21/21 at 9:00 PM
- 9/23/21 at 9:00 PM
- 12/2/21 at 9:00 AM

d. Nystatin Powder 1000,000 grams b.i.d. for 10 doses
- 8/21/21 at 9:00 PM.

These findings were confirmed with Assistant Director of Nursing (ADON) A on 1/31/22 between 11:59 AM and 12:11 PM.

D. Patient #6 (Admission 6/11/21)

1. Practitioner Orders
a. 6/11/21
- Metoprolol 25 mg by mouth b.i.d.
- Xanax 0.5 mg by mouth b.i.d.
- Aromasen 25 mg by mouth daily

b. 6/12/21
- Ducolax 5 mg by mouth daily

2. Medication Administration Record revealed no evidence the following medications were administered in accordance with practitioner orders, and/or that the physician was notified when the patient refused the medication, or in a circumstance in which patient's receipt of medication varied from what was ordered:
a. Metoprolol
6/11/21 - 6/21/21 (19 doses not given)
b. Xanax
6/12/21 - 6:00 PM dose refused
6/14/21 - 9:00 AM dose refused
c. Aromasen
6/11/21 - 6/18/21 (6 doses)
e. Ducolax
6/13/21 - administered 2 doses rather than the one ordered
6/17/21 - administered 3 times rather than the one ordered

These findings were confirmed with ADON A on 1/12/22 between 10:50 AM and 2:02 PM.

E. Patient #7 (Admission 10/8/21)

1. Practitioner orders
- 10/9/21 Hydrocortisone 1% cream to rash on left forearm t.i.d. until healed
- 10/11/21 Benadryl 100 mg by mouth at bedtime
- 10/12/21 Lidocaine 4% patch to back - 12 hours on - 12 hours off daily
- 10/19/21 Salicylic Acid Patches apply to the feet daily
- 10/28/21 Buspar 15 mg by mouth t.i.d.

2. M.A.R. revealed no evidence the following ordered medications/treatments were administered, that the patient refused the medication, or that the physician was notified that the patient's receipt of medication varies from what has been ordered by the medical staff:

a. Hydrocortisone 1% cream
- 10/19/21 at 4:00 PM

b. Benadryl 100 mg at bedtime
- 10/20/21 at 9:00 PM

c. Salicylic acid patches to feet daily
- 10/23/21 at 9:00 AM

d. Lidocaine 4% patch application/removal
- 10/17/21 at 9:00 AM
- 10/22/21 at 9:00 PM

e. Buspar 5 mg t.i.d.
- 10/20/21 at 9:00 PM

These findings confirmed during an interview with ADON A on 1/27/22 at 3:17 PM.

F. Patient # 9 (Admissions 7/26/21 and 8/7/21)

7/26/21 Admission
1. Practitioner orders
a. 7/26/21
- Calcium 600 mg by mouth daily
- Levothyroxine 25 mg by mouth daily
- Repaglinide 0.5 mg by mouth ac (before meals) - may use own
- Omeprazole 40 mg by mouth daily
- Accuchecks (blood glucose/sugar test) ac and HS (bedtime)
- Accucheck upon admission to unit
- Depakote ER 500 mg by mouth b.i.d.

b. 7/27/21
- Nystatin Topical 100,000 units per gram powder t.i.d. for candiditis
- Trazadone 100 mg by mouth QHS (every day at bedtime)
- Humalog (insulin) Sliding Scale ac beginning the morning of 7/28/21
Blood Sugar Insulin Coverage
0 - 150 0
151 - 200 3 units
201 - 250 5 units
251 - 300 8 units
301 - 350 10 units
351 - 400 12 units
Greater than 400 15 units and call medical (staff)

c. 7/28/21
- Haldol 5 mg by mouth QHS
- Lantus 45 units sq (subcutaneous) QHS
- Symbicort 80/4.5 (inhaler) 2 puffs b.i.d.
- Simvastatin 20 mg by mouth QHS
- Oxybutynin ER 15 mg by mouth QAM (every morning)

d. 7/30/21
- Benadryl 100 mg by mouth QHS

e. 7/31/21
- Clotrimazole 1% cream 5 gm (gram) intravaginally daily for 7 days
- HS Sliding Scale
Blood Sugar Insulin Coverage
70 - 250 0
251- 300 2 units
301-350 3 units
351 - 400 4 units
Greater than 400 call medical (staff)
- 9:20 PM One time order: "Humalog 10 units SubQ (subcutaneous) 1X (one time) now for BS (blood sugar) over 600. Recheck BS in 1 hour."

f. 8/1/21
- Humalog 5 units with each meal

g. 8/2/21 at 6:16 PM
- Discontinue Lantus 45 units sq QHS
- Lantus 48 units sq QHS

2. M.A.R. revealed no evidence the following ordered medications/treatments were administered, that the patient refused the medication, or that the physician was notified that the patient's receipt of medication varies from what has been ordered by the medical staff:
a. Calcium
8/4/21
b. Levothyroxine
8/5/21
c. Repaglinide
- 12:00 PM doses on 7/31/21, 8/1/21, and 8/5/21
- 5:00 PM dose on 8/3/21
d. Omeprazole
8/5/21
e. Haldol
7/31/21
f. Benadryl
7/31/21
g. Clotrimazole cream
8/5/21, 8/6/21
h. Accucheck upon admission
i. Humalog 5 units
- 7:00 am on 8/5/21, 8/6/21
- 12:00 pm on 8/2/21, 8/4/21,
j. Accucheck, Humalog 5 units and sliding scale insulin coverage
- 7:00 AM 8/5/21
- 11:00 AM/12:00 PM 8/6/21
k. Accucheck recheck one time order after blood sugar greater than 600
- 7/31/21 at 10:20 PM

3. M.A.R. revealed no evidence a second licensed nurse reviewed, confirmed, and signed that the correct insulin medication, dosage, time and route were prepared and administrated to the patient for the following insulin administrations:
a. Humalog sliding scale
- 8/1/21 at 11:00 AM
- 8/3/21 at 4:30 PM and 9:00 PM
b. Humalog 5 unit
- 8/1/21 at 7:00 AM and 12:00 PM

4. M.A.R. revealed no evidence the following sliding scale insulin doses were administered in accordance with practitioner orders:
a. 7/29/21 at 11:00 AM
- Accucheck documented as "HI"
- Humalog 25 units was administered, contrary to the sliding scale order to give 15 units if accucheck is above 400 and call medical staff.
- No evidence the medical staff was notified of the accucheck result of "HI".

5. M.A.R. revealed documentation that the following sliding scale insulin doses were administered; however, medical record revealed no evidence of a practitioner order:
a. 7/29/21 at 9:00 PM (HS)
- Accucheck = 524
- Humalog 15 units administered
- No HS sliding scale orders at that time.
- No evidence of medical staff notification or a one time orders for this dose.
b. 7/30/21 at 9:00 PM (HS)
- Accucheck = 584
- Humalog 15 units administered
- No HS sliding scale orders at that time.
- No evidence of medical staff notification or a one time orders for this dose.

6. M.A.R. revealed documentation that Lantus 45 units and Lantus 48 units were both signed off as administered at 9:00 PM on 8/2/21 and 8/3/21.
- Medical record review revealed Lantus 45 units sq was discontinued on 8/2/21at at 6:16 PM.

These findings were confirmed with ADON A on 1/26/22 between 2:30 PM and 4:15 PM.

7. M.A.R. revealed that the following medications were refused by the patient; however, there was no physician notification that the patient's receipt of the medication varied from what had been ordered by the medical staff:

a. Nystatin Topical - refused at 4:00 PM and 9:00 PM on 7/31/21, refused at 9:00 PM on 8/3/21 and 8/4/21 (4 doses)
b. Symbicort - All doses refused except 9:00 AM doses on 7/31/21 and 8/1/21 (15 doses)
c. Simvastatin refused at 9:00 PM on 8/3/21 and 8/4/21 (2 doses)
d. Trazadone - refused 8/1/21 and 8/3/21 (2 doses)
e. Oxybutynin ER - refused 7/29/21 and 7/30/21 (2 doses).
f. Levothyroxine - refused 7/31/21-8/2/21 (3 doses)
g. Depakote - refused on 8/1/21 (1 dose)
h. Repaglinide - refused 5:00 PM on 7/28/21, 12:00 PM and 5:00 PM on 7/29/21, and 5:00 PM on 8/1/21 (4 doses refused).
i. Omeprazole - refused on 8/1/21 and 8/2/21 (2 doses).

These findings were confirmed with ADON A on 1/12/22 between 10:50 AM and 2:02 PM.

8/7/21 Admission

1. Practitioner orders
a. 8/7/21
- Omeprazole 40mg by mouth daily
- Depakote DR 1000mg by mouth QHS
- Depakote DR 500mg by mouth Q AM
- Repaglinide 0.5mg PO AC, may use own
- Lantus 48 units sq QHS
- Humalog 5 units sq AC, hold if blood glucose is less than 150
- Humalog sliding scale sq AC
Blood Sugar Insulin Coverage
0 - 150 0
151 - 200 3 units
201 - 250 5 units
251 - 300 8 units
301 - 350 10 units
351 - 400 12 units
Greater than 400 15 units and call medical (staff)
- HS sliding scale insulin
Blood Sugar Insulin Coverage
70 - 250 0
251- 300 2 units
301-350 3 units
351 - 400 4 units
Greater than 400 call medical (staff)

b. 8/11/21
- Lipitor 40mg by mouth QHS

c. 8/15/21
- Hold am dose of Depakote until after blood drawn for lab testing then administer.

d. 8/16/21
- Humalog 3 units before each meal in addition to the sliding scale.
- Previous order for Humalog 5 units was not discontinued. No evidence of order being clarified with provider.

e. 8/20/21
- Depakote DR increased to 1000mg Q AM
- Lantus 48 units sq QHS discontinued
- Lantus 52 units sq at bedtime added
- Discontinue Humalog 3 units before each meal
- Humalog 6 units sq three times a day with meals

f. 8/23/21
- Discontinue Humalog 6 units
- Humalog 9 units sq before each meal three times a day in addition to sliding scale

2. M.A.R. revealed:

a. No evidence a second licensed nurse reviewed, confirmed, and signed that the correct insulin medication, dosage, time and route were prepared and administrated to the patient for the following insulin administrations:
- Lantus 48 units at 9:00 PM: 8/11/21, 8/14/21, 8/17/21, 8/18/21
- Humalog 5 units QAC:
9:00 AM: 8/9/21 - 8/15/21, 8/17/21 and 8/18/21
12:00 PM: 8/9/21, 8/14/21 and 8/15/21
4:30 PM: 8/7/21, 8/11/21, 8/13/21 - 8/17/21
- Humalog 3 units QAC:
8:00 AM: 8/18/21 - 8/20/21
12:00 PM: 8/16/21 and 8/18/21
5:00 PM: 8/16/21 - 8/18/21
- Lantus 52 units at 9:00 PM: 8/20/21,
- Humalog 6 units QAC:
7:00 AM: 8/21 - 8/22/21
12:00 PM: 8/19/21, 8/22/21
5:00 PM: 8/21 - 8/22/21
- Sliding Scale Humalog:
7:00 AM: 8/13/21
12:30 PM: 8/13/21, 8/16/21
4:30 PM: 8/7/21, 8/13/21, 8/14/21, 8/17/21, 8/21 -8/23/21
9:00 PM: 8/7/21, 8/15/21, 8/17 - 8/18/21, 8/20/21, and 8/22/21
- Humalog 9 units:
9:00 AM: 8/24/21
12:00 PM: 8/23/21
5:00 PM: 8/23/21

b. No evidence the following ordered medications/treatments were administered, that the patient refused the medication or that the physician was notified that the patient's receipt of medication varies from what has been ordered by the medical staff:

1. 8/9/21
8:00 AM - Regalinide
11:00 AM - Regalinide

2. 8/10/21
8:00 AM- Regalinide
11:00 AM - Regalinide
12:00 PM - Humalog 5 units standing dose

3. 8/11/21
8:00 AM - Regalinide
11:00 AM - Regalinide
12:00 PM Humalog 5 units standing dose

4. 8/12/21
11:00 AM - Regalinide
12:30 PM - Humalog 5 units standing dose
4:30 PM - Humalog 5 units standing dose

5. 8/13/21
12:00 PM - Humalog 5 units standing dose

6. 8/14/21at 9:00 PM
- Blood sugar = 256
- No evidence the patient received Humalog 2 units in accordance with the sliding scale insulin order.

7. 8/16/21
7:00 AM
- Blood sugar = 445
- No evidence the patient received Humalog 15 units in accordance with the sliding scale insulin order.
- No evidence medical staff was called.
9:00 AM
- Humalog 5 units standing dose
- Depakote
4:30 PM - Humalog 5 units standing dose
5:00 PM - Humalog 3 units standing dose documented - orders not clarified.

8. 8/19/21
12:00 PM - Humalog 3 units standing dose

9. 8/20/21
9:00 AM - Lipitor
12:30 PM - Blood glucose level or insulin administration (standing dose or sliding scale).
4:00 PM - Regalinide
5:00 PM - Humalog 6 units standing dose

10. 8/22/21
9:00 PM - Lantus insulin

11. 8/23/21
4:00 PM - Regalinide

12. 8/24/21
12:30 PM - Humalog 9 units standing order
4:00 PM - Regalinide

c. No evidence the following medications/treatments ordered by medical staff were administered in accordance with practitioner orders:

1. 8/7/21 at 4:30 PM
- Blood sugar = 573
- Humalog 20 units administered for the sliding scale coverage, contrary to the ordered 15 units and call medical staff.
- Medical record review revealed no additional provider orders or documentation of medical staff notification.

2. 8/8/21at 4:30 PM
- Blood sugar = 598
- Humalog 20 units administered for the sliding scale coverage, contrary to the ordered 15 units and call medical staff.
- Medical record review revealed no additional provider orders or documentation of medical staff notification.

3. 8/12/21 at 12:30 PM
- Blood sugar = 399
- Humalog 15 units administered for the sliding scale coverage, contrary to the ordered 12 units

4. 8/15/21 at 4:30 PM
- Blood sugar = "hi" (greater than 400)
- Humalog 12 units administered for the sliding scale coverage, contrary to the ordered 15 units and call medical staff.
- Medical record review revealed no additional provider orders or documentation of medical staff notification.

5. 8/18/21 at 7:00 AM
- Blood glucose = 476
- The amount of sliding scale insulin administered was not documented.
- Medical record review revealed no additional provider orders or documentation of medical staff notification.

6. 8/20/21 at 4:30 PM
- Blood glucose = 557
- Humalog 16 units given for sliding scale coverage, contrary to the ordered 15 units and call medical staff.
- Medical record review revealed no additional provider orders or documentation of medical staff notification.

7. 8/21/21
7:00 AM
- Blood glucose = 409
- Humalog 12 units given for sliding scale coverage, contrary to the ordered 15 units and call medical staff.
- Medical record review revealed no additional provider orders or documentation of medical staff notification.

8. 8/24/21 at 12:30 PM
- Blood glucose = 400
- Humalog 15 units given for sliding scale coverage, contrary to the ordered 12 units.
- Medical record review revealed no additional provider orders or documentation of medical staff notification.

d. The patient refused the following medications:

1. 8/17/21
6:00 AM - Blood glucose 357. Patient refused Humalog 12 units sliding scale insulin and 3 unit standing dose).
12:30 PM - Patient refused blood glucose reading and insulin (sliding scale and standing dose).

2. 8/19/21
5:00 PM - Humalog 3 units standing dose of insulin refused.

3. 8/21/21
12:30 PM - blood glucose and insulin (sliding scale and standing) refused.

Medical record revealed no evidence of physician notification when the patient's receipt of the medication varied from what had been ordered by the medical staff.

e. The M.A.R contained documentation that Humalog 6 units was administered on 8/19/21 at 12:00 PM; however, there was no medical staff order for this dose of Humalog.

These findings were confirmed with ADON A on 1/26/22 from 2:30 PM - 4:15 PM and 1/28/22 from 10:02 AM - 12:30 PM.

Based on observation, policy review and staff interview, it was determined that for 68 out of 68 patients on 12/30/21, the hospital failed to ensure that facilities were maintained in a manner to assure an acceptable level of safety and wellbeing of patients. Findings include:

The hospital policy titled "Safety/Hazard Surveillance" stated, "...To promote an environment for patients, staff, and visitors that is free from safety hazards and that all facility areas are in compliance with local and state regulations..."

A. Interview with Director of Plant Operations 1/28/22 9:35 AM revealed:

1. The Plant Operations team completes an environmental survey by walking through the entire facility every 2 weeks.

B. During an environmental tour of inpatient areas of the hospital on 12/30/21 between 11:45 AM and 12:45 PM, the following observations were made:

1. Unit D West:

a. Day Room with paint chipping off wall.

This finding was confirmed by Compliance Nurse #1 12/30/21 12:00 PM

b. Day Room; a blanket on floor by juice machine related to a water leak.

Chief Executive Officer (CEO) confirmed this finding during an interview on 12/30/21 at 12:02 PM and stated the leak has been present for 2 days.

2. Unit D East:

a. Patient Room #27; an exposed sprinkler head.

This finding was confirmed with CEO on 12/30/21 at 12:08 PM.

b. Patient Bathroom #25; bottom left corner of the drywall next to the shower stall had water damage with black discoloration and a hole.

This finding was confirmed with CEO on 12/30/21 at 12:11 PM

c. Patient Bathroom #25; a soap dispenser ring mount with no soap dispenser screwed to wall.

This finding was confirmed with Assistant Director of Nursing (ADON) on 12/30/21 at 12:12 PM.

3. Unit C:

a. Patient Room #42; wardrobe was not attached to the wall.

This finding was confirmed with ADON on 12/30/21 at 12:26 PM.

4. Unit A:

a. Patient Room #61; wardrobe was not attached to the wall.

This finding was confirmed with ADON on 12/30/21 at 12:45 PM.

C. During an environmental tour of the hospital on 1/7/22 between 10:55 AM and 11:20 AM, the following observation was made:

1. Hallway between Units C and D:

a. Leak from ceiling with large plastic container placed under leak to collect water.

CEO confirmed this finding during an interview on 1/7/22 at 11:07 AM and stated the leak was from the HVAC (heating, ventilation, and air conditioning) system.

D. During an environmental tour of inpatient areas of the hospital on 1/28/22 between 1:55 PM and 2:10 PM, the following observation was made:

1. Unit C:

a. Patient Room #42; an exposed sprinkler head.

This finding was confirmed with Director of Facilities Operations on 1/28/22 at 2:10 PM.

Based on observation, policy and document review, and staff interview, it was determined that the hospital failed to ensure infection control measures were adhered to in 4 out of 5 patient units (Units A, C, D, and E) observed on 12/30/21 and 1/19/22. Findings include:

Hospital policy titled, "COVID Response Plan" stated, "...The best prevention methods continue to be universal masking and proper social distancing, hand hygiene...For COVID-19 standard, contact, and droplet precautions are to be followed...A sign should be placed on the patient door indicating Isolation Procedures...Exposure Definition - Contact within 6 feet for a time period of 15 or more consecutive minutes if the health care provider (HCP) was not wearing a face mask and the patient was not wearing a mask, or if the HCP was not wearing eye protection if the person with COVID-19 was not wearing a mask..."

Hospital policy titled, "Infection Transmission Precautions (Personal Protective Equipment [PPE] and Isolation Precautions)" stated, "...MBH issues N95 masks, staff are required to complete a medical clearance and fit testing...if unable to complete fit testing...employees are required to complete a 'fit checking' and a medical review...MBH (MeadowWood Behavioral Health Hospital) is responsible for providing staff appropriate education and training on the utilization of PPE...to include precautions and utilization of appropriate PPE...to include donning and doffing PPE...will be provided based on CDC and WHO guidelines..."

Hospital policy titled, "Hand Hygiene" stated, "...The facility follows the CDC (Centers for Disease Control and Prevention) Guidelines for Hand Hygiene in Health Care Settings...Wear gloves for contact when contact with blood or other potentially infectious materials, mucous membranes, or non-intact skin is anticipated...Remove gloves and perform hand hygiene after patient contact. Do not wear the same gloves for the care of more than one patient..."

The Centers for Disease Control and Prevention (CDC) "Guideline for Hand Hygiene in Health-Care Settings" stated, "...Wearing gloves does not replace the need for hand hygiene...Failure to remove gloves after caring for a patient may lead to transmission of microorganizations from one patient to another...Indications for hand hygiene...Contact with environmental surfaces in the immediate vicinity of patient..."

Staff Meeting Agenda dated 6/17/21 stated, "...Social Distancing for Patients and Staff...Social Distancing on Patient Care units...It is a requirement for both patients and staff..."
The CDC guidelines entitled "How to Use Your N95 Respirator" stated, "...N95s must form a seal to the face to work properly...Your N95 must form a seal to your face to work properly...Jewelry, glasses, and facial hair can cause gaps between your face and the edge of the mask..."

1. During a tour of Unit D East on 12/30/21 between 11:54 AM to 12:29 PM D East the following was observed:
- The unit had one (1) COVID-19 positive patient and seven (7) patients in quarantine due to a COVID-19 exposure.
- No N95s on isolation cart.
- Assistant Director of Nursing (ADON) A utilizing a N95 respirator.
- Employee #1 wearing N95 over surgical mask.
- Staff were wearing isolation gowns at Unit D shared nurses' station, located between Unit D East (containing COVID-19 positive patient) and Unit D West (no COVID-19 positive patients).

During an interview on 12/30/21 between 11:54 AM and 12:11 PM, ADON A, who was present during the tour:
- Confirmed these findings.
- Reported that N95s are normally located in a drawer in the isolation cart.
- Confirmed that he/she (ADON A) had not been fit tested for an N95 and facility was not offering fit-testing at this time.

2. During a tour of Unit C Adolescent Unit on 12/30/21 between 12:29 PM and 12:42 PM with ADON A, the following was observed:
- The unit had 2 COVID-19 positive patients and 19 patients in quarantine due to a COVID-19 exposure.
- No isolation sign posted on the door of Room 36, the isolation room for the 2 COVID-19 positive patients.
- Red biohazard trash can overflowing with contaminated PPE (gowns, gloves, masks) outside of main entrance/exit to Unit C.
- No evidence of additional gowns or eye protection inside Unit C.
- No evidence of red biohazard trash disposal for PPE inside Unit C.

These findings were confirmed with ADON A, who was present at the time of the findings.

3. During an interview on 12/30/21 at 12:50 PM, Nurse #9:
- Stated "To be honest, we change (gowns) coming in and going out."
- Reported gowns are donned coming into Unit C, and doffed when leaving Unit C.

4. On 12/30/21 at 12:42 PM the following was observed:
- Housekeeper #2 was outside Unit C wearing disposable gloves, emptied red bag biohazard trash into cart used for PPE disposal (PPE had been used for care of COVID-19 positive patients and patients in quarantine because of a COVID-19 exposure), then pushed cart to an adjacent unit.
- Housekeeper #2 failed to perform hand hygiene and change gloves after emptying biohazard trash.

ADON A witnessed and confirmed this observation on 12/30/21 at 12:42 PM. In addition, ADON A reported that all employees have been trained on proper use of PPE.

4. During a tour of Unit D on 12/30/21 at 4:16 PM the following was observed:
- Red biohazard trash can was overflowing with contaminated PPE outside of Unit D.

This finding was confirmed with ADON A on 12/30/21 at 4:16 PM.

5. During an interview on 1/19/22 between 2:44 PM and 3:12 PM, Employee #48:
- Reported access to N95 respirators is provided via the isolations carts outside of units.
- Confirmed no fit testing for N95 had occurred.

6. On 1/19/22 at 3:12 PM, Staff #1 was observed with the mask not covering her nose on Unit C.

This finding was confirmed with Compliance Nurse #2 on 1/19/22 at 3:12 PM.

7. On 1/19/22 at 3:40 PM, Nurse #9 was observed with the mask not covering her nose on Unit C.

This finding was confirmed with Compliance Nurse #2 on 1/19/22 at 3:40 PM.

8. During an interview with Infection Preventionist A on 01/25/22 from 1:26 to 2:10 PM, it was reported that isolation signs are posted on unit doors, not patient room doors.

9. During an interview on 1/26/22 at 10:18 AM, Infection Preventionist A:
- Reported fit-testing equipment (for the N95 respirator fit testing) has been received, but he/she was not planning to conduct fit-testing for staff at this time.
- Confirmed that staff have not been educated on the proper use of N95 respirators or the purpose and importance of fit-testing.
- Confirmed PPE is donned on entrance to a unit, and doffed when exiting the unit.
- Confirmed that without exiting the unit, there is no opportunity to obtain clean PPE except for gloves.
- Confirmed no education on disinfection of PPE.

Based on observation, policy and document review, and staff interview, it was determined that for 4 out of 5 patient units (Units A, C, D, and E) observed on 12/30/21 and 1/19/22 the hospital and Infection Preventionist failed to develop and implement infection prevention and control policies and procedures which adhered to nationally recognized guidelines, to prevent the spread of COVID-19. Findings include:

The hospital policy titled, "Infection Control Plan" stated, "The primary goal of an infection prevention and control program is to reduce the occurrence of Healthcare Acquired Infections...to reduce the incident of HAIs in patients and to minimize transmission of infectious pathogens between patients, visitors, and healthcare providers...The infection control program emphasizes prevention of the spread of infection...Program is a systematic, coordinated and continuous approach governed by nationally recognized standards...such as...CDC (Centers for Disease Control and Prevention)...COVID-19 continues to present multiple challenges for facilities in preventing spread of infection and protecting patients and staff...proactive prevention...measures to reduce transmission...Infection prevention efforts must focus on breaking the chain of transmission of pathogens in the hospital setting. The presence of transmissible infection must be identified early...The infection control program will include, but not be limited to the following basic elements...Review and revision of Infection Control Policies and Procedures based on evidence-based guidelines that are available and applicable to all staff...Review and evaluation of all aseptic, isolation, and sanitation procedures employed in the facility...The infection control preventionist...is designated by job description to have authority and responsibility for overseeing and ensuring the following...Identify methods to limit exposure to patients, visitors, and staff to pathogens...Outbreak Response...Nursing staff will report...increased levels of infection to the Infection Control Practitioner as soon as they are noticed to enable early identification of a possible outbreak. The ICP (Infection Control Practitioner) will verify the diagnosis, define and identify possible cases and recommend strategies to curtail transmission..."

Hospital policy titled, "Infection Transmission Precautions (Personal Protective Equipment [PPE] and Isolation Precautions)" stated, "...Contact Precautions...Staff should wear: Gowns, gloves, surgical mask, eye protection...Staff should don PPE prior to entering the patient's room and doff and discard immediately before leaving the patient room into red bag waste receptacle..."

Hospital policy titled, "COVID Response Plan" stated, "...Exposure Definition - Contact within 6 feet for a time period of 15 or more consecutive minutes if the health care provider (HCP) was not wearing a face mask and the patient was not wearing a mask, or if the HCP was not wearing eye protection if the person with COVID-19 was not wearing a mask, or if the HCP was not wearing recommended PPE..."

The CDC guidance titled "COVID-19 Source Investigation" dated 2/23/21 stated, "...Case investigation for communicable disease control routinely involves contact tracing to: 1) discover the person(s) or event(s) that could be a potential source of infection, 2) identify people (contacts) with whom the person diagnosed with the communicable disease (case) may have interacted when they were infectious (potential exposure), and 3) prevent further disease transmission. COVID-19 case investigation and contact tracing efforts provide support to people who have been diagnosed with COVID-19 (cases) and exposed to SARS-CoV-2 (contacts) to facilitate prompt isolation and quarantine in order to prevent further spread of SARS-CoV-2..."

A. During an interview on 1/19/22 at 2:07 PM to 2:34 PM, Employee #19:
- Stated sharing nurses' station on D East and D West is concerning because the Unit D East had COVID-19 positive patients and patients on quarantine because of a COVID-19 exposure and Unit D West only had patients that were COVID-19 negative with no known exposure.
- Stated he/she did not receive training on donning and doffing PPE.
- Expressed concerns with the disposal of biohazard waste, specifically the contaminated PPE.

B. Review of the facility documents entitled "COVID Tracing" revealed:
- A COVID-19 outbreak was declared 12/18/21.
- The last COVID-19 positive patient in this outbreak was removed from isolation 2/1/22.
- No evidence contact tracing was completed for staff when additional patient cases were identified on 12/18/21, 12/21/21, 12/25/21, 12/29/21, 12/31/21, 1/1/22, 1/2/22, 1/4/22, 1/7/22 and 1/13/22.

C. During an interview on 1/25/21 between 1:26 PM and 2:10 PM, Infection Preventionist A:
- Confirmed the hospital policy entitled "COVID Response Plan" had not been updated since June 2020.
- Confirmed that staff have not been educated on use of eye protection to prevent exposure and that staff are considered "exposed" to COVID-19 without it.
- Reported that when a COVID-19 outbreak was identified 12/18/21, "it was too difficult" to conduct contact tracing for both staff and patients.

D. An interview with Infection Preventionist A on 01/26/22 at 10:18 AM revealed:
1. One-to-one education on donning and doffing PPE is done when an obvious opportunity for improvement is identified.
2. Rounding to observe for compliance with donning and doffing of PPE did not increase after 12/18/21 when the COVID-19 "outbreak" was declared.
3. Staff don and doff PPE prior to entrance to the unit.
4. With the exceptions of gloves, there is no opportunity to change PPE on the unit.

Based on policy and document review and staff interview, it was determined that for 68 of 68 current patients, based on census as of 12/30/21, the hospital failed to assess its discharge planning process on a regular basis. Findings include:

Review of facility documents revealed no evidence that a review of the discharge planning process was completed for the year of 2020 or for the first, second, and third quarters of 2021.

Interview with Director of Risk Management on 2/1/22 at 10:59 AM revealed that a review of the discharge planning process was not completed for the year of 2020 or for the first, second, and third quarters of 2021.

This finding was confirmed with the Director of Risk Management on 2/1/22 at 10:59 AM.

Based on medical record review, policy and document review and patient and staff interview, it was determined that for 6 of 14 discharged patients (Patient #'s 1, 4, 6, 9, 16, 18) in the sample, the hospital failed to discharge the patient with all necessary information for post-discharge care. Findings include:

The hospital policy titled "Discharge Process" stated, "...All patients, regardless of discharge type, complete aftercare plan that includes...prescriptions...Discharge instructions for medications and access to community resources...Social Serives will complete the DC (discharge) Care Plan to include...Crisis Safety Plan..."

The hospital policy titled "Discharge Instructions & Arrangement" stated, "...The RN(registered nurse)/LPN (licensed practical nurse) discharging the patient reviews all Discharge Care Plan with the patient, parent and or legal agent...confirms that these are clearly understood...has the patient, parent and or legal agent...sign the Discharge Plan Form...the RN/LPN reviews that prescriptions and the current medication form with the patient, parent, legal agent...if the prescription is not listed on the form the RN/LPN notifies the physician of this. The RN/LPN writes the medication on the form if the physician is not present to do so..."

The hospital document titled "Discharge Process and Documentation Map" stated, "...Is this a AMA (against medical advise) discharge? If YES Nurse verifies that the discharge order specifies this is an AMA discharge...Provider writes orders including prescriptions..."

The hospital policy titled "Discharge Planning - Inpatient" read, "...The Social Worker is responsible for coordinating the discharge planning process...facilitates communication and collaborative planning among the patient, parent, legal agent, family or designated lay caregiver as applicable, the physician, other team members, insurance providers/other funding sources, and aftercare providers in developing a realistic and effective aftercare plan..."

A. Patient #4 (Admission 11/26/21)

1. Staff interviews revealed:

a. Social Worker #2 interview 1/12/22 2:43 PM - 3:16 PM revealed:
- Signature of patient or parent is to be obtained on Discharge Care Plan for AMA discharges.
- The nurse makes copies of all discharge paperwork and medication prescriptions.

b. Director of Quality interview 1/28/22 9:27 AM-9:35 AM revealed:
- Confirmed that patients discharged AMA are to receive medication prescriptions, completed Discharge Plan Review, and patient or parent signature should be obtained on the Discharge Care Plan.

2. Medical record revealed:

a. "Practitioner Order Sheet" revealed:
- Practitioner order dated 12/5/21 2:40 PM: "Discharge patient today"

b. "Discharge Care Plan and Home Medications" revealed:
- No documentation the Discharge Plan Review field was completed.
- Current Medications field not completed with "pt (patient) left AMA" written in the place of medications.
- No documentation that the Discharge Care Plan was signed by patient or parent.

c. "Discharge Summary" revealed:
- Documentation that patient was discharged on Lexapro 10 mg (milligrams) by mouth daily.

d. No evidence to support that parent (mother) was given medication prescriptions for post-discharge care.

Findings confirmed with Director of Quality A on 1/28/22 between 9:27 AM and 9:35 AM.

B. Patient #16 (Admission 1/15/22)

1. Medical record review revealed:

a. "Discharge Care Plan and Home Medications" form revealed:
- Discharge medications not written legibly and written in medical jargon.
- Parent/guardian stated that he/she was unable to read medications and instructions.

Findings confirmed via interview with Director of Quality A on 2/1/22 at 2:22 PM.

C. Patient #18 (Admission 1/21/22)

1. Medical record review revealed:

a. "Discharge Care Plan and Home Medications" documented a facility and therapist for aftercare appointments; however, there was no evidence that an appointment obtained and scheduled prior to discharge.

Findings of failure to secure scheduled outpatient follow-up was confirmed with Director of Quality A on 2/1/22 at 3:11 PM.

D. Patient #1 (admission 11/17/21)

1. Medical record review revealed:

a. "Discharge Care Plan and Home Medications" form dated 11/22/21 revealed:
- "Current Medications" section is illegible.
- Directions are not written in layman's terms and doses of medications do not contain units such as "mg."

b. No evidence the "My Crisis Safety Plan" was completed.

Findings confirmed with Social Worker #1 on 1/7/22 at 11:23 AM and Assistant Director of Nursing (ADON) A on 1/13/22 from 2:20 PM-3:14 PM.

E. Patient #6 (admission 6/11/21)

1. Medical record review revealed:

a. "Discharge Care Plan and Home Medications" form dated 11/22/21 revealed no evidence the following discharge information was completed:
- The "Recovery and Support" section
- The "Scheduled Aftercare Appointments" including post discharge appointment dates and times
- The "Other Important Contact Information"
- The medication reason, indication, and route for all listed medications
- Question 6 of the "Columbia Suicide Severity Rating Scale, Discharge Screener"

Findings confirmed with Assistant Director of Nursing (ADON) A on 1/12/22 between 10:50 AM and 2:02 PM.

F. Patient #9
Admission 7/26/21
1. Medical record review revealed:

a. "Discharge Care Plan and Home Medications" form dated 8/6/21 revealed:
- No evidence the "Current Medications" section included indication and route for all listed medications.
- "Current Medications" section for Symbicort, Repaglinide, Humalog and Lantus instruct patient to follow up with primary care provider.
- No evidence in the "Scheduled Aftercare Appointments" section that a post discharge primary care provider (PCP) appointment was scheduled.
- No evidence of patient signature on the "Discharge Care Plan and Home Medications" form.

b. No evidence "My Crisis Safety Plan" was completed.

Admission 8/7/21

c. "Discharge Care Plan and Home Medications" form dated 8/24/21 revealed no evidence:
- The "Current Medications" section was completed.
- The "Current Medications" section included indications for all medications listed

Findings confirmed with ADON A on 1/26/22 from 2:30 PM - 4:15 PM and 1/28/22 from 10:02 AM - 12:30 PM.

Based on medical record review, policy review, staff interview, and observation, it was determined that social services records were not completed for 7 of 19 patients in the sample (Patient #'s 1, 2, 5, 6, 9, 16, 18). Findings include:

The hospital document titled "Social Worker III Job Description" stated, "...Essential Functions...conduct psychosocial assessment of patient and update as needed..."

The hospital policy titled "Discharge Planning - Inpatient" stated, "...The social worker...is responsible for coordinating the discharge planning process...Facilitates communication and collaboration planning among the patient, parent, legal agent, family or designated lay caregiver as applicable, the physician, other team members, insurance providers/other funding sources, and aftercare providers in developing a realistic and effective care plan...Obtains input from the patient and/or family into the discharge planning process...documents on an ongoing basis in the patient's medical record all recommendations and progress with the discharge plan...Utilizes family therapy sessions and calls as opportunities for enhancing patient/family input into and understanding/support of the aftercare plan as it is developed...Writes a final discharge planning note in the progress note section of the medical record..."

The hospital document titled "Discharge Process and Documentation Map" stated, "...Admission and assessment: Discharge planning starts at admission, with all assessments having a component of discharge planning...Individual sessions and family sessions: SW [social worker] meets individually with the patient throughout the stay to discuss treatment progress and discharge planning. Family input is obtained with consent or via legal representatives. Phone calls related to discharge planning and placement attempts are documented...Individual progress note, family session note, progress notes, discharge planning log...SW reviews the Crisis Safety Plan with the patient and updates if applicable...SW completes page 1 of the Discharge care Plan and Home medications Form. SW reviews with patient/legal rep (representative); patient/legal rep and SW sign..."

I. During an interview on 1/10/22 between 11:17 AM and 11:41 AM, Director of Quality A reported:
- The expectation is that social workers make 3 attempts to complete the "Psychosocial Assessment".
- All patients receive a discharge evaluation.
-The Social Worker is responsible for the discharge evaluation.
- The social worker should document anytime they speak with patient and/or family.
- If family cannot be contacted or patient did not want family involved, social worker would document this in a progress note ("Individual Session" notes or "Family Session" notes).

II. Patient #1 (Admission 11/17/21)

A. Medical record review revealed:
1. "Family Session Note" is blank and there was no documentation of Patient #1 declining a family session.

B. During an interview on 1/7/22 between 11:23 AM and 11:57 AM, Social Worker #1 confirmed these findings and reported:
- He/She spoke with patient daily but did not document.
- Family sessions should be offered and documented if the patient declines.

III. Patient #2 (Admission 12/7/21)

A. "Psychosocial Assessment" revealed:
- Social work documented on 12/9/21 as "unable to assess" patient.
- No evidence that social work reattempted assessment at a later date.

Findings were confirmed with Director of Quality A on 1/25/22 between 1:39 PM and 1:40 PM.

IV. Patient #5 (Admission 8/19/21)

A. "Psychosocial Assessment" revealed:
- Social work documented on 8/19/21 as "unable to assess" patient.
- No evidence that social work reattempted assessment at a later date.
Findings confirmed with DOQ A on 1/25/22 at 1:41 PM.

V. Patient #6 (Admission 6/11/21)

A. Medical record review revealed:
1. "Individual Treatment Plan" dated 6/11/21 stated:
- "Therapist will meet with patient for an individual session weekly for up to 15 minutes to mutually design and develop a safety/crisis plan to utilize as a prevention tool upon discharge".
2. Individual session notes documented by social work on 6/11/21 and 6/21/21 (10 days apart).

No evidence that social work completed weekly individual sessions.

Findings confirmed with Assistant Director of Nursing (ADON) A on 1/11/22 at 3:20 PM.

VI. Patient #9 (Admission 7/26/21)

A. Medical record review revealed:
1. Individual Treatment Plan dated 7/29/21 stated:
- "SW (social work) will set-up comprehensive aftercare plan addressing lack of supports; as well as her mental health diagnosis wand which supports can assist with this" with a frequency of "daily" indicated.
2. Individual session notes documented by social work on 7/28/21 and 8/6/21 (9 days apart).

No documentation that social work completed daily sessions.

Findings confirmed with ADON A on 1/26/22 between 2:30 PM and 4:15 PM.

VII. Patient #9 (Admission 8/7/21)

A. Medical record review revealed:
1. Interdisciplinary Treatment Plan dated 8/9/21 stated:
- Therapist will conduct an individual therapy session weekly.
2. Social work documented in individual session notes on 8/9/21 and 8/23/21 (14 days apart).

There is no evidence that social work conducted sessions weekly.

Findings confirmed with ADON A on 1/28/22 between 10:02 AM and 12:30 PM.

VIII. Patient #16 (Admission 1/15/22 at 9:45 PM)
A. Medical record review revealed:
1. "Interdisciplinary Treatment Plan" dated 1/18/22 stated patient to meet with social work one to two times per week.
2. Social work documented in "Individual Session Note" on 1/18 and 1/28/22 (10 days apart).

No evidence social work met with patient one to two times per week.

Findings confirmed during interview with Director of Quality A on 2/1/22 at 2:22 PM.

IX. Patient #18 (Admission 1/21/22)

A. Medical Record revealed:
1. "Interdisciplinary Treatment Plan" dated 1/23/22 stated social work to meet with patient one to two times per week.
2. Social work documented in "Individual Session/Note" on 1/23/22 and 1/31/22 (8 days apart).

No evidence that social work met with patient one to two times per week.

Findings confirmed during interview with Director of Quality A on 2/1/22 at 3:11 PM.

Based on medical record review, policy review and staff interview, it was determined that the treatment team failed to maintain an updated individualized comprehensive treatment plan for 2 of 19 patients (Patient #'s 5 and 8) in the sample. Findings include:

Hospital policy titled "Treatment Planning" stated, "...The Multidisciplinary treatment plan will be individualized and identify the specific needs and goals of the patient and the specific interventions to be conducted by staff to promote ongoing recovery...Identifying Data Sheet contains...the problem(s) that led to hospitalization...diagnoses...patient's liabilities...educational needs, discharge criteria...Each identified problem is addressed with patient objectives which serve as a progressive process to assist the patient in resolving the stated problem...All objectives will be reviewed for progress during the scheduled 7 day treatment plan review...Each clinical discipline develops specific intervention(s) that they will utilize to support and assist the patient in achieving the objective...The review and reassessment of progress and or lack of progress...is done every 7 days...Treatment Plan review Form documents the patient's progress for each of the stated problems and corresponding objectives..."

Review of medical record revealed:

A. Patient #5 (Admission: 8/19/21, Discharge: 12/7/21)

1. "Interdisciplinary Treatment Plan"
a. Psychiatric problem of "Confusion" initiated on 8/27/21.
- No evidence that the psychiatric problem of "Confusion" was updated or determined to be resolved between 10/15/21 and 12/7/21.
b. Medical problem of "Sleep Apnea" initiated on 8/19/21.
- No evidence that the medical problem of "Sleep Apnea" was updated or determined to be resolved between 9/2/21 to 9/20/21 and between 9/21/21 and 12/7/21.
c. Medical problem of "Seizures" initiated on 8/19/21.
- No evidence that the medical problem of "Seizures" was updated or determined to be resolved between 9/5/21 to 9/20/21 and between 9/21/21 and 12/7/21.
d. Medical problem of "Acute Pain/Tooth Ache" was initiated on 9/23/21.
- No evidence that the medical problem of "Acute Pain/Tooth Ache" was updated or determined to be resolved between 10/11/21 and 12/7/21.

These findings were confirmed with Assistant Director of Nursing (ADON) A on 1/31/22 12:35 PM.

B. Patient #8 (Admitted 3/11/21)
1. "Nursing Assessment" dated 3/11/21 at 6:00 PM contained the following documentation:
- "Morse Fall Assessment" score of 70
- High level of fall risk is a score greater than 45
- Moderate to high risk requires the implementation of the "Potential for Injury related to Falls Problem Sheet".

2. "Nursing Note Post Patient Fall" documented that Patient #8 fell on 3/12/21 at 2:15 AM.

3. "Interdisciplinary Treatment Plan" dated 3/12/21:
- Problem: "Potential Injury related to Fall"
- Level of Risk: High Morse Falls Score

4. No interventions documented to prevent falls on treatment plan before or after the patient fell on 3/12/21.

These findings were confirmed during an interview with ADON A on 1/31/22 between 2:35 PM and 2:53 PM.

Based on medical record review, policy review and staff interview, it was determined that the treatment team failed to identify staff members who will be responsible for facilitating interventions of the "Interdisciplinary Treatment Plan" for 2 of 19 patients in the sample (Patient #'s 1 and 5). Findings include:

Hospital policy titled "Treatment Planning" stated, "...Each discipline is required to identify staff member who will be responsible for facilitating the interventions in the 'person(s) responsible' section..."

A. Review of medical record revealed:

1. Patient #1 (Admission 11/17/21)

"Interdisciplinary Treatment Plan - Medical Problem Sheet...Problem: Risk for altered physiological wellbeing related to: Acute Withdrawals from..." dated 11/18/21, does not indicate which practitioner and nurse are the responsible person for the related parts of the care plan.

Findings confirmed by Assistant Director of Nursing (ADON) A on 1/13/22 from 2:20 PM-3:14 PM.

B. Patient #5 (Admission 8/19/21)

"Interdisciplinary Treatment Plan - Medical Problem Sheet...Problem: Potential for injury related to fall..." dated 10/20/21 and 10/27/21, does not indicate which practitioner is the responsible person for the related parts of the care plan.

Finding was confirmed with ADON A on 1/12/22 12:25 PM.