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Based on interview and record review, the facility failed to ensure the Condition of Participation for Governing Body was met as evidenced by:

1. The facility ' s Governing Body (responsible for guiding the hospital ' s long-term goals and policies, and assists with strategic planning and decision making) failed to ensure Medical Staff followed the facility ' s "Medical Staff Bylaws, Rules and Regulations," for two of 30 sampled patients (Patients 20 and 21) when Patient 20 and 21 were not seen by the physician within 24 hours of admission, per policy and procedures. This deficient practice had the potential for medical care and treatment to be delayed for Patients 20 and 21. (Refer to A – 0048)

2. The facility ' s governing body (responsible for guiding the hospital ' s long-term goals and policies and assists with strategic planning and decision-making) failed to assume full legal responsibility for implementing and monitoring policies governing the facility ' s process of background check for all contracted staff members by not ensuring the contracted services perform background check on one of three sampled contracted services staff members (Mental Health Worker [MHW 1]) prior working at the facility. This deficient practice had the potential exposing patients to criminals and put patients ' safety at risk for abuse. (Refer to A – 0084)

The cumulative effects of these deficient practices resulted in the facility ' s inability to provide quality healthcare in a safe setting.

Based on interview and record review, the facility ' s Governing Body (responsible for guiding the hospital ' s long-term goals and policies, and assists with strategic planning and decision making) failed to ensure Medical Staff followed the facility ' s "Medical Staff Bylaws, Rules and Regulations," for two of 30 sampled patients (Patients 20 and 21) when Patient 20 and 21 were not seen by the physician within 24 hours of admission, per policy and procedures. This deficient practice had the potential for medical care and treatment to be delayed for Patients 20 and 21.

Findings:

1. During a concurrent interview and record review on 8/7/2024 at 2:24 p.m. with the Nurse Manager 1 (NM 1), the NM 1 stated the following: Patient 20 Face Sheet indicated Patient 20 was admitted 7/31/2024 at 12:10 p.m. Patient 20 ' s "History and Physical" (H&P, a formal and complete assessment of the patient and the problem) was completed and dated 8/1/2024 at 3:43 p.m. Patient 20 ' s "Initial Psychiatric Evaluation (comprehensive evaluation conducted by a qualified mental health physician)" was completed 8/1/2024 at 2:05 p.m. The NM 1 verified Patient 20 ' s H&P and initial psychiatric evaluation was not completed within 24 hours, per policy.

The NM 1 further stated the following: Patient 20 ' s H&P and initial psychiatric evaluation should have been completed within 24 hours. Patient 20 should be seen by a Medical Doctor and Psychiatrist (a medical practitioner specializing in the diagnosis and treatment of mental illness) within 24 hours to evaluate the patient for the need of inpatient care and start the plan of care. If patients are not seen within 24 hours, there could be a delay in care.

During an interview on 8/9/2024 at 3:36 p.m. with the Chief Nursing Officer (CNO) and Chief Executive Officer (CEO), the CEO stated the following: The governing board (the highest decision-making authority within an organization) has the ultimate responsibility over the entire hospital. It is the responsibility of the governing board to ensure physicians complete the H&P and Initial Psychiatric Evaluations within 24 hours per policy. The CNO stated that physicians need to see patients within 24 hours.

During a record review of Patient 20 ' s Face Sheet, the Face Sheet indicated Patient 20 was admitted to the facility on 7/31/2024 at 12:10 p.m.

During a record review of Patient 20 ' s "Initial Psychiatric Evaluation", the initial psychiatric evaluation was dated and signed 8/1/2024 at 2:05 p.m. (more than 24 hours after admission).

During a record review of Patient 20 ' s "History and Physical", the H&P was dated and signed 8/1/2024 at 3:43 p.m. (more than 24 hours after admission).

During a record review of the facility's "Medical Staff Rules & Regulations," dated 2/6/2020, the rules and regulations indicated the following: " ...6.3 History & Physical, 6.3-1 General, a. A complete history and physical examination shall be completed and signed within twenty-four (24) hours of the patient admission ... 6.3-2 Psychiatric Evaluations: An initial Psychiatric Evaluation must be completed within twenty-four (24) hours of admission to a Psychiatric care unit ..."

During a review of the facility's policy and procedure (P&P) titled, "History and Physical," dated 9/2022, the P&P indicated the following: "Policy: The History and Physical must be completed within 24 hours of admission ..."

During a review of the facility's policy and procedure (P&P) titled, "Psychiatric Evaluation," dated 9/2022, the P&P indicated the following: "Policy: The existence of a Psychiatric Consultation must be documented immediately in the progress notes, the initial psychiatric evaluation report must be completed within twenty-four (24) hours ..."

2. During a concurrent interview and record review on 8/8/2024 at 1:29 p.m. with the Nurse Manager 1 (NM 1), the NM 1 stated the following: Patient 21 Face Sheet (a document that provides a patient's information at a quick glance) indicated Patient 21 was admitted 8/5/2024 at 4:34 p.m. Patient 21 ' s "History and Physical" (H&P, a formal and complete assessment of the patient and the problem) was completed and dated 8/6/2024 at 8:31 p.m. The NM 1 verified Patient 20 ' s H&P was not completed within 24 hours, per policy. The NM 1 further stated the following: Patient 21 ' s H&P should have been completed within 24 hours. Patient 21 should be seen by a Medical Doctor within 24 hours to evaluate the patient for the need of inpatient care and start the plan of care. If patients are not seen within 24 hours, there could be a delay in care.

During an interview on 8/9/2024 at 3:36 p.m. with the Chief Nursing Officer (CNO) and Chief Executive Officer (CEO), the CEO stated the following: The governing board has the ultimate responsibility over the entire hospital. It is the responsibility of the governing board to ensure physicians complete the H&P within 24 hours per policy. The CNO stated that physicians need to see the patients within 24 hours.

During a record review of Patient 21 ' s Face Sheet, the Face Sheet indicated Patient 21 was admitted to the facility on 8/5/2024 at 4:34 p.m.

During a record review of Patient 21 ' s "History and Physical", the H&P was dated and signed 8/6/2024 at 8:31 p.m. (more than 24 hours after admission).

During a record review of the facility's "Medical Staff Rules & Regulations," dated 2/6/2020, the rules and regulations indicated the following: " ...6.3 History & Physical, 6.3-1 General, a. A complete history and physical examination shall be completed and signed within twenty-four (24) hours of the patient admission ..."

During a review of the facility's policy and procedure (P&P) titled, "History and Physical," dated 9/2022, the P&P indicated the following: "Policy: The History and Physical must be completed within 24 hours of admission ..."

Based on interview and record review, the facility ' s governing body (responsible for guiding the hospital ' s long-term goals and policies and assists with strategic planning and decision-making) failed to assume full legal responsibility for implementing and monitoring policies governing the facility ' s process of background check for all contracted staff members by not ensuring the contracted services perform background check on one of three sampled contracted services staff members (Mental Health Worker [MHW 1]) prior working at the facility.

This deficient practice had the potential exposing patients to criminals and put patients safety at risk for abuse.

Findings:

During a concurrent interview and record review on 8/8/2024 at 4:07 p.m. with the Human Resources Coordinator (HRC), Mental Health Worker (MHW) 1 ' s personnel file was reviewed. The personnel file indicated, there was no background check document in MHW 1 ' s personnel file. HRC stated the following: background check was required for all employees prior working at the facility to make sure the employee was cleared with criminal background to prevent possible patient abuse. MHW 1 was hired on 8/2/2023 by the contracted company (CC 1) and background check should have been done for her (MHW 1). She (HRC) did not know why it was not done.

During an interview on 8/8/2024 at 4:58 p.m. with the Director of Nursing (DON), DON stated background check was required for all employees prior starting at the facility. Background check was done for safety of patients to ensure no criminals working at the facility.

During an interview on 8/9/2024 at 8:30 a.m. with the Director of Quality and Risk Management (DQRM), DQRM stated the following: MHW 1 was under the contracted company (CC 1). CC 1 was responsible to perform background check for its (CC 1) staff prior starting to work at the facility. The facility was also responsible to ensure the contracted services perform all the duties including background check. CC 1 did not perform background check for MHW 1 and this should not have happened. MHW 1 could potentially be a criminal and it would put patients ' safety at risk.

During an interview on 8/9/2024 at 3:06 p.m. with the Chief Executive Officer (CEO), CEO stated the following: governing body has the ultimate responsibility for the facility. The governing body oversaw contracted services and the facility ' s human resources. Background check was required for all employees prior working at the facility to ensure safety of patients.

During a concurrent interview and record review on 8/9/2024 at 3:39 p.m. with CEO, CC 1 ' s "Clinical Services Agreement (contract)," dated 10/5/2022 was reviewed. The contract indicated, "[contract services] and its employees and representatives who render services at the hospital ' s facility shall abide by all of its policies and procedures, including specifically (but not limited to) its anti-harassment and anti-discrimination policies." CEO stated the CC1 and its employees need to abide to the facility ' s policies and procedures.

During a review of the facility ' s policy and procedure (P&P) titled, "Human Resources 806 Background Investigations," dated 10/2020, the P&P indicated, "All prospective new hires and rehires will have background investigations (BIs) conducted at the time of employment. Background investigations will include a review of prior employment and a criminal conviction review. Certain criminal records will be an automatic bar to employment ... State regulations may specify that the criminal conviction search be clear before hiring. If an unacceptable background or criminal history is found and the applicant has been hired, the job offer will be withdrawn. If employment has already commenced, the employee will be terminated immediately. Convictions for the following offenses, as well as others not listed, shall be automatic bars to employment with [the facility]. 1) Homicide (includes murder, capital murder, manslaughter, and criminal negligent homicide), 2) Kidnapping, aggravated kidnapping, false imprisonment, 3) Indecency with a child, 4) Sexual assault, 5) Aggravated assault, 6) Injury to a child, elderly individual or disabled individual, 7) Abandoning or endangering a child, 8) Aiding suicide, 9) Sale or purchase of a child, 10) Arson, 11) Robbery or aggravated robbery ... the facility will be responsible for contacting any other state agency as required by law. This may include the abuse registry and any licensing boards or bureaus. If state law requires a criminal conviction review through a state agency, those forms must be completed as well as the Human Resources Profile background check. All prospective employees will also be reviewed for Medicare sanctions by review of a recent cumulative sanctions report by the compliance officer of the facility. Anyone listed on the sanctions list will not be eligible for employment at [the facility] owned or managed facility."

Based on observation, interview and record review, the facility failed to ensure the Condition of Participation for Patient Rights was met as evidenced by:

1. The facility failed to notify patient representatives, of patient-to-patient altercations (verbal or physical aggression) for two of 30 sampled patients (Patient 1 and 2), in accordance with the facility ' s policy regarding patient-to-patient altercations. This deficient practice had the potential for patient representatives to be unaware of patient-to-patient altercations, and patient ' s health status. (Refer to A – 0131)

2. The facility failed to provide a safe environment for two of 30 sampled patients (Patients 17 and 19), when Patients 17 and 19, both on a 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation) for gravely disabled (GD, a condition in which a person, as a result of a mental disorder, is unable to provide for his or her basic needs), were left unmonitored on the behavioral health unit (an area of the hospital that provides mental health care and treatment), not in accordance with facility policy. This deficient practice had the potential for the patients to cause harm to themselves or each other. (Refer to A – 0144)

3. The facility failed to report allegations of abuse to the appropriate health care regulatory agency for two sampled patients (Patient 1). This deficient practice had the potential for the incidents not to be investigated by the regulatory agency, and places other patients at risk of injury or harm. (Refer to A – 0145)

4. The facility failed to ensure a background check was performed on three of 10 sampled staff members (Mental Health Worker [MHW 1 and MHW 3] and Behavioral Health Assistant [BHA 1]) prior starting to work at the facility. This deficient practice had the potential exposing patients to criminals and put patients ' safety at risk for abuse. (Refer to A – 0145)

5. The facility failed to ensure patient electronic health records (eHR, a digital version of a patient's medical record) maintained secured, in one of three sampled units (Unit 3, medical surgical and behavioral health unit), when patient information on the workstation on wheels (WOW, a mobile computer) was left open and accessible for anyone to access in unit hallway. This deficient practice had the potential for unauthorized individuals to access patient ' s protected health information. (Refer to A – 0146)

The cumulative effect of these deficient practices resulted in the facility ' s inability to provide quality healthcare in a safe environment and placing patients at risk of abuse, or other patient right ' s violations, such as right to confidentiality, right to be informed of patients ' health status.

Based on interview and record review the facility failed to notify patient representatives, of patient-to-patient altercations (verbal or physical aggression) for two of 30 sampled patients (Patient 1 and 2), in accordance with the facility ' s policy regarding patient-to-patient altercations.

This deficient practice had the potential for patient representatives to be unaware of patient-to-patient altercations, and patient ' s health status.

Findings:

During a review of Patient 1 ' s Face sheet, the Face Sheet indicated Patient 1 was admitted to the facility on 7/6/2024 for severe psychosis (a mental disorder characterized by a disconnection from reality).

During a review of Patient 1 ' s nursing "Progress Note," dated 7/12/2024 at 5:51 p.m., indicated the following. Patient (1) struck on back of head by peer (Patient 2) unprovoked, no bleeding noted, no LOC (loss of consciousness, or change in patient ' s awareness) ...There was no documentation indicating that Patient 1 ' s responsible party was notified.

During a review of Patient 2 ' s Face Sheet, the Face Sheet indicated Patient 2 was admitted to the facility on 6/4/2024 for agitation (very worried or upset and shows this in their behavior, movements, or voice).

During a review of Patient 2 ' s nursing "Progress Note," dated 7/5/2024 at 2:41 p.m., the Progress Notes indicated the following. Patient (2) non-redirectable, high agitated ...yelling, striking out at peers (unknown) unprovoked ...Patient (2) stated "I felt threaten, so I hit her." There was no documentation in the medical record that Patient 2 ' s conservator was notified.

During a review of Patient 2 ' s nursing "Progress Note," dated 7/12/2024 at 5:30 p.m., the Progress Note indicated the following. At 4:15 p.m., Patient (2) non-redirectable, high agitated ...yelling, struck out at female peer (Patient 1) with closed fist ... Patient 2 stating "she hit me, threw coffee at me, I didn ' t start it." ... There was no documentation in the medical record that Patient 2 ' s conservator was notified.

During a review of Patient 2 ' s nursing "Progress Note," dated 7/18/2024 at 5:35 p.m., the Progress Note indicated the following. At approximately 5:10 p.m., Patient (2) hit another patient in the head with a closed fist. The Patient (2) walked up to other patient (unknown) and despite 1:1 sitter (a non-licensed person who provides 1:1 constant care or observation) within arms ' length away and attempting to hold his (Patient 2) arm back, Patient (2) pushed through the 1:1 sitter and hit the other patient (unknown) ... There was no documentation in the medical record that Patient 2 ' s conservator was notified.

During an interview on 8/8/2024 at 9:16 a.m., with Charge Nurse (CN) 1, CN 1 stated the following. Patient 1 and Patient 3 had an altercation in the Day/Dining Room during "coffee time," at 4:15 p.m. CN 1 heard Patient 1 and 2 arguing. Mental Health Worker (MHW) 3 reported that Patient 1 threw coffee at Patient 2, and stated "he hit her (Patient 2 hit Patient 1)," around the head area. Patient 1 and 2 were separated immediately. Patient 2 had coffee dripping from his shift. CN 1 assessed Patient 1. CN 1 stated she did not notify Patient 1 ' s representative of the incident. CN 1 stated that Patient 1 ' s representative should have been notified.

During an interview on 8/8/2024 at 10:27 a.m., with House Supervisor (HS) 1, HS 1 stated that when there is a patient-to-patient altercation, the family or patient representatives of both patients should be notified by patient ' s primary nurse or the charge nurse.

During an interview on 8/8/2024 at 10:27 a.m., with the Administrator (ADM), the ADM stated that family or patient representatives should be notified when patients are involved in an altercation, however, you should obtain permission from patient prior to notification. The ADM reviewed Patient 1 ' s medical record and verified Patient 1 ' s representative was not notified of the incident on 7/12/2024.

During a concurrent interview and record review, on 8/8/2024 at 3:17 p.m., with Social Worker (SW) 1, SW 1 stated the following. Patient 2 was conserved (a law-appointed a guardian or protector) by family. Patient 2 was involved in 3 altercations, on 7/5/2024, 7/12/2024, and 7/18/2024. SW 1 verified that there was no documentation in the medical record indicating that Patient 2 ' s family had been informed of the altercations.

During a review of the facility ' s policy and procedure (P&P) titled, "Patient -to-Patient Altercations," dated 3/2019, the P&P indicated the following. if two patients are involved in an altercation, staff will ...Separate the patients ...Notify each patient ' s representative ...

Based on observation, interview and record review, the facility failed to provide a safe environment for two of 30 sampled patients (Patients 17 and 19), when Patients 17 and 19, both on a 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation) for gravely disabled (GD, a condition in which a person, as a result of a mental disorder, is unable to provide for his or her basic needs),were left unmonitored on the behavioral health unit (an area of the hospital that provides mental health care and treatment), not in accordance with facility policy. This deficient practice had the potential for the patients to cause harm to themselves or each other.

Findings:

1. During a concurrent observation and interview on 8/6/2024 at 3:50 p.m. with the Director of Nursing (DON), Patient 17 was observed in the activity room, with Patient 19, without staff monitoring. There was no staff observed in the activity room, directly outside or in the hallway. The DON stated the following: Patients should not be left in the activity room alone. There should be continuous monitoring of patients when in the activity room. There should have been a staff sitting directly outside of the activity room and there was not. It was important to monitor patients in the activity room for safety precautions in case there was a physical altercation. The patients in the activity room could have been a danger to themselves or others.

During an interview on 8/6/2024 at 4:05 p.m. with the Certified Nursing Assistant 4 (CNA 4), the CNA 4 stated the following: She (CNA 4) was assigned to monitor the activity room from 3 p.m. – 7:00 p.m. she (CNA 4) left the activity room to assist another patient. When she (CNA 4) left the activity room, she (CNA 4) should have notified another staff to cover monitoring the activity room. Patients should not have been left in the activity room alone. She (CNA 4) was supposed to continuously monitor the activity room, while patients are in the room. She (CNA 4) was supposed to sit outside of the room in a chair or be in the activity room to monitor patients. While the patients were unmonitored, there could have been an argument, physical fight, or medical condition.

During a concurrent interview and record review on 8/7/2024 at 3:19 p.m. with the Nurse Manager 1 (NM 1), the NM 1 stated the following: Patient 17 ' s "Initial Psychiatric Evaluation," dated 8/7/2024 at 9:05 a.m., indicated poor impulse control, a danger for safety and required supervision to prevent violent acting out.

During a record review of Patient 17 ' s Face Sheet, the Face Sheet (a document that provides a patient's information at a quick glance) indicated Patient 17 was admitted to the facility on 8/6/2024 at 1:49 p.m.

During a record review of Patient 17 ' s "Initial Psychiatric Evaluation (comprehensive evaluation conducted by a qualified mental health physician)", dated 8/7/2024 at 9:05 a.m., the Initial Psychiatric Evaluation indicated the following: Patient 20 was admitted to the facility on a 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation) for gravely disabled (GD, a condition in which a person, as a result of a mental disorder, is unable to provide for his or her basic needs), with a diagnosis of schizophrenia. The psychiatric evaluation further indicated Patient 17 "appears unable to control impulses to others, a danger for safety," and "requires supervision to prevent violent acting out."

During a record review of Patient 17 ' s "Interdisciplinary Care Plan," dated 8/7/2024 at 7:16 a.m., the care plan indicated the following: "danger to self (DTS)/danger to others (DTO) Care Plan; Problem type: Actual; History: anxiety, paranoia (mental illness characterized by systematized delusions), impulsive unpredictable."

During a review of the facility's policy and procedure (P&P) titled, "Activities Room Monitoring Psych Rehab," dated 5/7/2022, the P&P indicated the following: " ...2. Scope: This policy applies to all staff members, including clinical and non-clinical personnel, involved in the operation and supervision of the psych rehab activity room ... 3. Objectives: Ensure the safety of patients and staff ... 4. Monitoring Methods: Staff present immediately on the outside of the room... 4.1 Direct Supervision: Staff members will be present during all group activities ... monitor patient interactions, behavior, and safety ..."

1. During a concurrent observation and interview on 8/6/2024 at 3:50 p.m. with the Director of Nursing (DON), Patient 19 was observed in the activity room, with Patient 17, without staff monitoring. There was no staff observed in the activity room, directly outside or in the hallway. The DON stated the following: Patients should not be left in the activity room alone. There should be continuous monitoring of patients when in the activity room. There should have been a staff sitting directly outside of the activity room and there was not. It was important to monitor patients in the activity room for safety precautions in case there was a physical altercation. The patients in the activity room could have been a danger to themselves or others.

During an interview on 8/6/2024 at 4:05 p.m. with the Certified Nursing Assistant 4 (CNA 4), the CNA 4 stated the following: She (CNA 4) was assigned to monitor the activity room from 3 p.m. – 7:00 p.m. she (CNA 4) left the activity room to assist another patient. When she (CNA 4) left the activity room, she (CNA 4) should have notified another staff to cover monitoring the activity room. Patients should not have been left in the activity room alone. She (CNA 4) is supposed to continuously monitor the activity room, while patients are in the room. She (CNA 4) is supposed to sit outside of the room in a chair to monitor or be in the activity room. While the patients were unmonitored, there could have been an argument, physical fight, or medical condition.

During a concurrent interview and record review on 8/7/2024 at 3:35 p.m. with the Nurse Manager 1 (NM 1), the NM 1 stated the following: Patient 19 ' s "Initial Psychiatric Evaluation," dated 7/27/2024 at 11:29 a.m., indicated Patient 19 was a danger to self and others.

During a record review of Patient 19 ' s Face Sheet, the Face Sheet indicated Patient 19 was admitted to the facility on 7/26/2024 at 10:24 p.m.

During a record review of Patient 19 ' s "Initial Psychiatric Evaluation (comprehensive evaluation conducted by a qualified mental health physician)", dated 7/27/2024 at 11:29 a.m., the Initial Psychiatric Evaluation indicated the following: Patient 19 was admitted to the facility with a diagnosis of schizophrenia, paranoid type. The psychiatric evaluation on a 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation) for gravely disabled (GD, a condition in which a person, as a result of a mental disorder, is unable to provide for his or her basic needs) and Danger to Others (DTO) further indicated Patient 19 "appears unable to control impulses to others, a danger for safety," and "requires supervision to prevent violent acting out."

During a record review of Patient 19 ' s "Interdisciplinary Care Plan," dated 7/26/2024 at 11:52 p.m., the care plan indicated the following: "DTS/DTO Care Plan; Problem Type: Actual; DTS/DTO Problem: Violence: other-directed."

During a review of the facility's policy and procedure (P&P) titled, "Activities Room Monitoring Psych Rehab," dated 5/7/2022, the P&P indicated the following: " ...2. Scope: This policy applies to all staff members, including clinical and non-clinical personnel, involved in the operation and supervision of the psych rehab activity room ... 3. Objectives: Ensure the safety of patients and staff ... 4. Monitoring Methods: Staff present immediately on the outside of the room... 4.1 Direct Supervision: Staff members will be present during all group activities ... monitor patient interactions, behavior, and safety ..."

Based on interview and record review, the facility failed to follow its ' policy regarding abuse when;

1. The facility failed to report allegations of physical abuse to the appropriate health care regulatory agency for one of 30 sampled patients (Patient 1). This deficient practice had the potential for the incidents not to be investigated by the regulatory agency, and places other patients at risk of harm or injury.

2. The facility failed to ensure a background check was performed on three of 10 sampled staff members (Mental Health Worker [MHW 1 and MHW 3] and Behavioral Health Assistant [BHA 1]) prior starting to work at the facility. This deficient practice had the potential exposing patients to criminals and put patients ' safety at risk for abuse.

Findings:

1. During a review of Patient 1 ' s Face sheet, the Face Sheet indicated Patient 1 was admitted to the facility on 7/6/2024 for severe psychosis (a mental disorder characterized by a disconnection from reality).

During a review of Patient 1 ' s nursing "Progress Note," dated 7/12/2024 at 5:51 p.m., the Progress Note indicated the following. Patient (1) struck on back of head by peer (Patient 2) unprovoked, no bleeding noted, no LOC (loss of consciousness, or change in patient ' s awareness), ambulatory, able to make needs known. Vital signs WNL (within normal limits), PEERLA (pupils are equal, round, reactive to light and accommodation), grips intact, respirations even and unlabored, no external injury noted, denies any dizziness, given ice pack. Notified provider with no new orders at this time, just monitor patient. Will update provider of any changes.

During a review of Patient 1 ' s nursing "Progress Note," dated 7/12/2024 at 10:06 p.m., the Progress Note indicated the following. At around 8:15 p.m., "Charge Nurse came inside after speaking with Patient 1 and Patient 1 ' s family member ...Charge nurse informed that Patient 1 ' s family member wanted Patient 1 to be sent to the Emergency Department (ED) for evaluation ...Patient 1 sent for evaluation of face and head. S/P (status post) head trauma secondary to getting punched ...

During a review of Patient 2 ' s Face Sheet, the Face Sheet indicated Patient 2 was admitted to the facility on 6/4/2024 for agitation (very worried or upset and shows this in their behavior, movements, or voice).

During a review of Patient 2 ' s nursing "Progress Note," dated 7/12/2024 at 5:30 p.m., the Progress Note indicated the following. At 4:15 p.m., Patient (2) non-redirectable, high agitated ...yelling, struck out at female peer (Patient 1) with closed fist ... Patient 2 stating "she hit me, threw coffee at me, I didn ' t start it." ...

During an interview on 8/8/2024 at 9:16 a.m., with Charge Nurse (CN) 1, CN 1 stated the following. On 7/12/2024 at 4:15 p.m., Patient 1 and Patient 2 had an altercation in the Day/Dining Room during "coffee time." CN 1 heard Patient 1 and 2 arguing. Mental Health Worker (MHW) 3 reported that Patient 1 threw coffee at Patient 2 and stated "he hit her (Patient 2 hit Patient 1)," around the head area. Patient 1 and 2 were separated immediately by MHW 3. CN 1 assessed Patient 1 and vital signs were within normal limits and no visible injury was noted. CN 1 notified the provider of the incident. This incident could be considered as physical abuse.

During an interview on 8/8/2024 at 11:01 a.m., with Mental Health Worker (MHW) 3 the following. On 7/12/2024 at approximately 4 p.m., MHW 3 was passing out coffee in the Day / Dining Room. Patient 1 called Patient 2 "the N word," and thew coffee at Patient 2 ' s upper chest area. Patient 2 "rushed" at Patient 1 and punched her with closed fist, does not recall the which part of the body was hit, or the number of times. MHW 3 immediately separated Patients 1 and 2. The incident happened so fast. MHW 3 check Patient 1 ' s vital signs (blood pressure, heart rate, respiratory rate, and temperature) and informed Charge Nurse (CN) 1. Patient 1 stated she (Patient 1) was okay, no bruising or bleeding observed.

During an interview on 8/9/2024 at 12:55 p.m. with the Director of Quality and Risk Management (DQRM), the DQRM stated the following. The incident on 7/12/2024 between Patient 1 and 2 was referred to Administration and was investigated. The DQRM learned of the incident on 8/6/2024 when DQRM returned from time off. The regulatory agency conducted an investigation 7/17/2024 due to a complaint. Patient 1 did not suffer any injuries and the case was closed. The incident was not reported to the regulatory agency. The DQRM verified that the facility ' s policy and procedure indicated that cases of alleged abuse should be reported to the regulatory agency. The DQRM stated the facility ' s practices does not match the facility ' s policy.

During a review of the facility ' s policy and procedure (P&P) titled, "Patient -to-Patient Altercations," dated 3/2019, the P&P indicated the following. if two patients are involved in an altercation, staff will ...Separate the patients ...Complete a Report/Accident form and document the incident findings, and any corrective measures ...Report incidents, findings, and corrective actions to appropriate agencies as outlined in out facility ' s abuse reporting policy.

During a review of the facility ' s policy and procedure (P&P) titled, "Abuse – Management of Suspected Child, Adult, Disabled Person or Elderly Abuse, Neglect," dated 3/8/2019, the P&P indicated the following. It is the policy of the Medical Center under guidance of applicable laws, that any person having reasonable cause to believe that any person is in the state of abuse, exploitation, or neglect shall report the information to the appropriate regulatory agency ...Cases of suspected sexual assault, physical abuse or neglect should be given priority ...All cases of suspected abuse / neglect must be reported to authorities ...A person, including an employee ...or other person associated with the department, who reasonably cause a person to believe that the physical or mental health or welfare of a patient of the department who is receiving medical services has been, is or will be adversely affected by abuse or neglect by any person shall, provide a mandatory report of information supporting the belief to the Department of Health, or the appropriate health care regulatory agency, by telephone, in writing, or by personal visit within 24-36 hours of alleged event ...


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2. During a concurrent interview and record review on 8/8/2024 at 4:07 p.m. with the Human Resources Coordinator (HRC), Mental Health Worker (MHW) 1 ' s personnel file was reviewed. The personnel file indicated, there was no background check document in MHW 1 ' s personnel file. HRC stated the following: background check was required for all employees prior working at the facility to make sure the employee was cleared with criminal background to prevent possible patient abuse. MHW 1 was hired on 8/2/2023 by the contracted company (CC 1) and background check should have been done for her (MHW 1). She (HRC) did not know why it was not done.

During a review of MHW 3 ' s personnel file, undated, MHW 3 ' s personnel file indicated MHW 3 ' s hire date of 3/4/2024 and there was no background check document in MHW 3 ' s personnel file.

During a review of BHA 1 ' s personnel file, undated, BHA 1 ' s personnel file indicated BHA 1 ' s hire date of 10/23/2023 and there was no background check document in BHA 1 ' s personnel file.

During an interview on 8/8/2024 at 4:58 p.m. with the Director of Nursing (DON), DON stated background check was required for all employees prior starting at the facility. Background check was done for safety of patients to ensure no criminals working at the facility.

During an interview on 8/9/2024 at 2:15 p.m. with HRC, HRC stated MHW 3 and BHA 1 were facility ' s employees and the Human Resources department did not have the background check document for MHW 3 and BHA 1.

During an interview on 8/9/2024 at 3:06 p.m. with the Chief Executive Officer (CEO), CEO stated background check was required for all employees prior working at the facility to ensure safety of patients.

During a review of the facility ' s policy and procedure (P&P) titled, "Human Resources 806 Background Investigations," dated 10/2020, the P&P indicated, "All prospective new hires and rehires will have background investigations (BIs) conducted at the time of employment. Background investigations will include a review of prior employment and a criminal conviction review. Certain criminal records will be an automatic bar to employment ... State regulations may specify that the criminal conviction search be clear before hiring. If an unacceptable background or criminal history is found and the applicant has been hired, the job offer will be withdrawn. If employment has already commenced, the employee will be terminated immediately. Convictions for the following offenses, as well as others not listed, shall be automatic bars to employment with [the facility]. 1) Homicide (includes murder, capital murder, manslaughter, and criminal negligent homicide), 2) Kidnapping, aggravated kidnapping, false imprisonment, 3) Indecency with a child, 4) Sexual assault, 5) Aggravated assault, 6) Injury to a child, elderly individual or disabled individual, 7) Abandoning or endangering a child, 8) Aiding suicide, 9) Sale or purchase of a child, 10) Arson, 11) Robbery or aggravated robbery ... the facility will be responsible for contacting any other state agency as required by law. This may include the abuse registry and any licensing boards or bureaus. If state law requires a criminal conviction review through a state agency, those forms must be completed as well as the Human Resources Profile background check. All prospective employees will also be reviewed for Medicare sanctions by review of a recent cumulative sanctions report by the compliance officer of the facility. Anyone listed on the sanctions list will not be eligible for employment at [the facility] owned or managed facility."

Based on observation, interview and record review, the facility failed to ensure patient electronic health records (eHR, a digital version of a patient's medical record) maintained secured, in one of three sampled units (Unit 3, medical surgical and behavioral health unit), when patient information on the workstation on wheels (WOW, a mobile computer) was left open and accessible for anyone to access in unit hallway. This deficient practice had the potential for unauthorized individuals to access patient ' s protected health information.

Findings:

During a concurrent observation and interview on 8/6/2024 at 1:34 p.m. with the Director of Nursing (DON) in Unit 3, a workstation on wheels (WOW, a mobile computer) was observed open with electronic health records (eHR, a digital version of a patient's medical record) unlocked and accessible in the unit hallway. The DON verified there was no staff in sight to safeguard the patient information on WOW. The DON stated the following: When not in use, staff are supposed to close the eHR. The eHR should be locked and protected to protect patient information. If the eHR is left open and unattended, anyone can access patient information which should be private for Health Insurance Portability and Accountability Act (HIPAA, regulates the use and disclosure of protected health information [PHI]) purposes.

During an interview on 8/6/2024 at 1:40 p.m. with the Registered Nurse 7 (RN 7), the RN 7 verified the WOW was unattended and unlocked with patient information open and accessible by anyone. The RN 7 stated the following: The eHR should not be left unattended with open patient information. She (RN 7) is supposed to log in and out with a password to access the eHR. If the eHR is left open, anyone can access and see patient information.

During a review of the facility's policy and procedure (P&P) titled, "HIPAA Policies and Procedures," dated 9/2022, the P&P indicated the following: "Policy: [the facility] to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), maintains that patient information must be kept private and confidential ..."

Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation for Nursing Services was met as evidenced by:

1. The facility failed to ensure one of 30 sampled patients (Patient 20) was reassessed by a Registered Nurse (RN) after Ativan (medication used to treat anxiety), Haldol (a medication used to treat mental/mood disorders) and Benadryl (a medication used to treat allergies that has sedative effects) were administered concurrently as emergency medications (immediate administration of psychotropic medications [medications used to treat mental health disorders] to a person to treat severe agitation and/or aggressive behaviors). This deficient practice had the potential for the medication to be ineffective or for medication adverse reactions not to be identified, which may cause a delay in care and interventions. (Refer to A – 0395)

2. The facility failed to ensure a care plan (a summary of a patient ' s health conditions, specific care needs, and current treatment) was developed for two of 30 sampled patient ' s (Patient 15 and Patient 26) medical diagnosis of epilepsy (seizures) for Patient 15, and anemia (not enough red blood cells to carry oxygen in the blood) for Patient 26. This deficient practice had the potential for Patient 15 to be at risk for injury due to lack of appropriate nursing interventions for patients with epilepsy and had the potential for Patient 26 not receiving monitoring and evaluation for anemia and blood transfusion. (Refer to A – 0396)

3. The facility failed to ensure two of 10 sampled staff members (Mental Health Worker [MHW 3] and Behavior Health Assistant [BHA 1]) had a BLS (Basic Life Support, type of care that first-responders provide to anyone who is experiencing a cardiac or respiratory arrest) card in their personnel file. This deficient practice had the potential for the staff ' s inability to identify and respond to a medical emergency if a patient suffers from a cardiac (heart) or respiratory arrest. (Refer to A – 0397)

4. The facility failed to reassess (to reevaluate a patient ' s health status) one of 30 sampled patients (Patient 19) after the administration of as needed medication, Ativan (a medication for anxiety), in accordance with policy and procedure. This deficient practice had the potential for the medication to be ineffective or for medication adverse reactions not to be identified, which may cause a delay in care and interventions. (Refer to A – 0398)

5. The facility failed to ensure nursing staff performed a proper risk assessment on three of 30 sampled patients (Patient 3, 29, and 30) in accordance with its policy and procedure for suicidal risk assessment. This deficient practice had the potential to result in nursing staff not recognizing patients ' suicidal thoughts, and not providing interventions to prevent patients from harming self. (Refer to A – 0398)

6. The facility failed to ensure blood pressure medication was administered safely for one of 30 sampled patients (Patient 14) when Patient 14 was administered blood pressure medication without Patient 14 ' s blood pressure or pulse rate being evaluated or assessed. This deficient practice had the potential for Patient 14 to experience serious side effects of low blood pressure or heart rate such as confusion, dizziness, blurry vision, weakness, or fainting. (Refer to A – 0405)

7. The facility failed to ensure antibiotics (medications used to treat infection) were given in a timely manner for two of 30 sampled patients (Patients 16 and 18) in accordance with the physician ' s order (a doctor ' s instructions for care and treatment) and the facility ' s policy and procedure regarding medication administration. This deficient practice resulted in a delay in treatment and had the potential for the antibiotics to be ineffective. (Refer to A – 405)

The cumulative effect of these deficient practices resulted in the facility ' s inability to provide quality health care in a safe environment.

Based on interview and record review, the facility failed to ensure one of 30 sampled patients (Patient 20) was reassessed by a Registered Nurse (RN) after Ativan (medication used to treat anxiety), Haldol (a medication used to treat mental/mood disorders) and Benadryl (a medication used to treat allergies that has sedative effects) were administered concurrently as emergency medications (immediate administration of psychotropic medications [medications used to treat mental health disorders] to a person to treat severe agitation and/or aggressive behaviors).

This deficient practice had the potential for the medication to be ineffective or for medication adverse reactions not to be identified, which may cause a delay in care and interventions.

Findings:

During a record review of Patient 20 ' s Face Sheet (a document that provides a patient's information at a quick glance), the Face Sheet indicated Patient 20 was admitted to the facility on 7/31/2024 at 12:10 p.m.

During a record review of Patient 20 ' s "Initial Psychiatric Evaluation (comprehensive evaluation conducted by a qualified mental health physician)", dated 8/1/2024 at 8:54 a.m., the initial psychiatric evaluation indicated the following: Patient 20 was admitted to the facility with a chief complaint of agitation (state of anxiety or nervous excitement) and aggression, and had a history of schizoaffective disorder, bipolar type (mental illness that causes a person to experience dramatic changes in their thoughts, moods, and behaviors).

During a concurrent interview and record review on 8/7/2024 at 1:29 p.m. with the Nurse Manager 1 (NM 1), Patient 20 ' s medical record was review and indicated the following: Patient 20 ' s "Emergency Medication (immediate administration of psychotropic medications [medications used to treat mental health disorders] to a person to treat severe agitation and/or aggressive behaviors) Intervention (EMI) Assessment (to gather a patient ' s health status) and Reassessment (to reevaluate a patient ' s health status)," dated 8/1/2024 at 9:00 a.m., was completed by Licensed Vocational Nurse 3 (LVN 3). The NM 1 verified the EMI assessment and reassessment was not co-signed by a Registered Nurse (RN).

During the same interview and record review on 8/7/2024 at 1:29 p.m. with the NM 1, the NM 1 stated the following: The EMI assessment and Reassessment is completed after a patient is given "emergency medications", such as Ativan (medication used to treat anxiety), Haldol (a medication used to treat mental/mood disorders) and Benadryl (a medication used to treat allergies that has sedative effects) concurrently. The LVN can collect and enter data on the EMI assessment and Reassessment, after the administration of emergency medications. Patient 20 ' s EMI assessment and Reassessment should have been co-signed by an RN, when LVN 3 collected and entered the data. The co-signature of the Registered Nurse would have indicated that the patient was reassessed by a Registered Nurse, to include a face-to-face (where the nurse physically assesses the patient) reassessment, within one hour of emergency medication administration. The EMI assessment and reassessment required the co-signature of the RN because was not in the scope of LVN 3 to reassess the patient. LVN 3 can only collect and enter the data. The NM 1 confirmed that the EMI assessment and reassessment did not have a place for the RN to co-sign. The NM 1 further confirmed the medical record did not indicate that a face-to-face was performed by an RN.

During an interview on 8/8/2024 at 11:12 a.m. with the Director of Nursing (DON), the DON stated the following: The facility did not have a specific policy for the use of emergency medications and the facility used the "Restraint (any physical measure that immobilizes or reduces the ability to move freely) and Seclusion (to isolate in a room or space from which a person cannot willfully escape)" and "Psychotropic Medication (mental health medication) Use" policies, which included the use of emergency medications. After emergency medications are administered to a patient, the patient should have a face-to-face reassessment to assess patients physiological and the effects of the medication, per policy. The reassessment should occur within one hour of emergency medication administration, per policy by an RN.

During a record review of Patient 20 ' s "Electronic Medication Administration Record (eMAR, a record for the administration of medication to patients)," dated 8/1/2024, the eMAR indicated the following:

On 8/1/2024 at 9:00 a.m., Benadryl 50mg/ml injection was administered to Patient 20 by intramuscular (within the muscle) injection.

On 8/1/2024 at 9:00 a.m., Ativan 2mg injection was administered to Patient 20 by intramuscular injection.

On 8/1/2024 at 9:00 a.m., Haldol 5mg injection was administered to Patient 20 by intramuscular injection.

During a review of the facility's policy and procedure (P&P) titled, "Restraint and Seclusion Policy" dated 3/9/2022, the P&P indicated the following: "Emergency Medication Intervention is a one-time order (which may be repeated if necessary) for one or more medications that is used as part of a patient ' s standard medical or psychiatric (relating to mental illness) treatment and is administered within the standard dosage for the patient ' s condition. This includes use of antipsychotic medications (used to treat psychosis [lose contact with reality]) to manage violent behavior ..."

During a review of the facility's policy and procedure (P&P) titled, "Psychotropic Medication (medications used to treat mental health disorders) Use," dated 9/2019, the P&P indicated the following: " ...Policy: ...E. Emergency Medication Intervention (EMI) injection shall be assessed and assessed by nursing staff in electronic Health Record (eHR, a digital version of a patient's medical record) including ... conclusion assessment, and patient behavior face to face interview."

Based on observation, interview, and record review, the facility failed to ensure a care plan (a summary of a patient ' s health conditions, specific care needs, and current treatment) was developed for two of 30 sampled patients (Patient 15 and Patient 26) when:

1. A care plan was not developed for Patient 15 ' s medical diagnosis of epilepsy (seizures). This deficient had the potential for Patient 15 to be at risk for injury due to lack of appropriate nursing interventions for patients with epilepsy.

2. A care plan was not developed for Patient 26 ' s medical diagnosis of anemia (not enough red blood cells to carry oxygen in the blood). This deficient practice had the potential for Patient 26 not receiving monitoring and evaluation for anemia and blood transfusion.

Findings:

1. During a concurrent observation and interview on 8/7/24 at 9:16 a.m., with the Mental Health Worker (MHW) 4, in Patient 15 ' s room, Patient 15 was sleeping on a mattress that was placed on the floor. MHW 4 stated Patient 15 was confused and lays on the floor without anything under him. MHW 4 further stated MHW 4 placed the mattress on the floor so Patient 15 would be laying on a barrier between himself and the floor.

During a review of Patient 15 ' s History and Physical (H&P), dated 8/4/24, the H&P indicated Patient 15 was admitted on 8/3/24 for Altered Mental Status (changes in awareness, movement and behavior). The H&P further indicated Patient 15 had a past medical history of hypertension (high blood pressure), epilepsy, and stroke. The H&P indicated, "Current Active Home Meds: ... KEPPRA [seizure medication] 500 MG [milligram] TAB [tablet] ...Plan ...Seizure Precautions ..."

During a review of Patient 15 ' s "Interdisciplinary Team Progress Note Nursing" (Nursing Note) dated 8/3/24, the Nursing Note indicated "Medical HX [History]: HTN [Hypertension], Epilepsy ..."

During a review of Patient 15 ' s physician ' s order, dated 8/3/24, the physician ' s order indicate "Nursing Name: Seizure Precautions ... Status New."

During a concurrent interview and record review on 8/8/24 at 3:42 p.m., with the Utilization Review Case Manager (URCM), Patient 15 ' s active Nursing Care Plan was reviewed. URCM stated no seizure care plan was developed for Patient 15.

During an interview on 8/8/24 at 4:03 p.m., with the Behavioral Health Unit Clinical Manager (CM) 1, CM 1 stated a seizure precaution care plan should be in place for patients with a medical diagnosis of epilepsy. CM 1 stated the care plan should include interventions to implement such as placing the mattress on the floor for precaution and to prevent injury, turning the patient to the side during an active seizure, and recording the duration of an active seizure. CM 1 further stated the care plan served as a communication tool for all floor staff to be aware of patients with history of seizures.

During an interview on 8/9/24 at 10:56 a.m., with the Director of Nursing (DON), the DON stated it was expected that a care plan was in place for any active or potential health issues, and patients with a history of seizures to have a seizure care plan in place.

During a review of the facility ' s policy and procedure (P&P) titled "Multidisciplinary Plan of Care," dated November 2019, the P&P indicated, "The admitting Licensed Nurse will initiate the care plan based on the admission assessment ..."

During a review of the facility ' s P&P titled "Hospital Plan for Provision of Care," dated March 2019, the P&P indicated, "Patient Care Plan: [Facility Name] meets the identified needs of patients in a coordinated, interdisciplinary and systematic way that addresses the entire spectrum of care including the period before admission, during admission, hospitalization, before discharge, and at discharge. This interdisciplinary approach aims for consistency, continuity, and quality of care. Services flow continuously from assessment through treatment and reassessment."


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2. During a review of Patient 26 ' s "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 7/31/2024, the H&P indicated Patient 26 was admitted to the facility with diagnoses of severe anemia (a condition marked by a deficiency of red blood cells or of hemoglobin [a component of red blood cells] in the blood, resulting in pallor and weariness). The H&P also indicated Patient 26 received blood transfusion at the facility.

During an interview on 8/7/2024 at 2:17 p.m. with registered nurse (RN 1), RN 1 stated care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) was developed upon admission by RN upon admission and update every shift to address patient ' s current problem.

During a concurrent interview and record review on 8/7/2024 at 3:28 p.m. with RN 1, Patient 26 ' s "Interdisciplinary Care Plan," dated 7/31/2024 was reviewed. The care plan indicated Patient 26 ' s active care problems with acute pain, skin integrity, fall, hypertension and danger to self or others. RN 1 stated there was no care plan developed for Patient 26 to address his (Patient 26 ' s) admitting diagnosis of anemia. RN 1 stated there should be care plan for anemia to provide nursing interventions including monitoring signs and symptoms of bleeding, and lab values including hemoglobin (a component of red blood cells) and hematocrits (volume percentage of red blood cells in blood) for anemia management. RN 1 stated without the care plan for anemia, nursing staff could not monitor and evaluate Patient 26 ' s progress.

During an interview on 8/9/2024 at 10:56 a.m. with the Director of Nursing (DON), DON stated care plan was a plan of treatment to identify problem and to provide interventions to address patients ' active and potential problems. DON stated care plan was needed to evaluate patients ' progress and to keep patients safe.

During a review of the facility ' s policy and procedure (P&P) titled, "Multidisciplinary Plan of Care," dated 11/2019, the P&P indicated, "[facility] to develop a care plan foreach patient admitted at the hospital ... the plan will include problems/needs, goals and interventions ... the plan will serve to facilitate continuity, coordination and communication among team members ... the admitting licensed nurse will initiate the care plan based on admission assessment."

During a review of the facility ' s policy and procedure (P&P) titled, "Hospital Plan for Provision of Care," dated 3/2019, the P&P indicated, "Patient care plan. [the facility] meets the identified needs of patient in a coordinated, interdisciplinary and systematic way that addresses the entire spectrum of care including the period before admission, during admission, hospitalization, before discharge and at discharge."

Based on interview and record review, the facility failed to ensure two of 10 sampled staff members (Mental Health Worker [MHW 3] and Behavior Health Assistant [BHA 1]) had a BLS (Basic Life Support, type of care that first-responders provide to anyone who is experiencing a cardiac or respiratory arrest) card in their personnel file. This deficient practice had the potential for the staff ' s inability to identify and respond to a medical emergency if a patient suffers from a cardiac (heart) or respiratory arrest.

Findings:

During a concurrent interview and personnel file review on 8/9/2024 at 2:03 p.m., with the Human Resources Coordinator (HRC), the HRC stated the following. MHW 3 was hired on 3/4/2024. BHA 1 was hired on 10/23/2023. The HRC verified that MHW 3 and BHA 1 ' s personnel file did not include a BLS card. The HRC stated that all clinical staff were required to have a BLS card.

During an interview on 8/9/2024 at 3:15 p.m., with the Director of Nursing (DON), the DON stated all staff working on the patient care units were required to posses a BLS card to ensure staff are able to respond in an event of medical emergency. Human Resources Department should ensure all staff have posses a BLS card prior to starting their positions.

During a review of MHW 3 ' s"Job Description," dated 3/4/2024, the Job Description indicated the following ... Demonstrates clinical competence in the provision of nursing care specific to adult patients ...Assist RN (registered nurse) in identification and treatment of significant change in patient ' s physical and/or mental status ...Must possess a current BLS card ...

During a review of BHA 1 ' s "Job Description," dated 10/23/2023, the Job Description indicated the following ... Demonstrates clinical competence in the provision of nursing care specific to adult patients ...Assist RN (registered nurse) in identification and treatment of significant change in patient ' s physical and/or mental status ...Must possess a current BLS card ...

During a review of the facility ' s policy and procedure (P&P) titled, "HR 211 Certificates & Licenses," dated 10/01/2020, indicated "It is a condition that employees in certain positions have and maintain a license, registration or certification to perform their jobs.

1. Based on observation, interview and record review the facility failed to reassess (to reevaluate a patient ' s health status) one of 30 sampled patients (Patient 19) after the administration of as needed medication, Ativan (a medication for anxiety), in accordance with policy and procedure. This deficient practice had the potential for the medication to be ineffective or for medication adverse reactions not to be identified, which may cause a delay in care and interventions.

2. Based on interview and record review, the facility failed to ensure nursing staff performed a proper risk assessment on three of 30 sampled patients (Patient 3, 29, and 30) in accordance with its policy and procedure for suicidal risk assessment. This deficient practice had the potential to result in nursing staff not recognizing patients ' suicidal thoughts, and not providing interventions to prevent patients from harming self.

Findings:

1. During a record review of Patient 19 ' s Face Sheet (a document that provides a patient's information at a quick glance), the Face Sheet indicated Patient 19 was admitted to the facility on 7/26/2024 at 10:24 p.m.

During a record review of Patient 19 ' s "Initial Psychiatric Evaluation (comprehensive evaluation conducted by a qualified mental health physician)", dated 7/27/2024 at 11:29 a.m., the Initial Psychiatric Evaluation indicated the following: Patient 19 was admitted to the facility with a diagnosis of schizophrenia, paranoid type (a mental illness that causes a person to experience paranoia [delusions] and hallucinations [an experience involving the apparent perception of something not present]).

During a record review of Patient 19 ' s "Electronic Medication Administration Record (eMAR, a record for the administration of medication to patients)," dated 7/29/2024, the eMAR indicated the following:

On 7/29/2024 at 4:41 a.m., Ativan (a medication for anxiety) 1mg tablet was administered to Patient 19 by mouth for anxiety.

During a concurrent interview and record review on 8/7/2024 at 3:35 p.m. with the Nurse Manager 1 (NM 1), Patient 19 ' s "As Needed Medication Report" indicated Patient 19 was reassessed by Registered Nurse 6 (RN 6) on 7/29/2024 at 6:38 a.m. The NM 1 confirmed the "as needed medication" report was to reassess (to reevaluate a patient ' s health status) the Ativan given on 7/29/2024 at 4:41 a.m. The NM 1 verified the "as needed medication" reassessment was delayed for Patient 19. The NM 1 stated the following: Patient 19 should have been reassessed within one hour after the administration of as needed medications, such as Ativan. Patient 19 was reassessed late (approximately almost 2 hours after administration). As needed medications should be reassessed to ensure the medication was effective and to assess for adverse reactions. If patients are not reassessed timely after the administration of PRN medications, an adverse reaction may be missed.

During an interview on 8/8/2024 at 11:50 a.m. with the Director of Nursing (DON), the DON stated the following: If a patient received an "as needed medication," such as Ativan, the patient should be reassessed within 30 minutes to one hour after administration. The documentation of as needed medications should be documented on the "As Needed Medication Report" to assess the medication effectiveness, vital signs, adverse reactions, or side effects. The facility did not have a policy that specifically stated the timing of when as needed medications should be reassessed after administration.

During a review of the facility's policy and procedure (P&P) titled, "Medication Administration (Procedures & Timing of Administration)," dated 5/2024, the P&P indicated the following: " ...C. Basic Safe Medication Practices ... viii. Right Response: To ensure that the drug led to the desired effect and document monitoring of the patient."


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2a. During a review of Patient 29 ' s "Psychiatric Initial Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health])," dated 8/1/2024, the Psych Eval indicated, Patient 29 was admitted to the facility ' s Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) with diagnosis of paranoid schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions). The Psych Eval also indicated, Patient 29 was placed on a 5150-hold (a legal hold allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) for danger to self (harming self).

During a concurrent interview and record review on 8/8/2024 at 11:40 a.m. with Registered Nurse (RN 1), Patient 29 ' s "Behavioral Health Daily Assessment/ Suicidal Ideation, (shift assessment, head to toe assessment of the patient by nursing staff)," dated from 8/2/2024 to 8/3/2024 was reviewed. The shift assessment indicated "Question number 2 Current suicidal thoughts: Have you actually had any thoughts of killing yourself? On the Suicide Risk Level Section Level 1 (Low Suicide Risk) Suicidal Ideation Without Plan" was left blank on the following days:

8/2/2024 at 8:10 p.m. filled out by Licensed Vocational Nurse (LVN) 2

8/3/2024 at 10:15 a.m. filled out by LVN 1

RN 1 stated question number 2 was part of the suicide risk screening under shift assessment but LVN 1 and LVN 2 did not complete. They (LVN 1 and LVN 2) should ask Patient 29 question number 2 to assess if Patient 29 had any active plan for hurting self so that nursing staff could provide intervention to prevent Patient 29 from harming self.

During an interview on 8/9/2024 at 10:53 a.m. with DON, DON stated the nursing staff will perform the suicide risk screening for all patients upon admission and every shift. DON stated the screening was done to identify potential risks and maintain safety for patients. DON stated question number 2 of suicide screening must be answered because it was part of the suicide risk screening.

During a review of the facility ' s policy and procedure (P&P) titled, "Patients at Risk for Suicide," dated 7/2020, the P&P indicated, "it is the policy of [the facility] to provide a safe environment of patients who present with a primary diagnosis or an active complaint of an emotional or behavioral disorder ... the screen will determine ' at risk status ' and will assist with implementing appropriate levels of observation ... attachment: [name] suicide severity rating scale ... Ask questions 1 and 2. If both are negative, proceed to ' Suicidal Behavior ' section ... Question 1: Have you wished you were dead or wished you could go to sleep and not wake up? (answer yes or no) Question 2: Have you actually had any thoughts of killing yourself? (answer yes or no)"

During a review of the facility ' s policy and procedure (P&P) titled, "Assessment/ Re-assessment, Patient," dated 3/2019, the P&P indicated, "it is the policy of [the facility] to conduct comprehensive, multidisciplinary assessment on each individual admitted to the hospital ... patients on legal holds must have accurate documentation that reflect patients ' behavior. The documentation of the assessment and reassessment of patient behavior must be done every shift ...licensed nurse shift assessment is done every twelve (12) hours."

2b. During a review of Patient 30 ' s "Psychiatric Initial Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health])," dated 8/1/2024, the Psych Eval indicated, Patient 30 was admitted to the facility ' s Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) with diagnoses of major depression (MDD - a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) without psychotic features (delusions and hallucinations) and dementia (a condition characterized by progressive or persistent loss of intellectual functioning).

The Psych Eval also indicated, Patient 30 was placed on a 5150-hold (a legal hold allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) for gravely disable (unable to take care self) and danger to others (harming other people).

During a concurrent interview and record review on 8/8/2024 at 1:51 p.m. with Registered Nurse (RN 1), Patient 30 ' s "Behavioral Health Daily Assessment/ Suicidal Ideation, (shift assessment, head to toe assessment of the patient by nursing staff)," dated from 8/4/2024 to 8/8/2024 was reviewed. The shift assessment indicated "Question number 2 Current suicidal thoughts: Have you actually had any thoughts of killing yourself? On the Suicide Risk Level Section Level 1 (Low Suicide Risk) Suicidal Ideation Without Plan" was left blank on the following days:

8/4/2024 at 9:36 p.m. filled out by Licensed Vocational Nurse (LVN) 4

8/8/2024 at 11:17 a.m. filled out by RN 5

RN 1 stated the suicide risk screening was incomplete. RN 1 stated it was part of standard assessment and should be completed.

During an interview on 8/9/2024 at 10:53 a.m. with DON, DON stated the nursing staff will perform the suicide risk screening for all patients upon admission and every shift. DON stated the screening was done to identify potential risks and maintain safety for patients. DON stated question number 2 of suicide screening must be answered because it was part of the suicide risk screening.

During a review of the facility ' s policy and procedure (P&P) titled, "Patients at Risk for Suicide," dated 7/2020, the P&P indicated, "it is the policy of [the facility] to provide a safe environment of patients who present with a primary diagnosis or an active complaint of an emotional or behavioral disorder ... the screen will determine ' at risk status ' and will assist with implementing appropriate levels of observation ... attachment: [name] suicide severity rating scale ... Ask questions 1 and 2. If both are negative, proceed to ' Suicidal Behavior ' section ... Question 1: Have you wished you were dead or wished you could go to sleep and not wake up? (answer yes or no) Question 2: Have you actually had any thoughts of killing yourself? (answer yes or no)"

During a review of the facility ' s policy and procedure (P&P) titled, "Assessment/ Re-assessment, Patient," dated 3/2019, the P&P indicated, "it is the policy of [the facility] to conduct comprehensive, multidisciplinary assessment on each individual admitted to the hospital ... patients on legal holds must have accurate documentation that reflect patients ' behavior. The documentation of the assessment and reassessment of patient behavior must be done every shift ...licensed nurse shift assessment is done every twelve (12) hours."

2c. During a review of Patient 3 ' s "Psychiatric Initial Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health])," dated 7/23/2024, the Psych Eval indicated, Patient 3 was admitted to the facility ' s Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) with diagnosis of schizoaffective disorder (mental illness that affects mood and has symptoms of hallucinations and/or delusions).

The Psych Eval also indicated, Patient 3 was placed on a 5150-hold (a legal hold allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) for danger to others (harming other people).

During a concurrent interview and record review on 8/8/2024 at 2:23 p.m. with Registered Nurse (RN 1), Patient 3 ' s "Behavioral Health Daily Assessment/ Suicidal Ideation, (shift assessment, head to toe assessment of the patient by nursing staff)," dated 8/2/2024 was reviewed. The shift assessment indicated "Question number 2 Current suicidal thoughts: Have you actually had any thoughts of killing yourself? On the Suicide Risk Level Section Level 1 (Low Suicide Risk) Suicidal Ideation Without Plan" was left blank by Licensed Vocational Nurse (LVN) 5. RN 1 stated LVN 5 did not complete the suicide risk screening on the shift assessment. RN 1 stated incomplete suicide risk screening could place patients at risk for harming self.

During an interview on 8/9/2024 at 10:53 a.m. with DON, DON stated the nursing staff will perform the suicide risk screening for all patients upon admission and every shift. DON stated the screening was done to identify potential risks and maintain safety for patients. DON stated question number 2 of suicide screening must be answered because it was part of the suicide risk screening.

During a review of the facility ' s policy and procedure (P&P) titled, "Patients at Risk for Suicide," dated 7/2020, the P&P indicated, "it is the policy of [the facility] to provide a safe environment of patients who present with a primary diagnosis or an active complaint of an emotional or behavioral disorder ... the screen will determine ' at risk status ' and will assist with implementing appropriate levels of observation ... attachment: [name] suicide severity rating scale ... Ask questions 1 and 2. If both are negative, proceed to ' Suicidal Behavior ' section ... Question 1: Have you wished you were dead or wished you could go to sleep and not wake up? (answer yes or no) Question 2: Have you actually had any thoughts of killing yourself? (answer yes or no)"

During a review of the facility ' s policy and procedure (P&P) titled, "Assessment/ Re-assessment, Patient," dated 3/2019, the P&P indicated, "it is the policy of [the facility] to conduct comprehensive, multidisciplinary assessment on each individual admitted to the hospital ... patients on legal holds must have accurate documentation that reflect patients ' behavior. The documentation of the assessment and reassessment of patient behavior must be done every shift ...licensed nurse shift assessment is done every twelve (12) hours."

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

1. Ensure blood pressure medication was administered safely for one of 30 sampled patients (Patient 14) when Patient 14 was administered blood pressure medication without Patient 14 ' s blood pressure or pulse rate being evaluated or assessed. This deficient practice had the potential for Patient 14 to experience serious side effects of low blood pressure or heart rate such as confusion, dizziness, blurry vision, weakness, or fainting.

2. Ensure antibiotics (medications used to treat infection) were given in a timely manner for two of 30 sampled patients (Patients 16 and 18) in accordance with the physician ' s order (a doctor ' s instructions for care and treatment) and the facility ' s policy and procedure regarding medication administration, when:

2.a. Patient 16 ' s vibramycin (medication used to treat infection) and augmentin (medication used to treat infection) were not administered timely.

2.b. Patient 18 ' s gentamicin (medication used to treat infection) was not administered timely.

These deficient practices resulted in a delay in treatment and had the potential for the antibiotics to be ineffective.

Findings:

1. During a record review of Patient 14 ' s History and Physical (H&P), dated 7/27/24, the H&P indicated Patient 14 was admitted on 7/27/24 for Schizoaffective exacerbation (symptoms of delusions, hallucinations, disorganized speech and behavior) and had a past medical history of chronic obstructive pulmonary disease (COPD: lung disease causing restricted airflow and breathing problems), hyperlipidemia (high cholesterol), and hypertension (HTN: high blood pressure).

During a record review of Patient 14 ' s physician ' s order, dated 7/27/24, the physician ' s order indicated "Coreg (a high blood pressure medication) 6.25 MG TAB [medication to lower blood pressure and heart rate, milligram – unit of weight] ...Frequency 2 times a day ... Care Plan: HTN Hold if SBP [systolic blood pressure: pressure in the veins when the heart pumps] below 110 or HR [heart rate] below 60 ..."

During a concurrent interview and record review on 8/8/24 at 3:01 p.m., with the Utilization Review Case Manager (URMC), Patient 14 ' s "electronic Medication Administration Record Report (eMAR)," dated from 7/27/24 to 8/8/24, was reviewed. The eMAR indicated the following for Coreg 6.25 mg tablet:

On 7/28/24 for the 5:00 p.m. scheduled time - "Actual Time: 7/28/2024 17:22 [5:22 p.m.] ... Is Given: Yes," however, no comment of blood pressure or pulse rate evaluated at time of medication administration.

On 7/29/24 for the 7:00 a.m. scheduled time, "Actual Time: 7/29/2024 06:14 [6:14 a.m.] ... Is Given: Yes," however, no comment of blood pressure or pulse rate evaluated at time of medication administration.

On 7/31/24 for the 7:00 a.m. scheduled time, "Actual Time: 7/31/2024 06:06 [6:06 AM] ... Is Given: Yes," however, no comment of blood pressure or pulse rate evaluated at time of medication administration.

The URCM verified the eMAR indicated the blood pressure medication was documented as administered to Patient 14.

Upon a subsequent interview and record review on 8/8/24 at 3:11 p.m., with the URMC, Patient 14 ' s "Nursing Vital Signs (VS: measurements of the body ' s most basic function which includes heart rate, breathing rate, temperature, and blood pressure)," dated from 7/28/24 to 8/8/24, was reviewed. The VS indicated the following:

7/28/24 at 5 p.m., no VS taken during the medication scheduled or administrated time.

7/29/24 at 6:07 a.m. "Unable to Obtain Vital Signs Due To: Pt. [patient] Refusal."

7/31/24 at 6:09 a.m. "Comments: Patient refused vital signs."



The URCM stated there was no documentation on the VS or on the eMAR that Patient 14 ' s blood pressure or pulse rate was evaluated or assessed prior to the administration of the blood pressure medication. The URCM stated the blood pressure medication should not be administered if a patient ' s blood pressure was not assessed. The URCM further stated a patient ' s current blood pressure may already be low and administering a blood pressure medication may lower the patient ' s blood pressure to an unsafe level. The URCM also stated a patient ' s blood pressure may be elevated and required further interventions in addition to blood pressure medication administration to address the high blood pressure.

During an interview on 8/8/24, at 4:03 p.m., with the Behavioral Health Unit Clinical Manager (CM) 1, CM 1 stated the facility ' s expectation was for the licensed nurse to not administer blood pressure medication if the patient ' s blood pressure was not assessed or evaluated. CM 1 further stated the facility ' s expectation was for the nurse to notify the attending physician if a patient refused to have their blood pressure assessed for blood pressure medication administration and follow what the physician orders.

During a review of the facility ' s policy and procedure (P&P) titled "Medication Administration (Procedures & Timing of Administration)," revised date May 2024, the P&P indicated "E. Use of Professional Judgment: Staff are expected to use their professional in organizing and prioritizing patient care work-loads to assure that medications are delivered in a safe and timely manner. In exercising such judgment, staff must take into account the following: ... 5. Prioritization of additional activities that may be required for particular drugs, such as vital signs assessments ... to ensure safe and timely medication administration."


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2a. During a record review of Patient 16 ' s Face Sheet, the Face Sheet (a document that provides a patient's information at a quick glance) indicated Patient 16 was admitted to the facility on 8/2/2024 at 3:48 p.m.

During a record review of Patient 16 ' s "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 8/3/2024 at 10:47 a.m., the H&P indicated the following: Patient 16 was admitted to the facility with diagnoses of dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), complicated urinary tract infection (UTI, bacterial infection of the urinary tract [the kidneys, ureters, bladder, and urethra]), and multiple skin breakdowns with suspected infection consistent with cellulitis (deep infection of the skin caused by bacteria).

During a review of Patient 16 ' s physician ' s orders (a doctor ' s instructions for care and treatment), dated 8/3/2024 at 11:27 a.m., the order indicated to administer Vibramycin (medication used to treat infection) 100mg one tablet two times per day by mouth.

During a review of Patient 16 ' s physician ' s orders, dated 8/5/2024 at 10:11 p.m., the order indicated to administer Augmentin medication used to treat infection) 500/125 mg one tablet three times per day by mouth.

During a concurrent interview and record review on 8/7/2024 at 1:30 p.m. with the Nurse Manager 1 (NM 1), NM 1 verified Patient 16 had an order on 8/3/2024 for Vibramycin 100mg two times per day and an order for Augmentin 500/125mg three times per day. The NM 1 further verified the following doses Vibramycin and Augmentin were not administered to Patient 16 timely: Vibramycin 100mg tablet by mouth due at 9:00 p.m. was administered on 8/5/2024 at 10:00 p.m.; Vibramycin 100mg by mouth due at 9:00 p.m. was administered on 8/7/2024 at 10:24 p.m.; Vibramycin 100mg by mouth due at 9:00 a.m. was administered on 8/8/2024 at 10:05 a.m.; Augmentin 500/125mg tablet by mouth due at 8:00 a.m. was administered on 8/6/2024 at 8:49 a.m.; Augmentin 500/125mg tablet by mouth due at 12:30 p.m. was administered 8/6/2024 at 11:53 a.m.; Augmentin 500/125mg tablet by mouth due at 5:30 p.m. was administered on 8/6/2024 at 4:48 p.m.; Augmentin 500/125mg tablet by mouth due at 8:00 a.m. was administered on 8/7/2024 at 10:25 a.m.; Augmentin 500/125mg tablet by mouth due at 8:00 a.m. was administered 8/8/2024 10:09 a.m.; Augmentin 500/125mg tablet by mouth due at 5:30 p.m. was administered on 8/8/2024 at 4:43 p.m.;

During the same interview and record review on 8/7/2024 at 1:30 p.m. with the NM 1, the NM 1 stated the following: Patient 16 ' s antibiotics should have been given when due, within a 30-minute timeframe, and per the physician ' s order. It is important to give antibiotic on-time to ensure the dose is therapeutic since antibiotics (medications used to treat infection) are time sensitive. If given too early or too late, the antibiotics may not reach therapeutic levels to treat infections.

During a review of the facility's policy and procedure (P&P) titled, "Medication Administration (Procedures & Timing of Administration)," dated 5/2024, the P&P indicated the following: "Policy: ... 3. Time-Critical Scheduled Medications: These are medications for which an early or late administration of greater than 30 minutes might cause harm or have a significant, negative impact on the intended therapeutic or pharmacological effect. The following medications must be administered at the EXACT time indicated when necessary, otherwise within 30 minutes before or after their scheduled dosing time, for a total window of 1 hour: i. Antibiotics ... H. Drug Administration Procedures:.. 2. Verify the drugs to be administered with prescriber's order based on the 8 Rights of Safe Medication Practices ... v. Right Time."

2b. During a record review of Patient 18 ' s Face Sheet (a document that provides a patient's information at a quick glance), the Face Sheet indicated Patient 18 was admitted to the facility on 7/24/2024 at 8:12 p.m.

During a record review of Patient 18 ' s "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 7/25/2024 at 2:31 p.m., the H&P indicated the following: Patient 18 was admitted to the facility with diagnoses of extended spectrum beta-lactamase (ESBL, a strain of bacteria) urine, history of falls and hypotension (low blood pressure).

During a review of Patient 18 ' s physician ' s orders (a doctor ' s instructions for care and treatment), dated 8/1/2024 at 12:22 p.m., the order indicated to administer Gentamicin (medication used to treat infection) 80 mg one injection every 12 hours.

During a review of Patient 18 ' s physician ' s orders, dated 8/5/2024 at 7:53 p.m., the order indicated to administer Gentamicin 80 mg one injection every 12 hours.

During a concurrent interview and record review on 8/8/2024 at 10:41 a.m. with the Nurse Manager 1 (NM 1), NM 1 verified Patient 18 had an order on 8/1/2024 at 12:22 p.m. for Gentamicin 80mg every 12 hours, with a renewal order on 8/5/2024 at 7:53 a.m. The NM 1 further verified the following doses of Gentamicin were not administered to Patient 16 timely: Gentamicin 80mg intramuscular due at 9:00 p.m. was administered on 8/1/2024 at 8:11 p.m.; Gentamicin 80mg intramuscular due at 9:00 a.m. was administered on 8/4/2024 at 9:58 a.m.; Gentamicin 80mg intramuscular due at 9:00 p.m. was administered on 8/4/2024 at 8:08 p.m.; Gentamicin 80mg intramuscular due at 9:00 p.m. was administered on 8/5/2024 at 9:40 p.m.; Gentamicin 80mg intramuscular due at 9:00 a.m. was administered on 8/6/2024 at 11:16 a.m.; and Gentamicin 80mg intramuscular due at 9:00 a.m. was administered on 8/7/2024 at 10:10 a.m.

During the same interview and record review on 8/8/2024 at 10:41 p.m. with the NM 1, the NM 1 stated the following: Patient 18 ' s Gentamicin should have been given when due, within a 30-minute timeframe, and per the physician ' s order. It is important to give Gentamicin on-time to ensure the dose is therapeutic since Gentamicin is time sensitive. If Gentamicin is given too early or too late, it may not reach therapeutic levels to treat infection.

During a review of the facility's policy and procedure (P&P) titled, "Medication Administration (Procedures & Timing of Administration)," dated 5/2024, the P&P indicated the following: "Policy: ... 3. Time-Critical Scheduled Medications: These are medications for which an early or late administration of greater than 30 minutes might cause harm or have a significant, negative impact on the intended therapeutic or pharmacological effect. The following medications must be administered at the EXACT time indicated when necessary, otherwise within 30 minutes before or after their scheduled dosing time, for a total window of 1 hour: i. Antibiotics ... H. Drug Administration Procedures: ... 2. Verify the drugs to be administered with prescriber's order based on the 8 Rights of Safe Medication Practices ... v. Right Time ..."

Based on observation, interview, and record review, the facility failed to ensure medical records were complete and accurate for two of 30 sample patients (Patient ' s 1 and 2). Patient 1 ' s vital signs were not documented in the medical record. Patient 2 ' s gender and height were inaccurate. This deficient had the potential to affect treatment plans and the inability to detect changes in the patient 1 ' s condition.

Findings:

During a review of Patient 1 ' s Face sheet, indicated Patient 1 was admitted to the facility on 7/6/2024 for severe psychosis (a mental disorder characterized by a disconnection from reality).

During a review of Patient 1 ' s nursing "Progress Note," dated 7/12/2024 at 5:51 p.m., indicated the following. Patient (1) struck on back of head by peer unprovoked, no bleeding noted, no LOC (loss of consciousness, or change in patient ' s awareness) ...Vital signs (blood pressure, heart rate, respiratory rate, temperature) WNL (within normal limits) ...

During a review of Patient 1 ' s "Vital Signs Flowsheet," dated 7/12/2024, no vital signs were documented correlating with the Progress Notes dated 7/12/2024 at 5:51 p.m., regarding vital signs WNL.

During a concurrent interview and record review, on 8/7/2024 at 11:37 a.m., with the Utilization Review Case Manager (URCM), the URCM stated the following. URCM verified there were no vital signs documented in the flowsheets that correlated with the Progress Notes dated 7/12/2024 at 5:51 p.m. The URCM stated vital signs should be documented to identify changes in patient ' s condition.

During a review of the facility ' s policy and procedure titled, "Vital Signs," dated 3/19/2019, the P&P indicated vital signs shall be recorded in the EMR (Electronic medical record) under the Vital signs ' flowsheet.

During a tour of the East Unit on 8/7/2024 at 8:41 a.m., Patient 2 was observed in his room, lying on the bed, calm, awake and alert. Patient 2 was a male and approximately 6 feet tall.

During a review of Patient 2 ' s H&P (H&P, a formal and complete assessment of the patient and the problem), dated 6/5/2024 at 12:15 p.m., the H&P indicated Patient 2 was a female ...who was displaying aggressive behavior and repeatedly assaulting staff ...She conveyed no complaints during my encounter ...

During a review of Patient 2 ' s "Admission Assessment," dated 6/4/2024 at 5:20 p.m., the Admission Assessment indicated Patient 2 ' s height was 60 inches (152 cm or 5 feet).

During a concurrent interview and record review on 8/8/2024 at 11:30 a.m., with Clinical Manager (CM) 1 and the Administrator (ADM) of the Behavior Health (BH), CM 1 and the ADM verified the "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 6/5/2024, was inaccurate because it indicated Patient 2 was a female, when in fact, Patient 2 is a male. In addition, CM 1 and the ADM verified that Patient 2 ' s nursing "Admission Assessment," dated 6/4/2024 indicated Patient 2 was 60 inches tall (5 feet). The ADM and CM 1 stated that Patient 2 was approximately 6 feet tall. The ADM and CM 1 stated that medical records should be accurate.

During a review of the facility ' s policy and procedure (H&P) titled, "History and Physical," dated 9/2022, the P&P indicated the following. The History and Physical ... should contain adequate information to support the diagnosis and treatment plans. This information should be comprehensive enough to inform a surgeon, consultant, or other practitioner of all the precautions to be taken during treatment. The Medical History include the following criteria at minimum: including, Patient ' s Sex ...

During a review of the facility ' s policy and procedure (H&P) titled, "Chart Completion," dated 9/2022, the P&P indicated the following...The process utilized for calculating/counting incomplete medical records and determining delinquent status must comply with all applicable federal, state, accrediting agency ...The Health Information Services Director/Manager is responsible for overseeing the accuracy and completeness of these processes.

Based on observation, interview and record review, the facility failed to ensure its staff to adhere to the facility ' s infection control program in accordance to its policy and procedure when:

Two staff members (Mental Health Worker [MHW 1] and Certified Nursing Assistant [CNA 1]) did not perform hand hygiene when entering patient rooms, before and after patient care;

There were 2 bottle of body wash, a wash cloth in the bathroom and a open box of facial tissue on top the bedside cabinet and a piece of dried food left in the bedside table tray in one unoccupied patient room;

One CNA (CNA 2) did not wear personal protective equipment (PPE, worn to prevent or minimize exposure to hazards) when entering a contact isolation room; and

Six staff not N95 respirator (N95, respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) fit tested upon hired and annually.

This deficient practice had the potential to result in putting patients and staff at risk for transmissions of infections within the facility.

Findings:

During a concurrent observation and interview on 8/6/2024 at 1:36 p.m. with the Mental Health Worker (MHW 1) in a patient ' s (Patient 25 ' s) room, MHW 1 walked into Patient 25 ' s room holding a heating pad, MHW 1 put gloves on before applying heating pad to Patient 25 ' s abdomen then took off the gloves and threw the gloves into the trash can. MHW 1 stated she (MHW 1) did not perform hand hygiene (a term used to cover both hand washing using soap and water, and cleaning hands with waterless or alcohol-based hand sanitizers) before and after touching Patient 25. MHW 1 stated wearing gloves could not replace performing hand hygiene.

During an interview on 8/6/2024 at 1:43 p.m. with the Director of Nursing (DON), DON stated the expectation was for staff to perform hand hygiene before entering patient ' s room, before and after touching patient to prevent spread of infection.

During a concurrent observation and interview on 8/6/2024 at 1:47 p.m. with the Certified Nursing Assistant (CNA 1) in a patient ' s (Patient 26 ' s) room, CNA 1 walked into Patient 26 ' s room and walked out of Patient 26 ' s room without performing hand hygiene. CNA 1 stated, "I should ' Gel in and gel out (applying alcohol-based hand sanitizer when entering and leaving patient ' s room) ' but I did not do it."

During an interview on 8/9/2024 at 11:42 a.m. with the Director of Infection Control (IC 1), IC 1 stated the following: all staff needed to perform hand hygiene because dirty hands can transmit disease. Hand hygiene is priority. Staff needed to perform hand hygiene before and after contacting patients, before applying gloves and after removing gloves.

During a review of the facility ' s policy and procedure (P&P) titled, "Hand Hygiene," dated 11/2022, the P&P indicated, "effective hand hygiene in order to prevent transmission of bacteria, germs and infections ... the purpose of hand hygiene is to remove dirt, organic materials, and transient microorganisms from the hands and wrists and to prevent the transfer of organisms to other people. Hand hygiene is the single most effective methods of preventing spread of infectious microorganisms ... All personnel will use the hand-hygiene techniques ... hands must be cased for by hand washing with soap and water or by hand antisepsis with alcohol based hand rubs ...before and after patient contact ... before applying gloves ...after removing gloves."

During a concurrent observation and interview on 8/6/2024 at 2:10 p.m. with the Director of Nursing (DON) in an unoccupied patient room (RM 1), there were 2 bottle of body wash, a wash cloth in the bathroom and a open box of facial tissue on top the bedside cabinet. DON stated the following: those items should not be in an unoccupied patient room. There was a patient in RM 1 but was discharged yesterday (8/5/2024). RM 1 was unoccupied since then. Environmental Services (EVS) Staff was responsible for cleaning the patients room after patient was discharged.

During a concurrent observation and interview on 8/6/2024 at 2:24 p.m. with the EVS staff (EVS 1) in RM 1, there were a piece of dried food left in the bedside table tray. EVS 1 stated the bedside table tray was dirty. EVS 1 stated the EVS staff was responsible for cleaning the bedside table tray from last night (8/5/2024) after the patient was discharged.

During an interview on 8/9/2024 at 9:40 a.m. with the EVS supervisor (EVSS), EVSS stated the following: EVS staff was responsible to clean and disinfect the room after patient was discharged. There should not be any body wash bottles, and wash cloth left in the bathroom. All used items should be thrown away. The EVS staff should also clean and disinfect the bedside table tray. There should be no piece of food left in the bedside table tray.

During a review of the facility ' s policy and procedure (P&P) titled, "Environmental Decontamination and Terminal Cleaning," dated 11/2022, the P&P indicated, "the Environmental Services Department has the responsibility for the reduction of the level of microorganisms in the hospital environment and to ensure the infectious agents do not become disseminated, so as to provide a safe environment for all who enter it, be they patients, employees and visitors ... terminal cleaning ... the thorough cleaning of a patient room following discharge to remove germs ...remove soiled linen ...discard open facial tissue boxes ...clean and wipes down all tables, nightstands and rolling tables."

During a concurrent observation and interview on 8/6/2024 at 3:11 p.m. with Certified Nursing Assistant (CNA 2) at a patient ' s (Patient 27 ' s) room, there was a sign indicating "Contact Precaution" outside Patient 27 ' s room and CNA 2 walked into Patient 27 ' s without any personal protective equipment (PPE, worn to prevent or minimize exposure to hazards). CNA 2 stated, "I have to put on PPE when entering isolation room but I did not."

During a concurrent interview and record review on 8/8/2024 at 11:05 a.m. with registered nurse (RN 1), Patient 27 ' s "physician order (orders written by physicians to direct care and treatment)," dated 8/3/2024 was reviewed. The physician order indicated contact isolation. RN 1 stated contact isolation is a type of transmission-based precaution in which staff should wear PPE including gloves and gown upon entering Patient 27 ' s room to prevent transmission of disease.

During a concurrent interview and record review on 8/9/2024 at 10:59 a.m. with the Director of Nursing (DON), the facility ' s "Contact Precaution" sign, undated, was reviewed. The sign indicated, "wear gloves and gown when entering room." DON stated the expectation was for all staff to follow facility ' s transmission-based precaution protocol. DON stated the staff needed to follow the isolation sign posted outside patient room and to wear proper PPE including wearing gloves and gown when entering room to prevent spread of infection.

During a review of the facility ' s policy and procedure (P&P) titled, "Isolation Precaution," dated 11/2022, the P&P indicated, "contact precautions are intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the patient or the patient ' s environment ... Healthcare personnel caring for patient on contact precaution wear a gown and gloves for all interactions that may involve with the patient or potentially contaminated areas in the patient ' s environment."

During a concurrent interview and record review on 8/8/2024 at 2:47 p.m. with the Human Resources Coordinator (HRC), Certified Nursing Assistant (CNA) 3 ' s personnel file was reviewed. The personnel file indicated, CNA 3 ' s hire date of 5/29/2024 and there was no N95 respirator (N95, respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) fit test document in CNA 3 ' s personnel file. HRC stated the following: the N95 respirator fit test was not done upon hired. N95 respirator fit test was done by cardiopulmonary department. Human Resource department did not keep record for employees N95 respirator fit test record.

During a concurrent interview and record review on 8/8/2024 at 3:03 p.m. with HRC, the personnel files for charge nurse (CN 1), registered nurse (RN 2), licensed vocation nurse (LVN 1), and mental health worker (MHW 1 and MHW 2) were reviewed. The personnel files indicated the followings:

CN 1 date of hire: 3/5/2019 with no N95 respirator fit test record

RN 2 date of hire: 3/29/2021 with no N95 respirator fit test record

LVN 1 date of hire: 11/5/2023 with no N95 respirator fit test record

MHW 1 date of hire: 8/2/2023 with no N95 respirator fit test record

MHW 2 date of hire: 7/14/2022 with no N95 respirator fit test record

HRC stated Human Resource department did not have all employees N95 respirator fit test record.

During an interview on 8/8/2024 at 4:13 p.m. with the Director of Quality and Risk Management (DQRM), DQRM stated there was no system in place at this moment to keep track which employee was N95 respirator fit tested.

During an interview on 8/9/2024 at 10:17 a.m. with the Cardiopulmonary Supervisor (CPS), CPS stated the following: N95 respirator fit test was required for employees so that they could wear N95 respirator properly when taking care of airborne precaution (prevent transmission of infectious agents that remain infectious over long distances when suspended in the air) patients to prevent getting sick and spread of infections. Cardiopulmonary department did not keep a log to keep track which employee had received N95 respirator fit test and when N95 respirator fit test was done. CPS stated, "as of this time, we cannot tell which staff is N95 respirator fit tested and who is due for fit test."

During an interview on 8/9/2024 at 11:27 a.m. with the Director of Infection Control (IC 1), IC 1 stated Cardiopulmonary Department and Human Resources Department were responsible for performing and keeping records of N95 respirator fit test for employees. IC 1 stated there was policy and procedure in placed for the facility to follow. IC 1 stated N95 respirator fit test was required for registered nurses, licensed vocational nurses, certified nursing assistants, mental health workers, respiratory therapists, laboratory technicians and housekeeping staff upon hired and annually.

During a review of the facility ' s policy and procedure (P&P) titled, "Tuberculosis [TB, a serious illness that mainly affects the lungs. It can spread when a person with the illness coughs or sneezes to put tiny droplets with the germs into the air] Exposure Plan," dated 11/2022, the P&P indicated, "[the facility] is committed to maintaining an injury and illness free workplace and is making every efforts to protect patients, visitors and employees from tuberculosis, and other aerosol transmissible disease ... proper fit of N95 respirators is essential ... all fit testing will be performed by qualified individuals who have been appropriately trained. All personnel using respirators must be fit tested prior to use. Personnel in the following departments will also be fit tested on annual basis: medical surgical (general patient population hospitalized for various causes such as illness and surgery), surgery, housekeeping ..."