HospitalInspections.org

.
Based on observation, document review, and interview, the hospital's governing body failed to provide effective oversight of the hospital.

Failure to provide effective oversight to prevent substandard practices for patient safety, and patient rights, resulted in an unsafe environment for patients.

Findings included:

Observations, interviews, patient record reviews, and review of hospital policies and procedures, showed that the governing body failed to implement policies and procedures that ensure practitioners admitted only patients meeting the hospital's admission criteria to the facility, and practitioners authenticated all telephone and/or verbal orders within 48-hours.

Cross Reference: A0049

Due to the scope and severity of deficiencies cited under 42 CFR 482.12, the Condition of Participation for Governing Body was NOT MET

.

.

Based on observation, interview, and document review, the governing body failed to implement policies and procedures that ensure only patients meeting the hospital's admission criteria were admitted to the facility for 2 of 6 patient records reviewed (Patients #1201, #1208) (Item #1) and that ensure practitioners authenticate all verbal and/or telephone orders within 48-hours for 6 of 6 patient records reviewed (Patients #1201, #1202, #1206, #1207, #1209, #1210) (Item #2).

Failure to implement policies and procedures and ensure the hospital uses an effective admission process to verify that all patients meet established admission criteria creates the likelihood that practitioners will admit patients with acute medical conditions, and failure to ensure that providers authenticate verbal and telephone orders within 48 hours places patients at risk for serious injury, serious harm, or death.

Item #1 Effective Processes for Established Admission Criteria

Findings included:

1. Document review of the hospital's policy titled, "Rules and Regulations of the Medical Staff of Cascade Behavioral Health," effective 06/07/21, showed the following:

a. Each Admitting Physician must abide by the criteria for admitting patients to the Hospital and each program as approved by the Medical Staff and the Governing Board.

b. Admitting Physicians are responsible for obtaining information prior to admission as may be necessary to establish that the patient meets all admission criteria and to promote the safety of the patient and that of other patients at the Hospital.

c. The Hospital, through the Chief Medical Officer (CMO) or the Chief Executive Officer (CEO), reserves the right to refuse admission or to recommend to the Admitting Physician that a patient be referred to another facility because such patient's needs cannot be met and/or because treatment cannot be adequately provided by the Hospital.

Document review of the hospital's policy titled, "Admission Criteria," policy number PC.A.200, reviewed 03/21, showed the following:

a. Addiction Recovery Services criteria for admission to the Detox unit included the need for medical care and intensive nursing care for one or more of the following: IV fluid and/or medication administration; frequent monitoring for unstable vital signs; serious head trauma or loss of consciousness with persistent mental status or neurological changes; requiring close observation; drug overdose or intoxication compromising the patient's mental status, cardiac function or vital signs; presence of medical conditions that require inpatient treatment (liver failure, pancreatitis, acute gastrointestinal bleeding, cardiovascular disorders requiring monitoring); recurrent or multiple seizures.

b. Inpatient Geriatric Psychiatric Patient admission exclusion criteria included: medical care needs beyond the resources of the unit; the presence of a medical condition that requires intensive management and is beyond the hospital's capacity to treat, including patients who refuse treatment and medications; exceptions may be made on a case by case basis by the Medical Director with agreement by the Chief Executive Officer or designee; additional Medical Screening may occur when other acute medical conditions are present including: Congestive Heart Failure (CHF); Blood Pressure - systolic , < 100 or > 170 and/or diastolic >100; Arrythmia (an irregular heart beat); Dysphagia; Modified Diet to include mechanical soft, mechanical chopped, pureed, ground; Liquids-thin honey, nectar, pudding; medically complex patients will be considered on an individual basis depending on available staffing and/or current milieu.

Patient #1201

2. On 10/18/21 at 1:30 PM, Investigator #12 interviewed an Intake Clinician (Staff #1207) about the intake process. Staff #1207 stated that certain medical conditions that cause patients to be excluded from admission include severe mental retardation, dementia, indwelling urinary catheters, insulin pumps, wound vacs, bariatric patients requiring specialized equipment, patients requiring physical therapy (PT) or occupational therapy (OT), patients requiring CPAP who do not have their own equipment at the time of admission, pregnancy after the first trimester, some Level II and all Level III sex offenders. Staff #1207 stated that patients requiring wheelchairs for mobility must be able to toilet themselves, and if they require assistance with transfers to and from the wheelchair, the provider must approve the admission, depending on the acuity of the unit. If the patient meets mental health criteria for admission, but has a complicated medical history, Staff #1207 stated that intake staff will text the information to the Admitting Provider on call. Staff #1207 stated that the Admitting Practitioners "rarely" spoke with providers at other hospitals when accepting patients transferred from outside facilities. Staff #1207 confirmed that the hospital does not admit patients who require medications administered intravenously (IV).

On 10/22/21 at 10:30 AM, investigator #12 interviewed an Intake Clinician (Staff #1208) working on 09/29/21 when an acute care hospital requested to transfer Patient #1201 to the facility. The interview showed that:

a. The hospital does not admit patients if they require IV medication administration. Staff #1208 did not recall seeing that Patient #1201 was on any IV blood pressure medications.

b. Patients must be taking their medications reliably. If they are not, the intake clinicians will run it by the provider and let them decide whether or not to admit the patient.

c. When providing admission request information to the physician, Staff #1208 stated that she enters the most recent vital signs provided by the facility. Additional information is provided on a case by case basis or if requested by the provider. Staff #1208 stated that she did look at the patient's vital sign information, but she did not discuss it with the admitting provider.

d. The former Internal Medicine Lead Physician (Staff #1223) preferred to communicate by text message. The request to admit Patient #1201 was sent to Staff #1223 by text message. The provider received a picture of the intake form sent via text message. Staff #1208 did not recall Staff #1223 asking any additional questions about Patient #1201 before accepting the patient for admission.

3. Investigator #12 reviewed the medical record for Patient #1201 who was admitted on 09/30/21 for the involuntary treatment of Depression and Anxiety. The medical record showed that:

a. Patient #1201 had a history of atrial fibrillation, high blood pressure, chronic obstructive pulmonary disease (COPD), stage III kidney disease, an abnormal head CT (computerized tomography), and an abnormal lung CT. Patient #1201 was hospitalized at an acute care hospital between 09/13/21 to 09/29/21, she was being treated for atrial fibrillation, high blood pressure, electrolyte imbalance, kidney failure, and severe protein calorie malnutrition. The acute care hospital requested to transfer Patient #1201 and faxed clinical documents to Cascade Behavioral Hospital on 09/29/21.

b. Before accepting the patient for admisson, Cascade Behavioral Hospital received clinical documents with the following information for review:

i. Patient #1201's blood pressure and/or heart rate taken 09/29/21:

· 4:00 AM 167/111 and 147 beats per minute
· 4:29 AM 155/120 and 153 beats per minute
· 7:15 AM heart rate 118 beats per minute
· 7:32 AM 136/91
· 12:26 PM 143/117 and 145 beats per minute
· 3:11 PM 114/70 and 88 beats per minute

ii. Medications given to Patient #1201 on 09/29/21:

· 2:34 AM Lopressor 10 mg IV
· 4:06 AM Hydralazine 10 mg IV
· 6:37 AM Lopressor 10 mg IV
· 9:30 AM Hydralazine 50 mg tablet by mouth; multivitamin tablet by mouth; verapamil tablet SR 240 mg tablet by mouth; (refused Toprol XL 50 mg tablet by mouth)
· 11:05 AM Timoptic eye drops
· 11:48 AM Pred Forte eye drops
· 3:56 PM Hydralazine 50 mg tablet by mouth; Lopressor 10mg IV; saline flush IV

iii. Progress note dated 09/26/21 at 11:43 AM stating prior to discharge to inpatient psych facility, "Afib with RVR will need to be better controlled (patient will need to be good enough to take her medications)."

c. Review of the Intake Assessment form, showed that:

i. Patient #1201's current medications included "IV Lipressor" (Lopressor)
ii. The patient was not compliant with taking medications, refused scheduled and PRN meds sometimes, but "not for the past two shifts"

d. The provider accepted the patient for admission on 09/29/21 at 4:30 PM

e. On 09/30/21 at 7:45 AM, Patient #1201 was not breathing and did not have a pulse. Staff started cardiopulmonary resuscitation (CPR) and called 911. Paramedics transported Patient #1201 to a nearby hospital, but the patient did not survive and was pronounced dead at 10:13 AM.

4. On 11/04/21 at 11:30 AM, Investigator #12 interviewed the Internal Medicine Lead Physician (Staff #1212), who stated that patients requiring IV medication to maintain a normal blood pressure due to high blood pressure and heart rate due to atrial fibrillation (an irregular heart rhythm) did not meet criteria for admission. Staff #1212 also stated that the practitioner would require a more in depth review of the medical record to consider admitting a patient weighing 85 pounds with severe protein calorie malnutrition, a weight loss of five pounds in two weeks, and a body mass index of less than 17. Staff #1212 stated that Patient #1201 did not appear to meet the hospital's admission criteria.

Patient #1208

5. On 11/15/21 at 4:30 PM Investigator #12 and Investigator #15 observed a Code Blue response on the 2 North Detox/Rehab Unit. Investigators observed Patient #1208 lying on his left side on the bathroom floor, surrounded by three staff. The patient admitted to smoking fentanyl prior to admission, earlier that day, but denied use of any other drugs or alcohol.

6. On 11/15/21 at 4:40 PM, Investigator #12 and Investigator #15 interviewed the Attending Provider (Staff #1224) following Patient #1208's Code Blue. Staff #1224 stated that Patient #1208 had a negative urine tox screen but attributed the patient's seizures to alcohol withdrawal. Staff #1224 stated that he was not aware that Patient #1224 had a prior history of seizures, that the patient attributed the seizures to fentanyl withdrawal, or that the patient was supposed to have a work-up for a seizure disorder. Staff #1224 stated that he did not know if the Internal Medicine Lead was aware of the patient's past medical history, but that "it would have been beneficial to know." Staff #1224 confirmed that the hospital did not have a way to communicate if a patient that did not meet admission criteria was reviewed and deemed safe for admission.

7. On 11/16/21 at 10:45 AM, Investigator #12 and Investigator #15 interviewed the Internal Medicine Lead Physician (Staff #1212). The interview showed that Staff #1212 is called for all patient admissions to the Detox Unit and when there is a medical concern regarding a psychiatry patient. Staff #1212 stated that if a patient requires IV fluids, they would need to be sent out to an acute care hospital. The hospital will admit patients with a history of seizures as long as they are controlled, the patient was on medications and had appropriate records and tests.

Investigators reviewed the Admission Criteria policy with Staff #1212 to clarify the hospital's admission criteria to the Detox Unit. The interview showed that the hospital did not admit patients requiring IV fluids and/or medications, frequent behavior monitoring due to agitation and/or confusion, unstable vital signs, patients experiencing seizures, patients experiencing severe head trauma, or loss of consciousness with persistent mental status or neurological changes requiring close observation, drug overdose or intoxication that has compromised the patient's mental status, cardiac function or vital signs, biomedical conditions requiring inpatient treatment, acute gastrointestinal bleeding, cardiovascular conditions that require monitoring, recurrent multiple seizures and severe altered mental status.

8. On 11/17/21 at 9:00 AM, Investigators #12, #15, and #16 interviewed the hospital's Governing Board. The interview showed that the Governing Board reviews new hospital policies and those policies that require revision. Investigators reviewed the hospital's Admission Criteria policy with the Governing Board. The Governing Board stated that the admission criteria was incorrect and that the hospital did not admit patients requiring IV fluids and/or medications, frequent behavior monitoring due to agitation and/or confusion, unstable vital signs, patients experiencing seizures, patients experiencing severe head trauma, or loss of consciousness with persistent mental status or neurological changes requiring close observation, drug overdose or intoxication that has compromised the patient's mental status, cardiac function or vital signs, biomedical conditions requiring inpatient treatment, acute gastrointestinal bleeding, cardiovascular conditions that require monitoring, recurrent multiple seizures and severe altered mental status. During the interview, the governing board members stated that the policy needed reviewing and revising.

Item # 2 Authenticate Orders

1. Review of the hospital document titled, "Rules and Regulations of the Medical Staff of Cascade Behavioral Health," effective 06/07/21, showed the following:

a. Each Admitting Physician must abide by the criteria for admitting patients to the Hospital and each program as approved by the Medical Staff and the Governing Board.

b. All entries to the medical record must be legibly written, dated, timed, and authenticated.

c. All telephone orders given to a licensed nurse, or in the case of the order for a medication, either to a licensed nurse or a licensed pharmacist, must be signed within forty-eight hours by the Attending Physician or by any medical MD/DO or Advanced Registered Nurse Practitioner Provider.

d. Any order dictated over the phone shall be signed, dated, and timed by the person who took the order and shall include the name of the Practitioner giving the order. The Practitioner must acknowledge that the read-back is accurate.

2. Investigator #12 reviewed the medical records of six patients admitted to the facility between 09/04/21 and 11/03/21. The medical record review showed that:

a. 5 of the 6 patient records reviewed (Patients #1201, #1206, #1207, #1209, #1210) contained telephone or verbal orders from providers that were missing provider signatures or that were signed by a practitioner greater than 48-hours from the time the order was given.

b. 4 of the 6 patient records reviewed (Patients #1201, #1206, #1207, #1209) contained Psychiatric Admission Orders that were not signed by a practitioner.

3. On 11/10/21 at 5:00 PM, during an interview with Investigator #12, Staff #1201 verified that it is the expectation of the hospital that all telephone orders are authenticated by a medical provider within 48 hours.
.

.

Based on interview, policy review, and record review, the hospital failed to ensure that the patient's rights were protected by providing informed consent (detailing the risks, benefits, and alternatives) for all prescribed psychotropic medications, as demonstrated by 7 of 9 records reviewed (Patient #1502, #1504, #1505, #1506, #1507, #1508, and #1509).

Failure to ensure that patients receive informed consent for all prescribed psychotropic medications, including scheduled and PRN (as needed) medications violates the patient's rights to receive details of the risks, benefits and alternatives for all psychotropic medications prior to administration.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Informed Consent, Psychotropic Medications," policy number MM.01.110, last revised 08/21, showed the following:

a. All patients (and legal representatives of patients) who have psychotropic medication ordered will be informed of the benefits and risks involved in taking the prescribed medication.

b. The ordering practitioner will discuss the prescribed medications with the patient and/or legal representative at the time the new psychotropic medication is ordered.

c. Information sheets are available to provide to the patient.

Patient #1502

2. On 11/09/21 at 1:30 PM, Investigator #15 and the Director of Risk (Staff #1501) reviewed the medical record for Patient #1502, a 94-year-old female voluntary patient, admitted on 09/04/21, with a psychiatric diagnosis of Generalized Anxiety Disorder (GAD), Major Depressive Disorder (MDD), and Suicidal Ideation (SI). Review of the Patient's medical record showed the following:

a. On the Informed Consent for Psychotropic Medications, dated 09/05/21, signed by both the provider and Patient #1502, staff documented that the Patient had been given detailed information about the proposed medications including the purpose for the treatment, common short-term and long-term side effects, contraindications and clinically significant interactions with other medications.The provider documented that the Patient had been given information regarding the following psychotropic medications: Lexapro (Depression), Restoril (Insomnia), and Klonopin (Anxiety).

b. Patient #1502 had been prescribed the following additional psychotropic medications during their admission: Ativan (Anxiety), Vistaril (Agitation), and Gabapentin (Anxiety).

c. The Informed Consent for Psychotropic Medication was not updated to include the additional psychotropic medications: Ativan, Vistaril, and Gabapentin. Investigator #15 failed to find evidence that the hospital informed Patient #1502 of the benefits and risks involved in taking the prescribed psychotropic medications.

Patient #1504

3. On 11/09/21 at 3:00 PM, Investigator #15 and the Director of Risk (Staff #1501) reviewed the medical record for Patient #1504, a 52-year-old male, admitted involuntarily on 10/26/21, with a psychiatric diagnosis of Delusional Disorder and Auditory Hallucinations. Review of the Patient's medical record showed the following:

a. The Informed Consent for Psychotropic Medications, dated on 10/27/21 was signed by the provider. Staff documented that the Patient "refused to sign." Two psychotropic medications were marked: Thorazine (Antipsychotic) and Depakote (Mood Stabilizer). Investigator #15's review of the Informed Consent found no evidence to document that the Patient had been given detailed information about the proposed medications including the purpose for the treatment, common short-term and long-term side effects, contraindications and clinically significant interactions with other medications.

b. Patient #1504 had been prescribed the following additional psychotropic medications: Ativan (Agitation), Olanzapine (Extreme Agitation), Haldol (Psychosis), and Cogentin (Extrapyramidal Side Effects).

c. The Informed Consent for Psychotropic Medication was not updated to include the additional psychotropic medications: Ativan, Olanzapine, Haldol, and Cogentin. Investigator #15 failed to find evidence that the hospital informed Patient #1504 of the benefits and risks involved in taking the prescribed psychotropic medications.

Patient #1505

4. On 11/09/21 at 3:45 PM, Investigator #15 and the Director of Risk (Staff #1501) reviewed the medical record for Patient #1505, a 49-year-old male, admitted involuntarily on 07/01/21, with a psychiatric diagnosis of Schizoaffective Disorder. Review of the Patient's medical record showed the following:

a. The Informed Consent for Psychotropic Medications, dated on 07/01/21 was signed by the provider. Staff documented that "Patient refused to consent to take medication." One psychotropic medication was marked: Zyprexa (Antipsychotic). Investigator #15's review of the Informed Consent found no evidence to document that the Patient had been given detailed information about the proposed medications, the purpose for the treatment, common side effects, including contraindications and clinically significant interactions with other medications.

b. Patient #1505 had been prescribed the following additional psychotropic medications: Ativan (Agitation), Haldol (Extreme Agitation), Ambien (Insomnia), and Abilify (Psychosis).

c. The Informed Consent for Psychotropic Medication was not updated to include the additional psychotropic medications: Ativan, Haldol, Ambien, and Abilify. Investigator #15 failed to find evidence that the hospital informed Patient #1505 of the benefits and risks involved in taking the prescribed psychotropic medications.

5. On 11/09/21 at 4:00 PM, during an interview with Investigator #15, Staff #1501 stated that each psychotropic medication prescribed for patients should be documented on the Informed Consent for Psychotropic Medications, including medications ordered on the patient's admission order, and any subsequent order after that. Staff #1501 verified that the Informed Consent's for Patient #1502, #1503, and #1505 were incomplete, and failed to include all the psychotropic medications prescribed, as outlined in the hospital's policy.

Patient #1507

6. On 11/10/21 at 10:00 AM, Investigator #15 and Registered Nurse (RN) (Staff #1505) reviewed the medical record for Patient #1507, a 64-year-old male, admitted voluntarily on 10/23/21, with a psychiatric diagnosis of Major Depressive Disorder (MDD) and Suicidal Ideation (SI). Review of the Patient's medical record showed the following:

a. The Informed Consent for Psychotropic Medications was completely blank and not filled out by staff.

b. Investigator #15's review of the medical record found that Patient #1507 had been prescribed the following psychotropic medications: Lexapro (Depression), Abilify (Psychosis), Zyprexa (Psychosis), Depakote (Mood), Buspar (Anxiety), and Ativan (Anxiety).

c. Investigator #15 found no evidence that the Patient had been given detailed information about the proposed medications, the purpose for the treatment, common side effects, including contraindications and clinically significant interactions with other medications.

7. On 11/10/21 at 10:15 AM, during an interview with Investigator #15, Staff #1505 stated that he was unfamiliar with the document titled "Informed Consent for Psychotropic Medications." Staff #1505 stated that he was "not sure who fills that out, I don't remember seeing it before."

Patient #1508

8. On 11/10/21 at 11:15 AM, Investigator #15 and Staff #1501 reviewed the medical record for Patient #1508, a 76-year-old female, admitted voluntarily on 09/15/21, with a psychiatric diagnosis of Major Depressive Disorder (MDD) and Alcohol Dependence. Review of the Patient's medical record showed the following:

a. Investigator #15 failed to find evidence of an Informed Consent for Psychotropic Medications in Patient #1508's medical record.

b. Patient #1508 had been prescribed the following psychotropic medications: Wellbutrin (Depression), Naltrexone (Alcohol Cravings), Paxil (Depression), Trazadone (Insomnia), and Vistaril (Agitation).

c. Investigator #15 found no evidence that the Patient had been given detailed information about the proposed medications, the purpose for the treatment, common side effects, including contraindications and clinically significant interactions with other medications.

Patient #1509

9. On 11/10/21 at 11:30 AM, Investigator #15 and Staff #1501 reviewed the medical record for Patient #1509, a 70-year-old male, admitted voluntarily on 09/14/21, with a psychiatric diagnosis of Major Depressive Disorder (MDD) and Alcohol Dependence. Review of the Patient's medical record showed the following:

a. Investigator #15 failed to find evidence of an Informed Consent for Psychotropic Medications in Patient #1509's medical record.

b. Patient #1509 had been prescribed the following psychotropic medications: Vistaril (Agitation, Trazadone (Insomnia), Fluoxetine (Depression), Bupropion (Bipolar Disorder/Mood), Naltrexone (Alcohol Cravings), and Vivitrol (Alcohol Cravings).

c. Investigator #15 found no evidence that the Patient had been given detailed information about the proposed medications, the purpose for the treatment, common side effects, including contraindications and clinically significant interactions with other medications.

Patient #1506

10. On 11/10/21 at 11:45 AM, Investigator #15 and Staff #1501 reviewed the medical record for Patient #1506, a 65-year-old female, admitted involuntarily on 09/07/21, with a psychiatric diagnosis of Schizoaffective Disorder. Review of the Patient's medical record showed the following:

a. Investigator #15 failed to find evidence of an Informed Consent for Psychotropic Medications in Patient #1506's medical record.

b. Patient #1506 had been prescribed the following psychotropic medications: Ativan (Agitation), Seroquel (Extreme Agitation), Risperidone (Schizophrenia), Zyprexa/Zydis (Psychosis), Depakote (Mood), and Clonazepam (Anxiety).

c. Investigator #15 found no evidence that the Patient had been given detailed information about the proposed medications, the purpose for the treatment, common side effects, including contraindications and clinically significant interactions with other medications.

11. On 11/10/21 at 12:30 PM, during an interview with Investigator #15, Staff #1501 verified that the Informed Consent's for Patient #1506, #1508, and #1509 were missing from the patient's medical records and that staff failed to document that the patient's had been provided informed consent for the prescribed psychotropic medications.

.

.

Based on observation, interview and document review the hospital failed to promote and protect each patient's right to receive care in a safe setting as evidenced by: the failure to ensure all emergency carts had supplies readily available for emergency use for 3 of 3 patient-care units reviewed (Item #1); the failure to ensure patient-care staff had knowledge and understanding of emergency medical response procedures (Item #2); the failure to ensure that unit doors were secured upon entering or exiting the patient-care area (Item #3).

Failure to ensure that emergency carts are stocked with clean supplies and readily available for use, failure to ensure that staff can quickly locate emergency supplies and equipment, and failure to restrict access to unauthorized areas places patients at risk for serious injury, serious harm, and death.

Item #1 Emergency Cart IV Supplies

Findings included:

1. Document review of the hospital's policy titled, "Emergency Cart," policy number PC.C.110, last reviewed 09/19, showed that all emergency carts will be stocked with adequate emergency supplies and equipmen, including airways, bag resuscitators, intravenous fluids, oxygen, sterile supplies and other necessary equipment. Emergency carts will be secured and easily accessible to patient-care staff on all units at all times for emergency use. At the end of a code, any used items will immediately be restocked by floor staff, and the cart will be re-locked.

Document review of the hospital's daily log for emergency cart inventory checks for the 2 North, 3 North and 3 West units showed a list of the cart's contents by drawer. The inventory list did not include items to initiate intravenous (IV) therapy as part of its contents.

2. On 10/18/21 at 12:30 PM, Investigator #12 toured the 3 North and 2 North patient-care units and inspected the emergency crash carts. The investigator found that each crash cart contained a 1-liter bag of 0.9% normal saline IV solution, but there were no supplies necessary to initiate IV therapy in either crash cart.

The investigator found that the 3 North crash cart had a used bag-valve mask and AMBU bag, and without these items readily available on the cart, it was not ready for emergency use.

3. On 10/18/21 at 1:00 PM, Investigator #12 interviewed the Director of Quality and Performance Improvement (Staff #1202). Staff #1202 stated that hospital staff did not perform IV therapy on patients, and the hospital did not carry any supplies to administer IV fluids. Staff #1202 stated that none of the emergency carts contained IV supplies as part of their inventory stock. When the investigator showed Staff #1202 the dirty bag-valve mask and ambu bag, staff #1202 stated that she agreed the items appeared dirty, and she immediately called to have the supplies replaced.


Item #2 Automated External Defibrillator (AED)

Findings Included:

1. Document review of the hospital's policy titled, "Emergency, Medical," policy number POC.EM.101, last reviewed 04/21, showed that upon arriving at the scene of a medical emergency, the registered nurse (RN) will assess the patient an determine the immediate interventions needed, and additional staff will assist with the Code Blue response, including retrieving the emergency medical cart and automated external defibrillator (AED).

2. On 10/18/21 between 12:30 and 1:00 PM, Investigator #12 toured the 3 North and 2 North patient-care units and interviewed patient-care staff. Three of four staff interviewed (Staff #1215, Staff #1216, and Staff #1217) stated they had received orientation to the department upon hire, but they were unable to locate the closest AED.

3. On 10/18/21 at 3:15 PM, Investigator #12 interviewed the Director of Risk (Staff #1201) who confirmed it was the expectation of the hospital that staff know where to locate the emergency medical equipment, including the AED, and this training occurs during the orientation and training process of all new employees.

Item #3 Unit Doors Not Latching

1. On 11/09/21 at 12:00 PM, Investigator #12 and Investigator #14 toured the 3 North inpatient unit, a 21-bed locked, patient-care unit. The observation showed a patient census of 17, with six patients requiring staff observation every 5-minutes. At 12:04 PM investigators observed a nutrition services staff member enter the locked unit with a tray of food. Investigators observed that the door did not close completely behind the staff member, creating a potential elopement risk for patients. At 12:09 PM, the nutrition services staff exited the unit through the same door, and again failed to ensure that the door closed securely upon exit. The investigators observed a red sign posted on the door reminding staff to "make sure door closes behind you."

2. Review of hospital documents showed that the hospital had seven instances of patients in unauthorized areas during the past two months, including two that involved the door on 3 North not latching properly.

3. On 11/15/21 at 1:30 PM, interview and document review with Staff #1201 showed that a workorder was entered on 11/13/21. Staff #1201 stated that the a hospital maintainance department hospital employee had evaluated the door and that the employee stated that "there was nothing wrong with the door" and that "staff just needed to make sure they pulled the door closed."
.

.

Based on interview and document review, the hospital failed to ensure that a specially trained registered nurse (RN) completed a 1-hour face-to-face consult within one hour of restraint initiation and the RN consulted the attending or on-call practitioner as soon as possible after completing the 1-hour face-to-face evaluation.

Failure to ensure that a specially trained RN performs a 1-hour face-to-face evaluation within 1 hour of the initiation of a restraint or notifies the attending or on-call practitioner as soon as possible after the completion of the evaluation risks serious physical harm, psychological harm and violation of patient rights.

Findings included:

1. Review of the hospital policy, "Restraint," Policy #POC.01.90, last reviewed 08/21, showed the following:

a. A physical restraint includes manual measures to limit or restrict body movement. Holding a patient who is not cooperative with receiving a medication injection is considered a physical hold.

b. Mechanical restraint includes the restriction or limitation of body movements by use of bed restraints (up to 4 points) in a Seclusion room with a restraint bed.

c. A chemical restraint is defined as a drug or medication used to manage a patient's behavior or restrict the patient's freedom of movement. Chemical restraints are medications used in addition to or in replacement of a patient's regular drug regimen to control extreme behavior in an emergency.

d. A practitioner or specially trained registered nurse shall conduct a face-to-face evaluation of the patient within one hour of initiation of restraint to assess physical and psychological status. The evaluation must be completed, even if the restraint has been discontinued prior to one hour.

Review of the hospital policy, "Seclusion," Policy #POC.01.91, last reviewed 08/21, showed the following:

a. Seclusion is the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving.

b. A practitioner or specially trained registered nurse shall conduct a face-to-face evaluation of the patient within one hour of initiation of seclusion to assess physical and psychological status.

2. Investigator #12 reviewed the medical records of three patients who were physically restrained by staff while a nurse administered an injection. The document review showed that:

a. On 11/06/21 at 9:30 PM staff obtained a telephone order to physically restrain Patient #1211. Staff performed a physical hold between 9:33 PM and 9:35 PM to administer medication. Documentation on the One Hour Face-to-Face Assessment document showed the letters "N/A" written on the form. There was no date or staff signature. There was no evidence that a nurse conducted a face-to-face assessment within 1 hour of initiation of restraint to assess the patient's physical and psychological status, even if the restraint was discontinued, according to hospital policy.

b. Staff obtained telephone orders for restraint and/or seclusion for Patient #1210 5 times between 09/30/21 and 10/17/21. Review of the One Hour Face-to-Face Assessment documents showed that:

i. Nursing staff failed to accurately document or complete the One Hour Face-to-Face Assessments for 5 of 5 records reviewed.

ii. Nursing staff failed to document evidence that a provider consult occurred as soon as possible following the 1-hour face-to-face assessment for five of five records reviewed.

c. Staff obtained telephone orders for restraint and/or seclusion for Patient #1209 5 times between 09/08/21 and 09/27/21. Review of the One Hour Face-to-Face Assessment documentation showed that:

i. Nursing staff failed to accurately document or complete the One Hour Face-to-Face Assessments for 5 of 5 records reviewed.

ii. Nursing staff failed to document evidence that a provider consult occurred as soon as possible following the 1-hour face-to-face assessment for five of five records reviewed.

3. On 11/15/21 from 9:30 to 11:45 AM, Investigators #12, #14, and #15 interviewed the Chief Nursing Officer (Staff #1203). The interview showed that all registered nurses were trained to do the face-to-face evaluation as part of the hospital's forms class and restraint and seclusion training. Nurses receive training that "the clock starts the minute we lay hands on the patient," and the 1-hour face-to-face assessment is expected to occur "within 59 minutes of this time." Staff #1203 verified that the 1-hour face-to-face assessment occurs with all patients in restraints and/or seclusion.

4. On 11/15/21 at 5:15 PM Staff #1201 confirmed the investigator's findings of the missing documentation of the 1-hour face-to-face assesssments and evidence that the nurse consulted the attending or covering provider as soon as possible following the 1-hour face-to-face assessment.
.

.
Based on observation, interview, and document review, the hospital and the director of nursing services failed to ensure that all nursing personnel received adequate orientation and training to know and adhere to the hospital's policies and procedures for 23 of 26 patient records reviewed (Patients #1201, #1202, #1203, #1204, #1205, #1206, #1207, #1209, #1210, #1212, #1504, #1505, #1506, #1507, #1508, #1509, #1511, #1513, #1514, #1515, #1516, #1517, #1604).

Failure of nursing personnel to show knowledge of and follow hospital's policies and procedures, including the performance of patient assessments, reassessments, and observations places patients at risk for serious injury, serious harm, or death.

Findings included:

1. Failure to ensure the development, implementation, review, and revision, when appropriate, of an interdisciplinary treatment plan for behavioral and medical problems.

Cross-reference: A0396

2. Failure of nursing personnel to document and report blood pressures outside of established parameters according to hospital policy, to implement and document patient observations every five minutes according to hospital policy, to implement and document performance of assessments, reassessments, restraint and seclusion according to hospital policy, to store and reconcile patient-own medications, including controlled substances, according to hospital policy.

Cross-reference: A0398

Due to the scope and severity of deficiencies cited under 42 CFR 482.23, the Condition of Participation for Nursing Services was NOT MET
.

.

Based on interview, policy review, and record review, the hospital failed to ensure that staff developed, implemented, reviewed, and revised, when appropriate, an interdisciplinary treatment plan for all patients that included behavioral and medical problems, with individualized patient-specific interventions, as demonstrated by 4 of 4 records reviewed (Patient #1502, #1504, #1506, and #1510).

Failure to ensure the development, implementation, review, and revision, when appropriate, of an interdisciplinary treatment plan for behavioral and medical problems places the patient's at risk for inappropriate, inconsistent and delayed care, creating the potential for negative patient outcomes, harm, or death.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Treatment Planning," policy number PC.T.200, last revised 02/21, showed the following:

a. Each patient admitted to the hospital shall have a written, individualized treatment plan that is responsive and timely to the treatment needs of the patient, based on information provided by the patient, patient's family, and assessment by the clinical treatment team.

b. The treatment plan serves as an organized tool, whereby the care rendered each patient is designed, implemented, assessed, and updated in an orderly and clinically sound manner.

c. Within 8 hours of admission, the Registered Nurse (RN) will initiate the Initial Nursing Treatment Plan that includes behavioral and medical problems with appropriate physician and nursing interventions as determined by the initial assessment and physicians' orders.

d. Within 72 hours of admission, the treatment team shall develop the interdisciplinary treatment plan that is based on a comprehensive assessment of the patient's presenting problems, physical health, emotional and behavioral status.

e. Identified medical problems that are stable, but the patient is receiving medication/treatment for the problem and need to be continually assessed for exacerbation, may be combined under the problem title "Medical Problems."

f. Goals and interventions will be addressed for each identified medical problem.

g. The initial treatment plan shall be reviewed, updated and/or revised within 7 days of a patient's admission. All subsequent updates to the plan shall occur at least every 7 days of hospitalization and as appropriate to patient needs.

h. Treatment plan reviews and updates shall include the following:

i. Review of progress towards goals and effectiveness of interventions for each problem on the Problem List.

ii. Modification or additions made to the goals and interventions, as appropriate.

Patient #1502

2. On 11/09/21 at 1:30 PM, Investigator #15 and the Director of Risk (Staff #1501) reviewed the medical record for Patient #1502, a 94-year-old female voluntary patient, admitted on 09/04/21, after being found at her independent living facility cutting her left wrist. The Patient was taken to the hospital and had a blood pressure of 257/77 on 09/03/21, prior to her admission to Cascade on 09/04/21. Upon admission, the patient's psychiatric diagnoses included Generalized Anxiety Disorder (GAD), Major Depressive Disorder (MDD), and Suicidal Ideation (SI) and medical diagnoses included of Hypertension (High Blood Pressure), Insomnia, Generalized Muscle Weakness (Required assistive devices to ambulate), Acute Urinary Tract Infection (UTI), and Sinus Arrhythmia. Review of the Patient's medical record showed the following:

a. On 09/05/21, the Interdisciplinary Master Treatment Plan (MTP) was initiated and one problem was identified: Psychiatric Problem #1 - Depression. Review of the MTP found no evidence that staff documented any additional psychiatric problems other than Problem #1 - Depression or added any medical problems to the MTP Problem List.

b. Staff initiated the following Individual Treatment Plans:

i. Psychiatric Problem #1 - Depressed Mood without Psychosis, dated 09/04/21.

ii. Medical Problem #1 - Potential Injury related to Fall - Impaired Gait - Ambulatory Aid or Wheelchair, dated 09/04/21.

iii. Medical Problem #2 - Hypertension (HTN), dated 09/04/21.

iv. Medical Problem #3 - Altered Elimination related to Urinary Tract Infection (UTI), dated 09/04/21.

v. Medical Problem unnumbered - Ineffective airway management - Upper Respiratory Infection (URI), dated 09/07/21.

c. Investigator #15 found no evidence that staff added any of the medical problems identified by the initiation of Individual Treatment Plans to the MTP Problem list.

d. On the Admission Order, dated 09/04/21, the provider ordered "wound protocol" to treat the Patient's laceration on their left wrist, which resulted from their suicide attempt on 09/03/21. Staff failed to include wound care on the MTP Medical Problem List or initiate an individual treatment plan to address the provider ordered "wound protocol."

e. On the History and Physical Assessment, dated 09/04/21, the provider documented the Plan of Care for Patient #1502 to include treatment/interventions for the following medical problems: HTN, Generalized Muscle Weakness, UTI, and Insomnia. Staff failed to include Insomnia on the MTP Medical Problem List or initiate an individual treatment plan to address the provider's plan of care.

f. Review of Patient #1502's medical record found that the Patient had been transported to the hospital on two different occasions for medical treatment. On 09/05/21, Patient #1502 experienced a hypotensive (low blood pressure) syncopal (fainting) episode, reported a heart rate of 30 beats per minute (bpm), and a loss of consciousness for 1 minute. On 09/10/21, the Patient experienced a second episode of loss of consciousness (for 2 minutes), reported as a hypertensive (high blood pressure) episode.

g. The Patient's MTP was not updated or revised to include the newly identified medical problem or to initiate a plan of care to address the two medical incidents requiring outside medical interventions.

3. On 11/09/21 at 1:45 PM, during an Interview with Investigator #15, Staff #1501 verified that Patient #1502's MTP was not updated to reflect the identified medical problems.

Patient #1504

4. On 11/09/21 at 3:00 PM, Investigator #15 and the Director of Risk (Staff #1501) reviewed the medical record for Patient #1504, a 52-year-old male, admitted involuntarily on 10/26/21, with a psychiatric diagnosis of Delusional Disorder and Auditory Hallucinations and Bilateral Fluid-Filled Blister on Left Heel. Review of the Patient's medical record showed the following:

a. On 10/29/21, the Interdisciplinary Master Treatment Plan (MTP) was initiated and one problem was identified: Psychiatric Problem #1 - Disturbed Thought. Review of the MTP found no evidence that staff documented any additional psychiatric problems other than Problem #1 - Depression or added any medical problems to the MTP Problem List.

b. Staff initiated the following Individual Treatment Plans:

i. Psychiatric Problem #1 - Disturbed Thought with Paranoia, Delusions, and Auditory and Visual Hallucinations, dated 10/26/21.

ii. Medical Problem #1 - Health Maintenance - Smoking Cessation, dated 10/26/21.

c. Investigator #15 found no evidence that staff added the identified medical problem (Smoking Cessation) to the MTP Problem list.

d. On the History and Physical Assessment, dated 10/26/21, the provider documented the Plan of Care for Patient #1504 to include treatment/interventions for the following medical problems: Fluid-Filled Blister to Left Heel. Staff failed to include this medical problem on the MTP Problem List or initiate an individual treatment plan to address the provider's plan of care.

e. On 10/28/21, the provider wrote an order for Bactrim (an antibiotic) to treat the Patient's newly diagnosed Cellulitis, related to the Left Heel Blister. The Patient's MTP was not updated or revised to include the newly identified medical problem or to initiate a plan of care to guide the interventions/treatment.

f. On 11/04/21, the provider wrote an order for Diclofenac (a topical gel to reduce inflammation) to treat the Patient's newly diagnosed Chronic Neck Pain, related to a cycling accident several years ago. The Patient's MTP was not updated or revised to include the newly identified medical problem or to initiate a plan of care to guide the interventions/treatment.

g. On 11/04/21, the provider wrote an order to perform a fecal occult blood test (to rule out a gastrointestinal bleed). The Patient's MTP was not updated or revised to include the newly identified medical problem/symptom or to initiate a plan of care to guide the interventions/treatment.

5. On 11/09/21 at 3:10 PM, during an Interview with Investigator #15, Staff #1501 verified that Patient #1504's MTP was not updated to reflect the identified medical problems.

Patient #1506

6. On 11/10/21 at 11:45 AM, Investigator #15 and Staff #1501 reviewed the medical record for Patient #1506, a 65-year-old female, admitted involuntarily on 09/07/21, with a psychiatric diagnosis of Schizoaffective Disorder and a medical diagnosis of Hypertension (HTN), Hypothyroidism, and Avascular Necrosis of Right Hip. Patient #1506 was found in front of an apartment complex, sitting in her wheelchair for five days, refusing food and drink. Review of the Patient's medical record showed the following:

a. On 09/07/21, the Interdisciplinary Master Treatment Plan (MTP) was initiated and one psychiatric problem was identified: Psychiatric Problem #1 - Disturbed Thought; and two medical problems were identified: Hypothyroidism and Fall Risk. Review of the MTP found no evidence that staff documented any additional psychiatric problems or added any medical problems to the MTP Problem List.

b. Staff initiated the following Individual Treatment Plans:

i. Psychiatric Problem #1 - Disturbed Thought with Paranoia and Delusions, dated 09/07/21.

ii. Medical Problem unnumbered - Hypothyroidism, dated 09/07/21.

iii. Medical Problem unnumbered - Potential for Injury related to Fall, dated 09/07/21.

c. On the History and Physical Assessment, dated 09/07/21, the provider documented the Plan of Care for Patient #1506 to include treatment/interventions for the following medical problems: Hypomagnesemia, Nicotine Abuse, Bilateral Lower Leg Edema, Insomnia, Urinary Incontinence, Osteoarthritis with Hip Pain. Staff failed to include these medical problems on the MTP Problem List or initiate an individual treatment plan to address the provider's plan of care.

d. On 09/25/21, the provider wrote an order for Triple Antibiotic Ointment and daily foot soaks to treat the Patient's newly diagnosed Ingrown Toenail. The Patient's MTP was not updated or revised to include the newly identified medical problem or to initiate a plan of care to guide the interventions/treatment.

e. On 10/03/21, the provider wrote an order for Clonidine (antihypertensive medication to treat high blood pressure). The Patient's MTP was not updated or revised to include the newly diagnosed medical problem or to initiate a plan of care to guide the interventions/treatment.

7. On 11/10/21 at 12:10 PM, during an Interview with Investigator #15, Staff #1501 verified that Patient #1506's MTP was not updated to reflect the identified medical problems.

Patient #1510

8. On 11/18/21 at 11:30 AM, Investigator #15 reviewed the medical record for Patient #1510, a 68-year-old female, admitted involuntarily on 10/05/21, with a psychiatric diagnosis of Brief Psychotic Disorder, Major Depressive Disorder (MDD) and Generalized Anxiety Disorder (GAD) and a medical diagnosis of Hypertension (HTN), Dehydration, Hyponatremia (Low sodium level in the blood), Anorexia, Hypokalemia (Low potassium), Hypomagnesemia (Low magnesium), Urinary Tract Infection (UTI), Insomnia, and Edentulism (Complete loss of teeth). Patient #1506 was found on the floor of her home in acute psychosis. Patient #1510 reported that she had all of her teeth pulled in June of 2021 and had dentures at home but did not bring them with her. Review of the Patient's medical record showed the following:

a. On 10/05/21, the Interdisciplinary Master Treatment Plan (MTP) was initiated and one psychiatric problem was identified: Psychiatric Problem #1 - Disturbed Thought - Confusion; and three medical problems were identified: Hypertension, Hypokalemia and Urinary Tract Infection. Review of the MTP found no evidence that staff documented any additional psychiatric problems or added any medical problems to the MTP Problem List.

b. Staff initiated the following Individual Treatment Plans:

i. Psychiatric Problem #1 - Disturbed Thought with Confusion, dated 10/05/21.

ii. Medical Problem #2 - Hypokalemia, dated 10/05/21.

iii. Medical Problem #3 - Altered Elimination related to UTI, dated 10/05/21.

iv. Medical Problem #4 - Hypertension, dated 10/05/21.

v. Medical Problem unnumbered - Health Maintenance - Smoking Cessation, dated 10/05/21.

vi. Medical Problem unnumbered - Insomnia, dated 10/05/21.

c. Investigator #15 found no evidence that staff added the following identified medical problems to the MTP Problem list: Smoking Cessation and Insomnia.

d. On the History and Physical Assessment, dated 10/05/21, the provider documented the Plan of Care for Patient #1510 to include treatment/interventions for the following medical problems: Dehydration, Hyponatremia, Anorexia, Hypomagnesemia, Insomnia, and Edentulism (with no dentures on site). Staff failed to include these medical problems on the MTP Problem List or initiate an individual treatment plan to address the provider's plan of care.

e. On 10/06/21, the provider wrote an order to restrict the Patient's Fluid Intake (Free Water Restriction) to 1.5 Liters per day related to the Patient's Hyponatremia. The Patient's MTP was not updated or revised to include the newly identified medical problem or to initiate a plan of care to guide the interventions/treatment.

f. On 10/07/21, the provider wrote an order for the staff to document the Patient's intake and output (I & O) related to the Patient's refusal to eat or drink. The Patient's MTP was not updated or revised to include the newly identified medical problem or to initiate a plan of care to guide the interventions/treatment.

g. Review of Patient #1510's medical record found that the Patient had been transported to the hospital for medical intervention on 10/13/21 related to: Failure to Thrive (FTT), Hyponatremia, Hypokalemia, Low GFR (Glomerular Filtration Rate-Kidney Failure), Very Poor Oral Intake, and requesting the administration of Intravenous (IV) fluids.

h. The Patient's MTP was not updated or revised to include the newly identified medical problems or to initiate a plan of care to address the medical incident requiring outside medical interventions.

9. On 11/15/21 at 12:00 PM, during an interview with Investigator #15, the Chief Nursing Officer (Staff #1508), stated that she was unable to speak to the treatment plans for Patient #1502, #1504, #1506, and #1501, however she was doing an in-depth training on treatment plans for the nurses currently. Staff #1508 reported that night shift staff is doing an audit for "checks and balances" to make sure that the treatment planning documentation is complete. Staff #1508 stated that the audits should have identified any missing treatment documentation.

.

.

Based on observation, interview, and document review the hospital failed to ensure that all nursing personnel: followed policies and procedures for documenting and reporting blood pressures outside of established parameters for 5 of 9 patient records reviewed (Patients #1201, #1202, #1207, #1210, #1212) (Item #1); followed the policies and procedures for patient rounding and documenting patient observations for 5 of 5 patient records reviewed (Patients #1201, #1203, #1204, #1205, #1604) (Item #2); followed the policies and procedures for performing and documenting Patient Assessments for 2 of 2 patient records reviewed (Patients #1503, #1505) (Item #3); followed the policies and procedures ensuring complete and accurate documentation of Nursing Reassessments for 4 of 4 patient records reviewed (Patients #1202, #1206, 1207, 1210) (Item #4); followed the policies and procedures for safe medication practices by ensuring the reconciliation and proper storage of medications, including controlled substances, brought in by patients for 5 of 5 records reviewed (Patients #1511, #1514, #1515, #1516, #1517) (Item #5).

Failure to ensure that all nursing personnel follow hospital policies and procedures while taking patient vital signs, performing and documenting patient observations, assessments, and reassessments, and storing patient own medications places patients at risk for serious injury, serious harm, or death.

Findings included:

Item #1 Vital Signs

1. Document review of the hospital policy titled, "Vital Signs & Parameters," policy number PC.VS.101, revised 09/21, showed that:

a. All patients will have vital signs, including blood pressure, pulse, temperature, respirations and oxygen saturation, taken upon admission, daily, and more frequently if ordered by the provider or warranted by the patient's condition. Nursing staff assigned to the patient will take the blood pressure, document the findings in the patient's chart and report all changes/abnormal findings to the charge nurse and physician.

b. Vital signs obtained by the Behavioral Health Associate (BHA) are reviewed by the nurse assigned to the patient. If a patient's systolic blood pressure is less than 90 mm/Hg or greater than 160 mm/Hg, or the diastolic blood pressure is less than 60 mm/Hg or greater than 105 mm/Hg, the nurse will assess the patient for symptoms. The nurse will treat the vital signs with any ordered PRN medications and recheck the vital signs in one hour. If no PRN meds are ordered, the nurse will contact the provider for orders.

c. Communication with the provider regarding vital signs outside of the parameters should include: all vital signs, patient assessments or complaints, patient allergies, and current medications. Any communications should be documented in the progress notes along with the provider's response.

2. Investigator #12 reviewed the medical records of five patients hospitalized between 09/04/21 and 11/20/21. The medical record review showed the following:

a. Patient #1201 transferred from an acute care hospital to the facility on 09/30/21 involuntarily for treatment of major depressive disorder with psychosis. Prior to the transfer, Patient #1201 was hospitalized since 09/13/21 for treatment of atrial fibrillation (an irregular heartbeat), high blood pressure, altered level of consciousness and suicide ideation.

Upon arrival to the 3 North unit on 09/30/21 at 12:40 AM, Patient 1201's blood pressure was 98/58. Prior to admission, the nurse to nurse report showed the patient's blood pressure was 119/72 on 09/29/21 at 9:00 PM, and the Intake Assessment form showed that at 4:30 PM, the patient's blood pressure was 114/72.

On 09/30/21 at 4:00 AM, a nurse signed a telephone order for admission orders from a provider listed as "Shelby," no last name, no credentials provided. There was no evidence of documentation showing that the nurse identified the patient's blood pressure was outside of parameters, reassessed the patient, repeated the blood pressure, or notified the provider of the patient's low systolic and diastolic blood pressure readings.

On 09/30/21 at 7:45 AM, nursing staff found Patient #1201 unresponsive, pulseless, and not breathing. Staff began cardiopulmonary resuscitation (CPR), called a Code Blue, and called 911. Paramedics transported the patient to a nearby acute care hospital at 8:25 AM, but the patient did not survive.

b. Four of eight patient records reviewed (Patients #1202, #1207, #1210, and #1212) showed patients had blood pressure readings outside of the parameters identified in the hospital's "Vital Signs & Parameters Policy." The record review showed that:

i. Patient #1202's blood pressure was outside of parameters on: 09/06/21-109/55 (low diastolic); 09/08/21-190/81 (high systolic); 09/08/21-180/80 (high systolic); 09/10/21 208/85 (high systolic)

ii. Patient #1207's blood pressure was outside of parameters on: 10/24/21-100/46 (low diastolic); 10/30/21-114/56 (low diastolic); 10/31/21-116/58 (low diastolic); 11/01/21-116/58 (low diastolic); 11/02/21-97/59 (low systolic and low diastolic)

iii. Patient #1210's blood pressure was outside of parameters on: 09/06/21-177/83 (high systolic)

iv. Patient #1212's blood pressure was outside of parameters: 10/08/21-125/58 (low diastolic); 10/14/21-189/77 (high systolic)

c. There was no evidence to show that nursing staff assessed the patient, rechecked the blood pressure, or notified the provider of the patients' blood pressure results.

3. On 10/19/21 at 4:00 PM, Staff #1201 confirmed that it was the hospital's expectation for staff to assess the patient, notify the provider, and document their actions when a patient's blood pressure falls outside of the established parameters. Staff #1201 confirmed the investigators findings that Patient #1201's blood pressure was outside of the hospital's established parameters, and nursing staff should have notified the provider of the patient's blood pressure reading.

Item #2 Patient Rounding and Observations

1. Document review of the hospital's policy, "Suicide Risk Assessment," no policy number, dated 08/21, showed that staff use the Columbia Suicide Risk Assessment process to screen every patient upon admission to identify protective factors and to assess the patient for thoughts, plans and suicide intent. If a patient is found to be at moderate or high risk for suicide, practitioner's orders for admission will include suicide precautions and the appropriate level of monitoring of the patient on the unit and that during the Intake process, patients found to be at moderate or high suicide risk are continually monitored until the patient is admitted and moved to the unit.

Document review of the hospital's policy titled, "Documentation Protocols," policy number PC.DP.300, revised 09/21, showed that all medical records are to be accurate, truthful, and complete.

Document review of the hospital's policy titled, "Patient Levels and Safety Precautions," policy number PC.PLSP.100, reviewed 01/19, showed that patients are screened for safety precautions on admission. Patients who have unstable medical conditions that may require immediate intervention will be placed on Medical Alert precautions. Patients will have "MA" indicated on the round sheet.

2. On 11/10/21 between 8:00 AM and 10:30 AM, Investigators #12, #15, and #16 observed patient-care activities on the 3 North inpatient unit. At the time of the observation, the unit had a census of 16 adult patients, and three patients requiring observation every 5 minutes. There were two Behavioral Health Associates (BHAs) (Staff #1225, Staff #1226) and one BHA orientee (Staff #1227) working in the unit. The investigators observed the staff performing the 5-minute observations. Investigator #12 observed staff members (staff #1225 and #1227) documenting the 5-minute observations as they occurred at 8:28 AM, 8:43 AM, and 8:50 AM. During the observation, Investigators #12 and #16 also noted that 5 pencils were on the table in the patient care area, and one pencil was on the bookshelf in the patient care area. No staff members were seen monitoring those areas.

During the observation, Investigator #16 interviewed Staff #1225, Staff #1226, and Staff #1227 regarding special precautions including suicide precautions and sexual high risk. The interviews showed that no staff could identify which patients were currently on special precautions for suicide or describe what behaviors to watch for or actions that were needed when working with patients on special precautions for suicide. The interview also showed that Staff #1225, Staff #1226, and Staff #1227 were unaware that the observed pencils could potentially be used for self-harm or that the pencils were easily available to patients.

3. On 11/10/21 at 2:00 PM, observation by Investigator #16 showed the arrival and admission of Patient #1604, a 63-year-old female voluntarily admitted after an intentional overdose of prescription medications. The patient was given hospital scrubs and directed by an intake specialist (Staff # 1604) to change into the scrubs in an unsupervised restroom down the hall.

4. On 11/10/21 at 2:05 PM an interview with Staff #1604 showed that Staff #1604 stated that he had not done the original intake for Patient #4 and was unaware of the reason for her admission (intentional overdose). When asked if it was safe to give items that could be used for ligature (hospital scrubs) to a patient at risk for suicide, and then send the patient unattended to the restroom, Staff #4 stated "No", but did not go to check on the patient.

5. Investigator #12 reviewed the medical record of Patient #1201, a 68-year-old involuntary patient admitted on 09/30/21 at 12:40 AM for the treatment of major depressive disorder with psychosis and anxiety. Pertinent medical history included recent hospitalization for atrial fibrillation (irregular heartbeat), high blood pressure, altered mental status, and suicide ideation. Document review showed the following:

a. On 09/30/21 at 12:40 AM, staff attempted to complete the Admission SAFE-T Columbia Suicide Screen during the intake process, but staff checked the box indicating that the patient refused the assessment. At 1:15 AM staff scribbled over this selection and marked the box showing that the patient was at moderate risk for suicide.

b. On 09/30/21 at 4:00 AM, a nurse entered telephone orders showing that Patient #1201 was placed on 5-minute observations. The nurse wrote "A-fib, COPD, HTN" (Atrial fibrillation, chronic obstructive pulmonary disease, hypertension) next to Medical Alert, but the nurse entering the order failed to check the box for the Medical Alert to indicate that medical precautions were needed. The nurse also failed to check the box for Suicide Precautions.

c. The Patient Observations Q5 (Five) Minute Observation Record for the 11:30 PM to 7:25 AM shift showed that Patient #1201 was on 5-minute observations and suicide precautions. Documentation showed that the patient remained calm, in her room, and appeared to be sleeping with chest rising/falling or sitting/lying from 12:55 AM until 7:25 AM.

d. The Patient Observations Q5 (Five) Minute Observation Record for the 7:30 AM to 3:25 PM shift showed that Patient #1201 remained on 5-minute checks, but no precautions were checked. Documentation showed that at 7:40 AM, Patient #1204 was calm, in her room, receiving medication. At 7:45 AM, the patient was calm, in her room, sitting/lying in bed, and at 7:50 AM, the patient was in her room talking with staff. At 7:55 AM, staff began documenting "CPR" until 8:30 AM when the patient went to the hospital.

e. Review of the admission orders and medication administration record showed that Patient #1201 had no active medication orders and no documentation of medications that were administered while hospitalized at the facility.

f. On 11/04/21 between 9:40 AM and 11: 30 AM, Investigator #12 interviewed three staff nurses who worked with Patient #1201 prior to the Code Blue event (Staff #1210, Staff #1220, Staff #1221). Staff #1210, Staff #1220, and Staff #1220 stated that they did not give Patient #1201 any medications on 09/30/21. Staff #1220 and Staff #1221 stated that they did not see or speak to Patient #1201 at any time before the Code Blue event.

g. Review of the Emergency Medical Service (EMS) documents showed that hospital staff reported Patient #1201's "last known well time" was 7:20 AM. The patient was breathing and did not appear in distress. When staff returned to the room at approximately 7:50 AM, Patient #1201 was not breathing and without a pulse.

6. On 11/04/21 at 4:00 PM, Investigator #12 interviewed Staff #1201 about the staff documentation process and rounding. Staff #1201 confirmed the investigators findings that staff did not complete truthful and accurate documentation when they documented on 09/30/21 that Patient #1201 had received medications or was talking with staff.

Item #3 Patient Assessments

Findings included:

1. Document review of the hospital's policy and procedure titled, "Nursing Standards for Patient Care," policy number PC.N.200, last revised 12/13, showed the following:

a. Each patient has an initial assessment that includes consideration of physical, perceived pain, psychological, social status, nutritional, functional/age related and educational needs upon arrival to the nursing unit.

b. All patients will have an initial nursing assessment within 8 hours of admission/transfer to a nursing unit.

c. A Registered Nurse (RN) assesses the patient's needs or validates an assessment of patient needs at the time of admission or within 8 hours of admission.

d. Assessment data are consistent with the therapies of other disciplines.

e. Assessment data are available to all personnel involved in the patient care.

f. Assessment serves as the foundation for the development of the nursing diagnosis and the implementation of the nursing care plan.

g. Each patient's care is based on identified nursing diagnosis and/or patient care needs and patient care standards.

h. Whenever possible, goals are mutually set with the patient and/or family and are based on the nursing assessment.

i. Care decisions are based on patient needs identified through evaluation of the assessment data.

2. Document review of the hospital's policy and procedure titled, "Treatment Planning," policy number PC.T.200, last revised 02/21, showed the following:

a. The purpose of treatment planning is to provide a complete, individualized plan of care based on an integrated assessment of the patient's specific needs and problems and prioritization of those needs/problems.

b. Within 8 hours of admission, the Registered Nurse (RN) will initiate the Initial Treatment Plan. This initial plan shall include behavioral and medical problems and appropriate interventions as determined by the initial nursing assessment.

3. Document review of the hospital's policy and procedure titled, "Documentation Protocols," policy number PC.L.300, last revised 09/21, showed that all medical records are to be accurate, truthful, and complete.

Patient #1505

4. On 11/09/21 at 3:45 PM, Investigator #15 and the Director of Risk (Staff #1501) reviewed the medical record for Patient #1505, a 49-year-old male, admitted involuntarily on 07/01/21, with a psychiatric diagnosis of Schizoaffective Disorder. Review of the Patient's medical record showed the following:

a. On the Initial Nursing Assessment, dated 07/01/21, nursing staff documented the date and time of the Patient's arrival to the unit, the Patient's legal status, and admission vital signs. Staff documented the Patient's chief complaint as "unable to assess." The body/safety search was performed by two staff; however, the time of the search was not documented.

b. Nursing staff failed to complete the Initial Nursing Assessment for Patient #1505. The following data was not documented (left blank) during the Initial Nursing Assessment performed on 07/01/21:

i. Educational Data and Learning Barriers and Preferences - Left blank.

ii. Hygiene and Sleep Patterns - Left Blank.

iii. Pain Assessment - Left Blank.

iv. Functional Screening - Left Blank.

v. Nutritional Screening - Left Blank.

vi. Falls History - Left Blank

vii. Elopement Risk Assessment - Left Blank.

viii. Alcohol/Drug History and Withdrawal Symptoms - Left Blank.

ix. Tobacco Use Screening - Left Blank.

x. Review of Systems - Left Blank.

xi. Psychiatric Assessment - Left Blank.

xii. Seclusion and Restraint Screening - Left Blank.

xiii. Abnormal Involuntary Movement Scale (AIMS) Screening - Left Blank.

xiv. Discharge Planning - Left Blank.

xv. Suicide Risk Assessment Screening - Left Blank. Nursing staff documented that they were "unable to assess."

c. The admitting RN documented in the Summary of the Initial Nursing Assessment that Patient #1505 was "disoriented and disorganized, unable to assess upon admission."

d. Page 9 of the Initial Nursing Assessment provided a space to document additional attempts to complete the assessment. "If unable to complete the assessment because the patient is unable or unwilling, document daily attempts. Add additional lines as needed." The document did not contain evidence of additional nursing staff's attempts to complete the Patient's Initial Nursing Assessment.

5. Staff #1501 verified that the Initial Nursing Assessment for Patient #1505 was not completed.

Patient #1503

6. On 11/09/21 at 4:30 PM, Investigator #15 reviewed the medical record for Patient #1503, a 68-year-old female, admitted involuntarily on 09/30/21 at 12:40 AM, with a psychiatric diagnosis of Depression and Anxiety and a medical history of Hypertension, Chronic Heart Failure, Chronic Atrial Fibrillation, Cardiomyopathy, Mitral Regurgitation, Peripheral Vascular Disease, Chronic Alcoholism, Kidney Disease - Stage III, Aortic Valve Stenosis, Severe Protein Calorie Malnutrition. Review of the Patient's medical record showed the following:

a. On the Initial Nursing Assessment, dated 09/30/21, nursing staff documented the date and time of the Patient's arrival to the unit, the Patient's legal status, and admission vital signs. Staff documented the Patient's chief complaint as "patient refused to talk." The body/safety search was performed by two staff at 12:50 AM.

b. Nursing staff failed to complete the Initial Nursing Assessment for Patient #1503. The following data was incomplete or not documented (left blank) during the Initial Nursing Assessment performed on 09/30/21:

i. Educational Data and Learning Barriers and Preferences - Left blank.

ii. Hygiene and Sleep Patterns - Nursing staff documented "patient refused to talk."

iii. Pain Assessment - Left Blank.

iv. Functional Screening - Nursing staff documented the Patient was "independent" for eating and "needed supervision" for dressing, bathing, and toileting.

v. Nutritional Screening - Nursing staff documented "patient refused to assess."

vi. Falls History - Nursing staff documented "patient refused."

vii. Elopement Risk Assessment - Nursing staff documented that the Patient was not an elopement risk.

viii. Alcohol/Drug History and Withdrawal Symptoms - Nursing staff documented that the "patient refused to assess."

ix. Tobacco Use Screening - Nursing staff documented that the "patient refused to assess."

x. Review of Systems - Nursing staff documented that the patient "refused assessment."

xi. Psychiatric Assessment - Left Blank.

xii. Seclusion and Restraint Screening - Left Blank.

xiii. Abnormal Involuntary Movement Scale (AIMS) Screening - Nursing staff partially completed the AIMS Screening.

xiv. Discharge Planning - Left Blank.

xv. Suicide Risk Assessment Screening - Left Blank.

c. The admitting RN documented in the Summary of the Initial Nursing Assessment that Patient #1503 "came from Multicare Covington Hospital, refused to take medications in Multicare. Vital signs are 98/58 blood pressure, 97.9 temperature, 61 pulse, 98% oxygen saturation. Patient was one-to-one observation in Hospital. Patient was on oxygen in Hospital. But Patient oxygen is 98% saturation on room air. Patient refused assessment. Continue to monitor the Patient Q5 (every 5 minutes)."

d. Page 9 of the Initial Nursing Assessment provided a space to document additional attempts to complete the assessment. "If unable to complete the assessment because the patient is unable or unwilling, document daily attempts. Add additional lines as needed." The document did not contain evidence of additional nursing staff's attempts to complete the Patient's Initial Nursing Assessment.

e. On 09/30/21 at 7:45 AM, after shift change, nursing staff entered Patient #1503's room to check her blood sugar. Patient #1503 was unresponsive. A Code Blue (hospital emergency code - critical status of patient) was called and staff notified 911. Medics arrived at Cascade and transported Patient #1503 to the hospital. The receiving hospital called the Charge Nurse to report that the Patient had passed away at 10:13 AM.

7. On 11/15/21 at 9:40 AM, during an interview with Investigator #12, #15 and #16, the Chief Nursing Officer (CNO) (Staff #1508) stated that she was not aware of Initial Nursing Assessments that were not being completed in a timely manner. Staff #1508 stated that the hospital is in the process of training and/or re-training nursing competencies to all nursing staff and explained that they have not trained the staff on nursing assessments. She reported that the new medical provider team has offered to train the nursing staff on assessment competencies.

When asked about the process for completing the Initial Nursing Assessment when the patient refuses to participate, Staff #1508 stated that she would have to refer to hospital policy but noted "you just have to re-engage." The CNO stated that "oversight is coming, next week on day shift the house supervisor will be auditing." "In real time, we are just not there yet."

Item #4 Patient Reassessments

1. Document review of the hospital's policy titled, "Documentation Protocols," Policy #PC.DP.300, revised 09/21, showed that all medical records are to be accurate, truthful, and complete. Entries must be confirmed by written signature, date, time and credentials. Staff signatures must be legible, use first and last name and credentials.

2. Investigator #12 reviewed four patient records. The document review showed the following:

a. Nursing signatures were missing from 3 of 4 patient records reviewed (Patients #1202, #1207, and #1210).

b. Nursing staff failed to document the last bowel movements for 3 of 4 patient records reviewed (Patients #1202, #1206, and #1207).

c. Nursing staff failed to perform daily skin assessments for 2 of 4 patient records reviewed (Patients #1202 and #1207).

d. Nursing staff failed to document daily education provided for 4 of 4 patient records reviewed (Patients #1202, #1206, #1207, and #1210).

e. Nursing staff failed to document daily progress toward treatment goals, whether patients participated in groups, if patients were progressing toward medical treatment goals and document how patients were meeting/not meeting their treatment goals in the daily progress notes for 4 of 4 records reviewed (Patients #1202, #1206, #1207, and #1210).

3. On 11/18/21, Investigator #15 reviewed the medical record for Patient #1510. Document review showed the following:

a. On the Daily Nursing Reassessments, dated from 10/08/21 to 10/21/21, nursing staff documented that Patient #1510 had a "good appetite."

b. On the Vitals Graphic (Form NURS-0011), dated from 10/08/21 to 10/21/21 staff documented that Patient #1510 refused 30 of 40 meals and ate 25% or less for 5 of 40 meals.

c. The information contained on the Daily Nursing Reassessments was incongruent with the data reported on the Vitals Graphics.

d. Nursing staff failed to document the Patient's oral intake and nutrition status accurately, based on the Vital Graphics data.

4. On 11/15/21 between 9:30 AM and 12:00 PM, Investigators #12, #15, and #16 interviewed the Chief Nursing Officer (Staff #1203) about the staff competency process. Staff #1203 stated that the hospital is retraining nursing staff on how to complete all nursing forms, and the goal for completion date is 12/07/21

Item #5 Medication Safety

Findings included:

1. Document review of the hospital's policy and procedure titled, "Medications Brought in With Patients," policy number PHR.118 and MM.03.01.03/MM.05.01.13, last reviewed 09/21, showed the following:

a. The purpose of the policy is to ensure that medications brought in with the patient during their stay are disposed of properly or stored properly in a manner consistent with State and Federal law, Joint Commission Standards, and professional practice.

b. When a patient brings in medications from home, it will be documented upon admission to the facility. Once the patient has been taken to the unit where they will be staying, the medications brought in by the patient will be inventoried by the staff nurse at that unit. The inventory sheet will be signed by the patient and the nurse conducting the inventory and will be faxed to the pharmacy and kept in the patient's chart. The same sheet and procedure will be used upon discharge.

c. If the medications brought in by the patient will not be administered during the patient's stay, all medications will be given back to the patient's family to be taken home if possible.

d. If the patient's family cannot be notified, then all medications are placed in a tamper resistant sealed bag.

e. Controlled substances that cannot be returned to the family, must be counted with the quantity noted on the inventory sheet. The patient and the staff member receiving the medications will sign the form.

f. The entire bag with the inventory form will be secured under lock in the medication room on the unit where the patient is located or other designated area.

g. Copies of the inventory form are kept with the bag of medications and in the patient's record.

h. When a patient has controlled substances being returned at discharge, the quantity being returned to the patient will be noted by the nurse (and witness if available) in the patient's medical record. The patient or care giver will also verify that the count is correct.

i. Documentation regarding disposition of medications will be maintained for a period of two years.

2. On 11/10/21 from 8:15 AM to 9:00 AM, Investigator #15 inspected the medication room on 3 North. The observation showed the following:

a. The sign on the upper cabinet door which contained the medications brought in by the patients, noted that the "cabinet doors must remain locked at all times."

b. All cabinet doors in the medication room were unlocked.

c. Inside the unlocked cabinet, Investigator #15 found a sealed bag containing medication brought in by Patient #1511. Inside of the sealed bag, there was an undated copy of the Patient's Belongings Inventory Sheet. Staff documented that the medication/s were "placed in bag and given to unit nurse." Staff failed to document the name of the medication/s or the quantity of the medication upon the Patient's admission, as directed by hospital policy.

d. The sealed bag contained the medication Alprazolam/Xanax, which is a controlled substance. Investigator #15 found that staff failed to ensure that staff inventoried and secured the medication in a locked cabinet, as directed by hospital policy.

e. In a binder titled "E Kit (Emergency Kit) and Temperature Binder," Investigator #15 found a page titled "controlled drug" log for Patient #1511, dated 11/03/21, that listed the medication Alprazolam, with a quantity of 57.5 pills. Staff documented that the inventory count had been verified by two nurses twice on 11/03/21 at 2:05 AM and 7:15 AM, and then again on 11/06/21 at 11:00 PM. No other staff documented verifying the medication count for the controlled substance.

4. Review of Patient #1511's medical records failed to find evidence that staff documented and inventoried the medications, including the controlled substance, that the patient brought in during admission.

5. On 11/10/21 at 8:30 AM, during an interview with Investigator #15, Registered Nurse (RN) (Staff #1505) stated that they were unsure of what to do if a patient brings in a controlled medication. Staff #1505 was unfamiliar with the "controlled drug" log for Patient #1511.

6. On 11/10/21 at 8:35 AM, during an interview with Investigator #15, RN (Staff #1507) stated that controlled medications brought in by patients should be in a locked cabinet. Staff #1507 stated that usually the staff will place the patient's "controlled drug" log on the bulletin board to help staff remember to count the medication during shift change.

7. On 11/10/21 at 8:40 AM, during an interview with Investigator #15, RN (Staff #1506) stated that controlled medications brought in by patients should be counted each shift and stored in the cabinet. When asked about the unlocked cabinet, Staff #1506 stated that is how we have always done it.

8. On 11/10/21 at 8:45 AM, during an interview with Investigator #15, the Director of Risk (Staff #1501) verified that the cabinet containing the controlled substances brought in by the patient was unlocked. Staff #1501 stated that nursing staff was not following the hospital's policy for safe medication inventory and storage.

9. On 11/15/21 from 5:00 PM to 5:15 PM, Investigator #12 and Investigator #15 inspected the medication room on 2 North. The observation showed the following:

a. The sign on the upper cabinet door which contained the medications brought in by the patients, noted that the "cabinet doors must remain locked at all times."

b. All cabinet doors in the medication room were unlocked. Inside the unlocked cabinet containing the medication brought in by patients, the Investigators found the following:

i. An unsealed bag containing medication brought in by Patient #1514. The unsealed bag contained the following controlled substances: Lorazepam (Ativan) and Trazadone HCL 50 mg. The bag failed to contain a copy of the Patient's Belongings Inventory Sheet. The Investigators counted a quantity of 6 - 1 mg Lorazepam and 20 - 50 mg Trazadone.

ii. An unsealed bag containing medication brought in by Patient #1515. The unsealed bag contained the following controlled substance: Buprenorphine/Naloxone. The bag failed to contain a copy of the Patient's Belongings Inventory Sheet. The Investigators counted a quantity of 26 Buprenorphine/Naloxone.

iii. An unsealed bag containing medication brought in by Patient #1516. The unsealed bag contained the following controlled substance: Naltrexone. The bag failed to contain a copy of the Patient's Belongings Inventory Sheet. The Investigators counted a quantity of 4.5 Naltrexone.

iv. A sealed bag containing medication brought in by Patient #1517. The sealed bag contained the following controlled substance: Dextroamphetamine. The bag failed to contain a copy of the Patient's Belongings Inventory Sheet. Keeping the sealed bag intact, the Investigators noted a bottle of the medication that was recently filled which appeared to contain 30 tablets and a partially filled prescription bottle containing approximately 10 tablets.

10. On 11/15/21 at 5:15 PM, during an interview with Investigator #12 and Investigator #15, Staff #1501 verified that the cabinet containing the controlled substances brought in by the patient was unlocked. Staff #1501 verified that the unlocked cabinet contained 4 patients' medication bags with unsecured controlled substances. Staff #1501 stated that this was another example of nursing staff not following the hospital's policy for safe medication inventory and storage.

.