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Based on interview and record review, the hospital failed to follow its policy and procedure titled, "Use of Seclusion and Restraint" for five of five sampled patients (Patient 23, Patient 20, Patient 24, Patient 22, and Patient 21) who received a chemical restraint (intentional use of any medications to subdue, sedate, or restrain an individual). This failure had the potential for post-sedation side effects to not be identified.

Findings:

During a concurrent interview and record review on 8/22/23 at 11:41 a.m. with Risk Manager (RM), Patient 23's medical record was reviewed. The following was noted:

The Physician Order (PO) dated 7/14/23 at 9:10 a.m. indicated, Benadryl (antihistamine which can cause drowsiness) 50 milligrams (mg-unit of measure) and Ativan 1 mg (medication used to treat seizures and can cause drowsiness) intramuscular (IM) one time for severe agitation and physical aggression. The Medication Administration Record (MAR) dated 7/14/23 at 9:20 a.m. indicated Benadryl 50 mg and Ativan 1 mg IM was given. RM stated there was no documented follow up by a physician within one hour after chemical restraint was administered.

The PO dated 7/15/23 at 7:25 p.m. indicated, Benadryl 50 mg and Ativan 1 mg IM one time for "assaultive/aggression." The MAR dated 7/15/23 at 7:50 p.m. indicated Benadryl 50 mg and Ativan 1 mg IM was given. RM stated there was no documented follow up by a physician within one hour after chemical restraint was administered.

The PO dated 7/16/23 at 6:20 p.m. indicated, Benadryl 50 mg and Ativan 1 mg IM one time for "severe agitation." The MAR dated 7/16/23 at 6:20 p.m. indicated Benadryl 50 mg and Ativan 1 mg IM was given. RM stated there was no documented follow up by a physician within one hour after chemical restraint was administered.

The PO dated 7/17/23 at 9:27 a.m. indicated, Haldol (medication used to treat mental illnesses and can be used to sedate patients) 2 mg and Benadryl 50 mg IM one time for "severe agitation." The MAR dated 7/17/23 at 9:35 a.m. indicated Haldol 2 mg and Benadryl 50 mg IM was given. RM stated there was no documented follow up by a physician within one hour after chemical restraint was administered.

The PO dated 7/19/23 at 3:35 p.m. indicated, Haldol 2 mg, Ativan 1 mg, and Benadryl 50 mg IM one time for "severe agitation." The MAR dated 7/19/23 at 3:40 p.m. indicated Haldol 2 mg, Ativan 1 mg, and Benadryl 50 mg IM was given. RM stated there was no documented follow up by a physician within one hour after chemical restraint was administered.

During a concurrent interview and record review on 8/22/23 at 2:35 p.m. with RM, Patient 20's medical record was reviewed. The following was noted:

The PO dated 7/14/23 at 6:31 p.m. indicated, Ativan 1 mg and Benadryl 50 mg IM one time for "severe agitation." The MAR dated 7/14/23 (time not legible) indicated Ativan 1 mg and Benadryl 50 mg IM was given. RM stated there was no documented follow up by a physician after chemical restraint was administered.

The PO dated 7/15/23 at 8:55 a.m. indicated, Ativan 1 mg and Benadryl 50 mg IM one time for "severe agitation." The MAR dated 7/15/23 at 9:05 a.m. indicated Ativan 1 mg and Benadryl 50 mg IM was given. RM stated there was no documented follow up by a physician after chemical restraint was administered.

The PO dated 7/15/23 at 7:25 p.m. indicated, Ativan 1 mg and Benadryl 50 mg IM one time for "DTO [danger to others], aggression, DTS [danger to self], verbally abusive." The MAR dated 7/15/23 at 7:45 p.m. indicated Ativan 1 mg and Benadryl 50 mg IM was given. RM stated there was no documented follow up by a physician after chemical restraint was administered.


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During a concurrent interview and record review on 8/22/23 at 11:15 a.m. with RM, Patient 24's medical record was reviewed. The following was noted:

The PO dated 7/9/23 at 8 p.m. indicated, Benadryl 50 mg and Ativan 2 mg IM one time for severe agitation. The MAR dated 7/9/23 at 8:20 p.m. indicated Benadryl 50 mg and Ativan 2 mg IM was given. RM stated there was no documented follow up by a physician within one hour after chemical restraint was given.

During a concurrent interview and record review on 8/22/23 at 11:30 a.m. with RM, Patient 22's medical record was reviewed. The following was noted:

The PO dated 7/20/23 at 1:38 a.m. indicated, Haldol 5 mg and Benadryl 50 mg and Ativan 2mg IM one time for "extreme agitation." The MAR dated 7/20/23 at 1:47 a.m. indicated Haldol 2 mg and Benadryl 50 mg and Ativan 2 mg IM was given. RM stated there was no documented follow up by a physician within one hour after chemical restraint was given.

The PO dated 7/20/23 at 7 p.m. indicated, Haldol 5 mg and Benadryl 50 mg and Ativan 2mg IM one time for "extreme agitation." The MAR dated 7/20/23 at 7:35 p.m. indicated Haldol 2 mg and Benadryl 50 mg and Ativan 2 mg IM was given. RM stated there was no documented follow up by a physician within one hour after chemical restraint was given.

During a concurrent interview and record review on 8/22/23 at 11:50 a.m. with RM, Patient 21's medical record was reviewed. The following was noted:

The PO dated 7/13/23 at 10 p.m. indicated, Zyprexa (medication used to treat mental conditions) 10 mg IM one time for "agitation." The MAR dated 7/13/23 at 10:10 p.m. indicated Zyprexa 10 mg IM was given. RM stated there was no documented follow up by a physician within one hour after chemical restraint was given.

During a review of the hospital's P&P titled, "Use of Seclusion and Restraint" dated 6/29/23, the P&P indicated, "It is the policy of [hospital] to minimize the use of seclusion and restraint through preventive measures and use of alternatives. Seclusion and/or restraint should be the selected intervention only when used as an emergency measure to control a patient's unanticipated, severely aggressive, or destructive behavior which places the patient or others in imminent danger and all less restrictive measures have been determined to be ineffective ... A drug used as a restraint is "a medication used to control behavior or to restrict the patient's freedom of movement and is not a standard treatment for the patient's medical or psychiatric condition ... "Emergency" (as it relates to seclusion and/or restraint) is an instance, in which there is an imminent risk of a patient harming himself/herself or others, including staff, when non-physical interventions are not viable and safety issues require an immediate physical response. Emergency intramuscular medications may be given with physician order ... The use of a restraint or seclusion must be: selected only when less restrictive measures have been found to be ineffective to protect the patient or others from harm. In accordance with the order of a physician or other licensed independent practitioner permitted by the state and hospital to order seclusion or restraint ... A physician or other licensed independent practitioner must see the patient and evaluate the need for restraint or seclusion within one hour after the initiation of this intervention."

Based on interview and record review, the hospital failed to:

1. Provide quality oversight in tracking adverse patient events.

This failure resulted in the hospital being unable to identify, analyze, and implement preventative measures to ensure patient safety.

2. Ensure patient safety when the Automated External Defibrillator (AED-a portable medical device used to deliver electric shock to victims whose heart is beating abnormally) in the Intake Unit was not checked daily for its functionality.

This failure had the potential to delay life saving interventions during an emergency.

3. Establish clear and well-defined safety measures and treatment interventions for one of one sampled patient (Patient 2) who had been diagnosed as gravely disabled (condition in which a person, as a result of a mental health disorder, is unable to provide for his or her basic personal needs for food, clothing, or shelter), danger to others (DTO-a person who, as a result of Mental Disorder, manifests behaviors that result in serious physical harm to others or the imminent threat thereof), and exhibited sexually acting out (SAO-any form of sexual behavior whose primary function is to avoid uncomfortable feelings and other facts) behavior.

This failure resulted in Patient 2 assaulting Patient 25, Patient 32, and Patient 33.

4. Ensure contraband (illegal and banned items) check was conducted for one of one sampled patient (Patient 35).

This failure had the potential to place patients and staff at risk for harm.

Findings:

1. During an interview on 8/22/23 at 8:52 a.m. with Medical Director (MD)1, MD 1 stated he provides oversight to the governing body. MD 1 stated, "We can do better identifying and documenting [opportunities for improvement]." MD 1 stated the same issues keep reoccurring with no resolution.

During an interview on 8/22/23 at 11:12 a.m. with Director of Clinical Services (DCS), DCS stated in the event of an assault the expectation is for patient needs to be identified. DCS stated the issue is there is no analysis of the data collected.

During a concurrent interview and record review on 8/22/23 at 3:57 p.m. with Director of Quality (DQ), the "Occurrence Report Summary" dated 8/9/23 was reviewed. The "Occurrence Report Summary" indicated, "On 6/10/2023 [sic] 0530 Patient 18 was cleared and returned to [hospital]. . . Interventions were initiated. . . for safety and risk mitigation, both treatment plans were updated." DQ stated the "Occurrence Report Summary" was incorrectly dated [Incident occured on 8/9/23 and Patient 18 was brought back to the hospital on 8/10/23] and the interventions were not implemented as documented.

During a concurrent interview and record review on 8/22/23 at 4:40 p.m. with Chief Nursing Officer (CNO), the "PI [process improvement] Contraband Data 2023" dated 2023, was reviewed. CNO stated she was unable to interpret the picture graphs and she was unable to provide any contraband data collected. CNO stated she was part of the quality oversight committee. CNO stated safety is a priority. CNO stated she doesn't know the hospital's methodology used for conducting PI projects. No additional information was provided.

During an interview on 8/23/23 at 4:02 p.m. with DQ, DQ was unable to provide PI records that reflect aggregate data (information tracked across time, across organizations, and across patient populations) and stated, "We can do better and improve." No additional documentation provided.



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2. During a concurrent observation and interview on 8/22/23 at 8:50 a.m. in the Intake Unit, with Risk Manager (RM) and Intake Lead (IL), an AED was on a shelf. IL stated the AED is checked daily by the registered nurse.

During a concurrent interview and record review on 8/22/23 at 8:55 a.m. with IL, the Emergency Check Log (ECL-includes oxygen, AED, and orange emergency bag), dated 8/2023, was reviewed. The ECL indicated AED was checked once on 8/1/23. IL stated that should have been checked daily by the nurses. IL was unable to provide equipment check for oxygen and the orange emergency bag. IL stated the only other ECL was done on 11/2022. The November 2022 ECL indicated the AED was inconsistently checked. The only time the AED was checked was on 11/1/22 to 11/7/22 and again on 11/12/22. IL stated November 2022 ECL was the only record he could find for the year 2022 and the only ECL in 2023 was done on 8/1/23. IL stated there was no other ECL for oxygen and orange emergency bag completed for 2023.

During a concurrent interview and review of the contents of the orange emergency bag on 8/22/23 at 8:53 a.m. with Intake Registered Nurse (RN) 5, the contents of the orange emergency bag, was checked. The orange emergency bag contents included the following items: Personal Protective Equipment (refers to gowns, masks, face shields, and goggles used to protect the wearer from injury or infection), emergency blankets, blood pressure (measures the pressure in the arteries as the heart pumps) machine and a stethoscope (medical instrument that detects sounds from the body, used in checking blood pressure), ambu bag (used to assist in mechanical breathing), nasal cannula (a small, flexible tube with two prongs used to deliver oxygen), non-rebreather masks (face mask connected to a reservoir bag that's filled with a high concentration of oxygen), biohazard bags (bags used to dispose potentially infectious wastes), gauzes, band-aids, Steri strips (tapes that keep the edges of the wound together), scissors, measuring tape, etc. RN 5 stated we do not place any medications in the orange emergency bag. RN 5 stated in the event of an emergency, the patient is brought to the inpatient unit and there the medications needed are administered to the patients. RN 5 stated it is important to check the AED daily for the safety of all patients.

3. During a concurrent interview and record review on 8/22/23 at 2:25 p.m. with Director of Utilization Review (DUR), Patient 2's Master Treatment Plan (MTP)dated 7/5/23, was reviewed. Patient 2's MTP indicated, "Grave Disability (condition in which a person, as a result of a mental health disorder, is unable to provide for his or her basic personal needs for food, clothing, or shelter), Hypertension (high blood pressure), Danger to others (DTO-a person who, as a result of Mental Disorder, manifests behaviors that result in serious physical harm to others or the imminent threat thereof), Sexually-acting out (SAO- any form of sexual behavior whose primary function is to avoid uncomfortable feelings and other facts). DUR stated Patient 2 was formerly in Unit 200 but moved to Unit 400 because on 7/10/23 he hit a female patient by the ear, as the female patient was walking out of the room towards the hallway, where Patient 2 was pacing. DUR stated the two patients were separated and Patient 2 was moved to Unit 400 on 1:1 observation and with a roommate.

During a concurrent interview and record review on 8/22/23 at 2:30 p.m. with DUR, Patient 2's Nursing Progress Notes (NPN) dated 7/13/23, 8/16/23, 8/19/23, 8/20/23, and 8/22/23, were reviewed. The NPN, dated 7/13/23, at 7:25 p.m. indicated, "Patient punch [sic] his roommate in the face when his roommate was trying to get into the room. [Patient 2] stated voices were telling him to punch his roommate. [Patient 2] stated his roommate attempted to stab him with a pen the night before the incident." The NPN, dated 8/16/23, at 1:52 p.m. indicated, "[Patient 2] was in the day room and suddenly [Patient 2] hit a patient in the face. [Patient 2] stated voices were telling him to hit someone." The NPN, dated 8/19/23, at 8:15 p.m. indicated, "[Patient 2] had sexually acting out behavior. [Patient 2] inappropriately touched the nurse while his vital signs were being checked that night. . . [Patient 2 stated] Voices were telling him to do that." The NPN, dated 8/20/23, at 12:46 p.m. indicated, "While [Patient 2] was standing by the door, [Patient 2] was inappropriately touching himself. Another patient reported, [Patient 2] followed a female patient who was walking in the hallway. [Patient 2] was placed on 1:1 observation and was moved to Unit 400 from Unit 200." The NPN, dated 8/22/23, at 3:50 p.m. indicated, "[Patient 2] was standing in Day Room and [Patient 2] punched another patient who walked past him. DUR stated Patient 2 was medicated with Ativan (medication to treat anxiety and agitation) 2 mg, Haldol (medication to treat hallucinations [sensing things such as visions, sounds, or smells that seem real but are not]) 5 mg, and Benadryl (antiallergy medication with sedative effect) 50 mg for severe aggression. Patient 2 was moved to a single room close to the nurse's station and placed on 1:1 observation. DUR stated Patient 2 had been placed in a room with another roommate, despite his gravely disabled, vulnerable, with DTO, and SAO precautions.

During a concurrent interview and record review on 8/22/23 at 3:11 p.m. with DUR, Patient 2's Physician's Orders (PO) dated 7/10/23, 7/13/23, 7/24/23, 7/31/23, 8/5/23, 8/8/23, 8/20/23 and 8/22/23 were reviewed. The PO dated 7/10/23, at 8:20 p.m. indicated, "New precaution order-DTO, hit to peer." The PO, dated 7/13/23 at 7:35 p.m. indicated, "No roommate. DTO Precaution due to hitting roommate, Transfer Unit 200." The PO, dated 7/24/23 at 10:20 a.m. indicated, "Discontinue No roommate order." The PO, dated 8/5/23 at 7:10 a.m. indicated, "No roommate order." The PO, dated 8/8/23 (no time) indicated, "Every five-minute observation, SAO Precaution." The PO, dated 7/31/23 at 7 p.m. indicated, "Start SAO precaution for safety." The PO, dated 8/20/23 at 12:46 p.m. indicated, "Start 1:1 Precautions due to inappropriately touching self and SAO Precaution. Move to Unit 400." The PO, dated 8/22/23, at 9 a.m. indicated, "Discontinue every five-minute observation. Every 15-minute monitoring." The PO, dated 8/22/23 at 4:26 p.m. indicated, Ativan 2 mg, Haldol 5 mg and Benadryl 50 mg PO (orally) x 1 now for severe agitation and assaultive behavior." DUR stated Patient 2 had a "No Roommate" order from 7/13/23-7/24/23. Patient 2 had another "No Roommate Order" on 8/5/23 but was discontinued on 8/7/23. Patient 2 had every five minutes monitoring and was changed to every 15 minutes on 8/22/23. Patient 2 was moved from Unit 200 to Unit 400 but continued to have a roommate, despite continued aggression toward other roommates. DUR stated for privacy purposes, the names of Patient 2's roommates were not identified in the chart.

During a concurrent interview and record review on 8/25/23 at 10 a.m. with RM, Patient 2's ORS, dated 7/10/23, 7/14/23, and 8/7/23 were reviewed. The ORS, dated 7/10/23 indicated Patient 2 hit Patient 25 by the ear. The ORS, dated 7/14/23 indicated Patient 2 hit Patient 32 in the nose. The ORS, dated 8/7/23 indicated Patient 2 hit Patient 33 in the face. The ORS indicated, "summary of events when Patient 2 hit Patient 25, Patient 32, and Patient 33 at different times, the investigations conducted by the facility, and the outcome of the interventions." RM confirmed the outcome of the intervention to separate Patient 2 from his three victims and moved him from one unit to another unit. RM stated Patient 2 continued to have a roommates and the intervention to move hime to different units did not prevent Patient 2 from hurting other patients. Patient 2's treatment plan was for staff to encourage him to join group activities and for staff to remind Patient 2 to not continue with his aggressive and sexually acting out behaviors. The treatment plans were not effective as Patient 2 continued "to hurt others or display sexual behaviors." The actions taken to separate Patient 2 from the victims to prevent the reoccurrence of the incidents did not work. RM was unable to provide any other actions or quality measures taken to mitigate the incidents. RM was unable to provide quality data, except the occurrence logs, to determine patterns of occurrence of incidences.














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4. During a concurrent interview and record review on 8/22/23 at 9:50 a.m. with RN 8, Patient 35's Admission Record (AR), dated 8/18/23 was reviewed. The AR indicated no contraband check was done on admission. RN 8 stated no contraband check was done.

During a review of the hospital's policy and procedure (P&P) titled, "Hospital Plan for the Provision of Patient Care" dated 2/22/22, the P&P indicated, "The Hospital Plan for the Provision of Patient Care Services has been designed to support and promote integration and improvement of patient care services. . . Clinical departments with responsibility for the provision of patient care services will operationalize a departmental plan of care to promote continuity of care and promote consistency in the quality of services provided to consumers. The Hospital and departmental plans for the provision of patient care services are reviewed on an ongoing basis as a component of the strategic planning process. . . Each Department Director assumes primary responsibility for coordinating patient care and administrative activities within the respective department with other departments and services in the organization. Assessment of the effectiveness of this collaboration is done through performance improvement activities. . . Performance Improvement/Risk Management: Performance Improvement function provides for coordinating the organization-wide performance improvement initiative to promote consistent quality of services provided throughout the facility. Performance Improvement staff work with medical staff, administration, department directors, and other staff within the facility to coordinate assessment activities and assist in aggregating data useful in strategies and operational decision-making."

During a review of the hospital's P & P titled, "Automated External Defibrillator (AED), Oxygen, Orange Bag, and Emergency Equipment," dated 8/24/23, the P&P indicated, "PROCEDURE: Defibrillator checked daily as per manufacturer's guidelines. Supplies are checked weekly (on Sundays), Oxygen tank checked weekly and after each use. Replace oxygen tank when level is outside of green."

During a review of the hospital's P&P titled, "Room Assignments and Responsibilities," dated 11/23/22, the P&P indicated, "7. At no time will a patient who has vulnerable or gravely disabled precautions be placed with a patient who is SAO or DTO. The only person who can override this will be a psychiatrist."

During a review of the hospital's P&P titled, "Contraband and Restricted Articles" dated 2022, the P&P indicated, "PURPOSE: To ensure a safe environment. To provide a monitoring system for patients who are utilizing sharps or items designated as contraband. PROCEDURE: On admission, patient will have his/her belongings checked in his/her presence."

During a review of the hospital's P&P titled, "Quality Assurance and Performance Improvement Plan" dated 7/24/23, the P&P indicated, "8. Follow-up: The QAPI Committee shall assure that steps taken to improve performance and safety are appropriately implemented, measured, and tracked to determine that the steps have achieved and sustained the intended effect."

Based on interview and record review, the hospital failed to follow its Plan of Correction (POC - actions taken by the hospital to correct deficiencies with dates specified as to the correction of the deficiencies) for eight of eight sampled patients (Patient 4, Patient 5, Patient 6, Patient 14, Patient 28, Patient 29, Patient 30, and Patient 31) for conducting audits to assess and measure the hospital's compliance or non-compliance as it relates to patients' rights and treatment plans.

This failure had the potential to result in the hospital not achieving its goal to meet the highest quality in patient outcomes and treatment for the patients, which could be detrimental to patient care.


Findings:

During a concurrent interview and record review on 8/22/23 at 9:31 a.m. with Director for Competency and Restoration Program (DCRP), the hospital's audit tools for Intake, dated 8/1/23, was reviewed. The Intake audit tools indicated the following indicators: Date of Admission, Notification of Patient's Rights, Information obtained regarding Advance Directives (legal documents that provide instructions for medical care), Bed Placement - patients on Sexually Acting Out (SAO) high risk will be placed in private room (blocked bed). DCRP was unable to find audits conducted for Patient 4, Patient 5, and Patient 6 who were admitted on 8/1/23. DCRP stated Patient 4, Patient 5, and Patient 6 were patients under the restoration program, which was a newly created program for patients who would undergo trial in court. DCRP stated patients under the restoration program were not part of the audit. DCRP acknowledged the plan of correction was to be conducted for all patients admitted to the hospital regardless of which unit the patients were placed. The POC indicated a 100% threshold for the hospital audits. DCRP stated, "Patient 4 had no record of audit, Patient 5 had no record of audit, and Patient 6 had no record of audit."

During a concurrent interview and record review on 8/23/23 at 9:13 a.m. with Director of Clinical Services (DCS), the hospital's audit tools for Social Services, dated 7/21/23 and 7/24/23 were reviewed. The audit tools indicated the following indicators: Date of Admission, Individualized treatment plans completed in 72 hours, Treatment plan review documented minimally every seven days and as needed for significant change in condition, Evidence of programming offered as posted as (evidenced in group notes), Evidence of outdoor/off unit activities (verified by video review on each unit) and completed discharge planning. DCS stated audits are conducted daily.

During a concurrent interview and record review on 8/23/23 at 9:30 a.m. with DCS, Social Services Audit Tool (SSAT), dated 7/21/23 was reviewed. The SSAT indicated, documented compliance rate for Patient 28's record, reviewed on 7/20/23, was 100 % with all indicators rated not applicable (NA). The documented compliance rate for Patient 29's record, reviewed on 7/20/23, was 100 % with all indicators rated NA. DCS stated "NA" indicated the audit was conducted prior to the specified treatment plan requirement of 72 hours or prior to the review of the treatment plan in seven days. DCS stated the NAs were included in the computation resulting in an audit rating of 100 %, which rendered the audit compliance results inaccurate. DCS acknowledged and stated, the audits were conducted prior to Patient 28 and Patient 29's discharge. DCS stated [Patient 28] was admitted on 7/20/23 and discharged on 7/27/23 and [Patient 29] was admitted on 7/20/23 and discharged on 7/27/23. DCS stated the SSAT was conducted on 7/21/23 for Patient 28 and Patient 29.

During a concurrent interview and record review on 8/23/23 at 9:45 a.m. with DCS, SSAT dated 7/24/23, was reviewed. SSAT indicated, the documented compliance rate for Patient 30's record, reviewed on 7/22/23, was 40%; the documented compliance rate for Patient 31's record, reviewed on 7/23/23, was 60 % and the documented compliance rate for Patient 14's record, reviewed on 7/21/23, was 20%. DCS was unable to show actions taken to improve the low non-compliance rate for the treatment plan audits.

During an interview on 8/23/23, at 10:55 a.m. with Director of Quality (DQ), DQ stated the audit tools need to be revised. The audit tools do not capture what needs to be captured. DQ acknowledged "NAs" were included in the Quality Report computation, which were calculated at 100% compliance and rendered the quality report to be inaccurate.

During an interview on 8/23/23 at 11:34 a.m. with DCS, DCS stated I do not have any data to support review of the medical records rated not applicable. We (referring to leadership auditors) do not go back to see if the treatment plans were developed in 72 hours or reviewed in seven days or as needed when conditions changed.

During a review of the facility's POC on Informed Decision, approved on 7/28/23,the POC indicated, "All admission charts are being audited daily. . . the Sustainability section for compliance indicated: The Director of Intake and/or designee will audit 100% of all new admission charts to ensure ongoing compliance until a threshold of 100% is reached and sustained for 90 days. Once achieved, continued compliance will be reviewed monthly through the auditing of 30 random charts. Compliance rates will be reported to QAPI Committee, bi-monthly to Medical Executive Committee (MEC), and quarterly to the Governing Noard (GB)."

During a review of the facility's POC on Treatment Plans, approved 7/28/23, the POC indicated, "Systemic Measures: A hardwire process hs been implemented to ensure that patient care plans and care plan reviews occur within hospital policy (within 72 hours of admission and reviewed minimally every seven days thereafter). Sustainablity: 100% of all discharged charts will be audited to ensure ongoing compliance until a threshold of 100% is reached and sustained for 90 days (this includes both inital care plan and weekly reviews. This will be reported monthly to QAPI Committee, bi-monthly to Medical Executive Committee (MEC), and quarterly to the Governing Board (GB)."

During a review of the hospital's policy and procedure (P&P) titled, "Quality Assurance and Performance Improvement Plan 2023," undated, the P&P indicated, "The primary goal of the Performance Improvement Plan is to objectively design, measure, assess, and improve quality and outcome of patient care, and the services provided that support high quality care to all customers. . .Assuring that the data obtained through Quality Improvement activities are analyzed appropriately, recommendations are provided and appropriately followed for problem resolution. . .A systematic approach to data collection is utilized to develop meaningful information."

Based on interview and record review, the hospital failed to ensure medical records contained accurate documentation of patient assessment and care provided for six of six sampled patients (Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12). This failure had the potential for pertinent patient medical information to be missed, which could negatively impact medical care.

Findings:

During a concurrent interview and record review on 8/22/23 at 11:45 a.m., with Director of Utilization Review (DUR), Patient's 7's Observation Rounds Precautions (ORP), dated 8/21/23 was reviewed. The ORP indicated, "Every 15-minute monitoring for suicidal/self-harm from 2:45 p.m. to 11:45 p.m. The observation sheet did not indicate a registered nurse has made rounds and provided oversight for the care rendered by the mental health worker (MHW). DUR stated, Registered nurses should make rounds every two hours to check on the patient's condition and to validate the care provided by the mental health worker and verify the accuracy of the rounding documentation. DUR stated there was no nurse signature on the rounding observation sheet.

During an interview on 8/24/23 at 9:40 a.m. with Registered Nurse (RN) 2, RN 2 stated we make rounds to have rapport with the patients. Patients are happy to share and happy to know that someone is there for them. Our patients are unpredictable, rounding helps us identify the warning signs. Registered nurses are to make rounds every two hours and we document in the rounding sheet our observation; any change in patients' condition, we document in the nursing progress notes.

During a concurrent interview and record review on 8/22/23 at 11:50 a.m. with Registered Nurse (RN) 4, Patient 8's Nursing Day Shift Notes (NDSN), dated 8/22/23 was reviewed. Patient 8's NDSN indicated, "Patient seen in the room. Patient 8 was alert, oriented x 3. Poor concentration, Impulsive, anxious. Appearance unkept. Cooperative. Participating in group activities. Intervention: administer all due meds as per MD order. provide safe and effective environment to the patient. Encourage the patient to verbalize his feelings with staff and using coping skills. . .Response: Med's complaints (sic) Needs verbalized. Following Directions. Plan: Will continue current treatment care plan. Will continue (sic) monitor the patient for safety. RN signature Time Blank." RN 4 stated she leaves the time blank until she is ready to end her shift. RN 4 stated she documents once during the shift, between 9 a.m. and 10 a.m. when Patient 8's morning medications are passed.

During a concurrent interview and record review on 8/22/23 at 11:55 a.m. with RN 4, Patient 9's NDSN, dated 8/22/23 was reviewed. Patient 9's NDSN indicated, "Situation: Patient seen in the room. Patient alert, oriented x 3. Poor concentration. Appearance unkept. Hyperverbal. Easily irritable. Passive Isolative, refusing group activities". The Intervention, Response, and Plan were written the same as the intervention, response, and plan written for Patient 8. NDSN had the RN signature and no time documented." RN 4 stated, "I have always documented that way. I don't put the time until the end of the shift." RN 4 stated she documents once during the shift, between 9 a.m. and 10 a.m. when Patient 9's morning medications are passed.

During a concurrent interview and record review on 8/22/23 at 12 p.m. with RN 4, Patient 10's NDSN, dated 8/22/23 was reviewed. The NDSN indicated, "Situation: Patient seen in the room. Patient alert, oriented x 3. Poor concentration. Impulsive anxious. Patient refusing group morning activities." RN 4 stated the written entries on the Intervention, Response, and Plan for Patient 8, Patient 9, and Patient 10 were the same. NDSN had the RN signature but did not have a time documented. RN 4 stated, "I document the same for every patient. The time is filled at the end of the shift." RN 4 stated she documents once during the shift, between 9 a.m. and 10 a.m. when Patient 10's morning medications are passed.

During a concurrent interview and record review on 8/22/23, at 12:05 p.m. with RN 4, Patient 11's NDSN, dated 8/22/23 was reviewed. The NDSN indicated, "Situation: blank. The sections on pain assessment, behavior, activity level, mood, and insight were all blank. The intervention, response, and plan were written the same as those written in Patient 8, Patient 9, and Patient 10's NDSN. The RN signature was signed but no time was documented. RN 4 stated, "I have not had the chance to complete my charting. My shift started at 6 a.m. but I have not completed my assessment."

During an interview on 8/22/23 at 4:40 p.m. with Chief Nursing Officer (CNO), CNO stated, she did not approve of end of the shift documentation or for every patient to have the same documentation. CNO stated, "Nursing care is individualized, and documentation should be done throughout the shift, dated, and timed as charting is completed."

During a concurrent interview and record review on 8/23/23 at 11:40 a.m. with Director of Clinical Services (DCS), Patient 12's Psychosocial Assessment, dated 8/14/23 was reviewed. The chief complaint documented was "I was feeling sick." The narrative summary indicated, "Patient 12 was a 17-year-old male, placed on 5250 hold (involves the involuntary placement of a person in a hospital or mental health facility that extends up to 14 days) for danger to self (DTS), danger to others (DTO), and Grave Disability (GD) with diagnosis of Bipolar Disorder. DCS stated the chief complaint could have been more specific than "I was feeling sick," considering the patient's presentation of DTS, DTO, and GD.

During a review of the hospital's policy and procedure (P&P) titled, "Assessment Nursing for Mental Health," dated 7/27/22, the P&P indicated, "4. Nursing daily assessments/progress notes: a. The daily nursing assessment is utilized to re-assess and document on the patient every shift. . .Each shift is responsible for documenting on the flow sheet. Each staff member must initial, print, and sign their name with title upon initial entry."

During a review of the hospital's P&P titled, "Rounds of Patient Observation," dated 7/27/22, the P&P indicated, "Monitoring: An RN will make rounds at a minimum of every 2 hours to audit and ensure that staff members are providing and accurately documenting correct level and frequency of observations. The RN will sign the Patient Observation Record and complete random review of the record to assure that patient safety is maintained."

Based on interview and record review, the hospital failed to follow its policy and procedure (P&P) titled, "Verbal Medication Orders," when physicians' telephone orders were not authenticated for six of six sampled patients (Patient 2, Patient 8, Patient 13, Patient 14, Patient 15, and Patient 25) within 24 hours. This failure had the potential to result in medication errors and delay in patient treatment.

Findings:

During a concurrent interview and record review on 8/22/23 at 12:10 p.m. with Director of Utilization Review (DUR), Patient 2's "Telephone Order Read Back (TORB)", dated 7/10/23, 7/13/23, 7/24/23, 7/31/23, 8/20/23 and 8/22/23 were reviewed. The TORB, dated 7/10/23 at 8:20 p.m., indicated, "New precaution order: DTO (danger to others), hit to peers." DUR stated the physician (MD) 4 has not signed the telephone order. The TORB, dated 7/13/23 at 10:20 a.m., indicated, " No roommate. Transfer Unit 200 on DTO precaution due to hitting roommate." DUR stated the nurse did not indicate the name of the physician who prescribed the telephone order, and the physician order has not been signed. The TORB, dated 7/24/23 at 10:20 a.m., indicated, "D/C (discharge) No roommate order." DUR stated MD 2 has not signed the telephone order. The TORB, dated 7/31/23, at 7 p.m., indicated "Start SAO (sexually acting out) precaution for safety." DUR stated the Nurse Practitioner (NP) 1 has not signed the telephone order. The TORB, dated 8/20/23 at 12:46 p.m., indicated, "Start 1;1 Precaution due to inappropriately touching self and SAO Behavior, and move to unit 400 due to safety." DUR stated MD 2 has not signed the telephone order. The TORB, dated 8/22/23, at 4:26 p.m., indicated, "Ativan (medication to treat anxiety) 2 mg (milligram, a unit of measure), Haldol (medication to treat schizophrenia [a serious mental illness that affects how a person thinks, feels, and behaves] 5 mg, Benadryl (allergy medication with sedative effect) 50 mg now for severe agitation. DUR stated MD 1 has not signed the telephone order.

During a concurrent interview and record review on 8/22/23 at 12:12 p.m. with DUR, Patient 8's TORB, dated 8/12/23 was reviewed. The TORB written by the nurse as ordered at 4:30 p.m., indicated, "Unit restriction due to COVID -19 (a highly contagious respiratory illness caused by the Coronavirus) Exposure. DUR stated NP 2 has not signed the telephone order for 10 days.

During a concurrent interview and record review on 8/22/23 at 12:14 p.m. with DUR, Patient 13's TORB, dated 8/2/23 was reviewed. The TORB written by the nurse as ordered at 8:15 p.m., indicated, "COVID test; Tylenol 650 mg for fever as well as pain every four hours PRN (as needed); Zofran 4 mg PO every 8 hours PRN for vomiting and nausea; Follow up with primary care healthcare provider if further problems after discharged tomorrow." DUR stated NP 3 has not signed the telephone order for 12 days.

During a concurrent interview and record review on 8/22/23 at 12:16 p.m. with DUR, Patient 14's TORB, dated 7/21/23 was reviewed. The pre-printed Adult Unit Physician Order, dated 7/21/23, filled in by the nurse per MD 3's telephone order, indicated, "Admission Orders." DUR stated, MD 3 has not signed the Admission Orders for Patient 14 since admission on 7/21/23, which was about one month late.

During a concurrent interview and record review on 8/22/23 at 12:20 p.m. with DUR, Patient 15's TORB, dated 7/15/23 was reviewed. The TORB written by the nurse at 12:30 p.m. indicated, "Med Consult for Hypertension (high blood pressure)." DUR stated MD 2 has not signed the telephone order for seven days.

During a concurrent interview and record review on 8/22/23, at 12:30 p.m. with DUR, Patient 25's TORB, dated 7/10/23 was reviewed. The TORB written by the nurse at 8:20 p.m. indicated, "New Precaution for Vulnerability-hurt by peer in hallway." DUR stated MD 4 has not signed the telephone order for 12 days.

During a review of the facility's policy and procedure (P&P) titled, "Verbal Medication Orders," dated 10/28/20, the P&P indicated, "Verbal/telephone orders for medications must include the following elements: date and time the order is received, the name of the individual prescribing the medication and his/her licensure (MD, DO, etc.). . .Authenticating Verbal Orders: Verbal/telephone orders must be cosigned/verified by a practitioner who is responsible for the care of the patient and is authorized to prescribe in accordance with state law and hospital policy. Verbal orders must be authenticated within the time frame defined in the medical staff rules and regulations and as required by state law and regulations (e.g., within 24 hours)."