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Based on observations, record reviews, and interviews, the hospital failed to ensure the requirements of the Condition of Participation of Patient Rights were met as evidenced by failing to ensure suicidal patients with physician orders for LOS on 3 separate units were observed as ordered for 2 (#7, #8) of 2 current inpatients with physician orders for LOS from a sample of 8 patients and 3 (R2, R4, R5) of 4 (R2, R3, R4, R5) random inpatients with physician orders for LOS from a sample of 5 random patients. Observations were made on 04/15/19 at 10:30 a.m. on Unit 4000 (#8), on 04/16/19 from 10:10 a.m. to 11:35 a.m. on Unit 4000 (#7), on 04/16/19 at 1:35 p.m. on Unit 1000 (R4), and on 04/16/19 at 1:55 p.m. on Unit 3000 (R2, R5) (see findings in tag A0144).
Findings:

An Immediate Jeopardy situation was identified on 04/16/19 at 3:50 p.m. and reported to S1Adm. The Immediate Crisis was that suicidal patients with physician orders for LOS observation (defined as the patient being in visual range of assigned staff at all times and during times of toileting, the staff should be in visual and hearing range of the slightly opened bathroom door) on 3 separate units were not observed as ordered. At the time of the observation, there were 5 suicidal patients with LOS observation orders.

On 04/17/19 at 11:40 a.m. S1Adm presented the first plan for lifting the immediacy of the Immediate Jeopardy situation, and the plan included the following:
1) Beginning at 6:00 p.m. on 04/16/19 training was completed with all direct care staff on the current day shift and continued into the night shift with signed attestation by each employee indicating that education had been received and the LOS policy had been reviewed. Each unit was met with individually and would continue with the arrival of the day shift on 04/17/19 with signed attestation after the training. Staff will not return to work any unit until training and signed attestation was complete.
2) Staffing Coordinator, CNO, House Supervisors, and charge nurses will ensure that one staff is assigned specifically to each patient on LOS monitoring. Should there arise a staffing issue that would prevent proper monitoring, the charge nurse will immediately notify the Staffing Coordinator, CNO, and/or House Supervisor to obtain correct staffing. Staffing Coordinator, MHT Supervisor, House Supervisor, and CNO will provide direct care duties (LOS or other) as needed until additional staff can be called in. Effective 04/17/19 all assigned LOS will be clearly indicated on the daily schedules and assignment sheets, and a clean copy of the assignment sheet will be rebuilt by the end of the day on 04/18/19.
3) Edited Leadership and Supervisor Observation Rounds to include specific monitoring of LOS and additional immediate action for non-compliance. Increasing frequency of rounds, going from once per shift to 3 times per shift. Leadership will complete three rounds per day shift Monday through Friday, House Supervisors will complete rounds three times per shift on evening and weekends. Two rounds per shift will focus exclusively on observation checks, one-to-one, and LOS compliance.
4) Round sheets to be turned in daily to Risk Manager (to Administrator while the Risk Manager position is vacant) who will double check and follow-up on any "no" answers.
5) Multiple monitors will be implemented for Rounding and reported as PI data including compliance with number of rounds completed, number of "no" answers checked for the question "Is the staff member conducting LOS monitoring in visual range of the patient at all times and only monitoring one patient?", and appropriate actions taken for "no" answers.
6) Current policy requires an assessment of the LOS in the shift nursing notes two times per day. Implement monitor for number/percentage of nursing notes that assess patient LOS status and report as monthly PI data. CNO or designee will monitor 100% of nursing progress notes for patients on LOS.
The "Daily Staffing Sheet", "Leadership Rounds" checklist, "Educational Attendance Roster", and "Line of Sight Training Attestation" for each employee who had received education thus far were submitted for review by the surveyors.

In an interview on 04/17/19 at 11:57 a.m., the surveyors informed S1Adm that the plan of removal was not accepted due to the following reasons:
1) The daily shift assignment sheet needed to be addressed as having the list of patients assigned to each nurse and MHT;
2) Leadership needs to be defined as to the specific leader title;
3) Round sheets reviews need to include the time frame that they will be monitored; and
4) Monitoring (number 5 and 6 listed above in the plan) needed to have the timeframe for monitoring.

S1Adm presented the revised second plan of removal on 04/17/19 at 1:50 p.m. with the following revisions:
1) No revisions made or required.
2) Revised to add that effective 04/17/19 all assigned LOS will be clearly indicated on the assignment sheets including the staff responsible. The assignment sheet will also indicate which staff are responsible for monitoring all other patients. Daily schedules will indicated which staff are assigned to LOS and will not include patient information.
3) Revised to add that current leadership rounding calendar will be followed and includes the CEO, CFO, DON, DCS, HRD, Director of Recreational Therapy, Director of Plant Operations, Director of Business Development, and HIM Director. Observation rounds are a permanent process, however the increased frequency of rounds will continue for at least 3 months or until compliance can be demonstrated.
4) No revisions made or required.
5) Revised to add that data will be reported daily Monday through Friday in flash meeting with reporting of weekend performance in Monday's meeting. Daily reporting will continue for at least 3 months and until compliance can be demonstrated. Once compliance is demonstrated, data reporting will continue as a permanent monthly monitor.
6) revised to add that data will be reported daily Monday through Friday in flash meeting with reporting of weekend performance in Monday's meeting. Daily reporting will continue for at least 3 months and until compliance can be demonstrated. Once compliance is demonstrated, data reporting will continue as a permanent monthly monitor.

In an interview on 04/17/19 at 1:50 p.m., the surveyors informed S1Adm that the second plan of removal was not accepted due to monitoring addressed in numbers 5 and 6 not having compliance defined, such as a percentage or measure.

S1Adm presented the third plan of removal on 04/17/19 at 3:42 p.m. with the following revisions to numbers 5 and 6:
5) Revised to add that daily reporting will continue for at least 3 months and until 100% compliance can be consistently demonstrated. Once 100% compliance is demonstrated, data reporting will continue as a permanent monthly monitor.
6) Revised to add that daily reporting will continue for at least 3 months and until 100% compliance can be consistently demonstrated. Once 100% compliance is demonstrated, data reporting will continue as a permanent monthly monitor.

Observations were conducted on 04/17/19 at 3:40 p.m. on Unit 1000. Patients R3 and R4 were no longer ordered to be on LOS. S37RN indicated the patients were all currently on Q 15 minute observation. 12 patients were observed in the television room watching a science fiction movie, and 2 patients were observed walking the halls. All patient observation sheets were reviewed and were all current.

In an interview on 04/17/19 at 3:45 p.m., S37RN confirmed she had received training regarding LOS Patient Supervision and a refresher on hospital policies regarding levels of observation and staff supervision according to orders by the physician. She indicated she had to sign an attestation verifying she had received the referenced training. She reported LOS was essentially like patients being on 1:1 Supervision, except the patient did not have to be within arm's reach, but had to be within the assigned staff member's direct line of sight, including when the patient went to the bathroom. She reported the patient had to be handed off if the MHT assigned had a break or otherwise was unable to observe the patient LOS, and whomever took over the patient had to observe that patient only and could not perform any other tasks.

In an interview on 04/17/19 at 3:50 p.m.. S36LPN confirmed she had received training regarding Line of Sight Patient Supervision and a refresher on hospital policies regarding levels of observation and staff supervision according to orders by the physician. She reported LOS was having the patient in her direct line of sight, like a 1:1, but not having to have the patient within arm's reach, but had to be within the assigned staff member's direct line of sight at all times, including when the patient went to the bathroom. She reported the patient had to be handed off if the MHT assigned had a break or otherwise was unable to observe the patient LOS, and whomever took over the patient had to observe that patient only and could not perform any other tasks. She confirmed she had to fill out an attestation indicating she had received education regarding patient levels of observation and Line of Sight.

In an interview on 04/17/19 at 4:37 p.m., S35MHT confirmed she had received training regarding Line of Sight Patient Supervision and a refresher on hospital policies regarding levels of observation and staff supervision according to orders by the physician. She reported LOS was having the patient in her direct line of sight, like a 1:1, but not having to have the patient within arm's reach, but had to be within the assigned staff member's direct line of sight at all times, including when the patient went to the bathroom. She reported the patient had to be handed off if the MHT assigned was unable to observe the patient LOS. She reported the patient's observation sheets had to be handed off directly to the staff who took over the patient, and the MHT could not perform any other tasks. She confirmed she had to fill out an attestation indicating she had received education regarding patient levels of observation and Line of Sight.

Observation on 04/17/19 at 4:05 p.m. on Unit 3000 revealed S40MHT was seated inside the open doorway to Room "b" observing Patient R5 who was lying in bed and was ordered to be on LOS. S40MHT indicated when Patient R5 goes to the bathroom, he (S40MHT) lowers the bathroom door that was attached by Velcro to a position that allows him (S40MHT) to be able to visualize Patient R5 while he's in the bathroom. He indicated he had received education on the LOS policy before he started his shift this day by his supervisor. He indicated LOS meant he had to keep the patient on LOS in his eyesight at all times.

In an interview on 04/17/19 at 4:10 p.m., S41LPN showed the surveyor the physician order for LOS for Patient R5 that was received on 04/16/19 at 3:14 a.m. She indicated she had received education on LOS by S2CNO this day before starting her shift. She indicated LOS meant the assigned staff had to keep the patient ordered to be on LOS within their eyesight at all times.

In an interview on 04/17/19 at 5:48 p.m., S1Adm was informed that the Immediate Jeopardy Plan of Removal was accepted. He was informed that, since there was not enough evidence to determine sustainability of the plan, the Condition of Participation of Patient Rights would remain at the condition level.

Based on record review and interviews, the hospital failed to ensure each patient/patient's representative who filed a grievance was provided a written notice of the hospital's decision regarding the resolution of the grievance for 1 (#2) of 1 grievance reviewed.

Findings:

Review of the hospital's policy titled"Grievance, Patient", revealed in part: All patient grievances will be investigated and the results of the investigation reported back to the complainant.
Definition: A patient grievance is a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient's representative, regarding patient care (when the complaint is not resolved at the time of the complaint, by staff present).
If a patient's complaint cannot be resolved at the time of the complaint, by staff present, is postponed for later resolution, is referred to other staff for later resolution, requires investigation, and/or further actions for resolution, then the complaint is a grievance for purposes of these requirements.
Procedure: 4. Director/Manager will investigate the grievance within 2 days, including, but not limited to: Patient interview; Witness interview; Staff interview; Chart review; and Communication with Directors/Managers. 5. The patient advocate will mail a written report (by certified mail) if the complainant is not the patient or the patient has been discharged.

Review of the hospital's complaints and grievances for 01/2019 - 04/2019 revealed no documented evidence of a grievance involving Patient #2.

In an interview on 04/15/19 at 12:23 p.m. with S2CNO, she reported she had spoken with Patient #2 and the patient's son because of concerns they had expressed regarding other patients coming into the patient's room at night. She further reported Patient #2's son had called their affiliate hospital and had complained that his mother had reported men had come into her room and had gotten into her bed. S2CNO confirmed she had questioned all of the nurses and MHTs on the unit and they reported they had seen other female patients going in and out of Patient #2's room, requiring redirection of those patients on the Geri-Psychiatric Unit. S2CNO indicated when she had spoken to staff on the Geri-Psychiatric Unit they reported there were no men going into the patient's room.

In an interview on 04/17/19 at 8:06 a.m. with Patient #2, she reported she had provided written notes to S2CNO regarding other patients coming into her room while she was hospitalized, as well as other concerns related to her care. Patient #2 reported S2CNO had told her she had received a complaint and had talked to her regarding her concerns. Patient #2 reported she had not received a written notice regarding the hospital's investigation into her grievance and resolution of the grievance. Patient #2 also indicated her son had not received written notice either.

In an interview on 4/17/19 at 3:01 p.m. with S31MD, he reported Patient #2 had told him a couple of demented patients had come into her room at night, but she had not seemed too distraught about it.

In an interview on 4/17/19 at 5:17 p.m. with S2CNO, she confirmed Patient #2's complaint had not been logged as a grievance. S2CNO further confirmed Patient #2 and her son had not been sent a written notice of the hospital's decision regarding resolution of the patient's grievance.

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

1) Failing to ensure suicidal patients with physician orders for LOS on 3 separate units were observed as ordered for 2 (#7, #8) of 2 current inpatients with physician orders for LOS from a sample of 8 patients and 3 (R2, R4, R5) of 4 (R2, R3, R4, R5) random inpatients with physician orders for LOS from a sample of 5 random patients. Observations were made on 04/15/19 at 10:30 a.m. on Unit 4000 (#8), on 04/16/19 from 10:10 a.m. to 11:35 a.m. on Unit 4000 (#7), on 04/16/19 at 1:35 p.m. on Unit 1000 (R4), and on 04/16/19 at 1:55 p.m. on Unit 3000 (R2, R5).

2) Failing to ensure a patient with physician orders for Q 15 minutes observation was observed as ordered for 1 (R1) of 6 (#7, #8, R1, R2, R4, R5) patients observed for implementation of physician observation orders from a sample of 8 patients and 5 random patients. Patient R1, who was observed to be asleep in his bed and had physician orders to be observed Q 15 minutes, was not observed on 04/16/19 for 30 minutes from 10:15 a.m. to 10:45 a.m.

3) Failing to ensure staff did not allow patients to enter other patients rooms without their permission for 1(#2) of 1 sampled patient record reviewed for complaints of patients being allowed to enter their rooms without permission from a total patient sample of 8 patients.

Findings:

1) Failing to ensure suicidal patients with physician orders for LOS on 3 separate units were observed as ordered:

An observation made on 04/15/19 from 10:25 a.m. to 10:45 a.m., during a tour of Unit 4000, revealed at 10:30 a.m. Patient #8 was in his room lying on his bed. Further observation revealed Patient #8 was alone in his room, and no other staff were near the patient's room towards the end of the hallway. In an interview 04/5/19 at 10:33 a.m. in the nursing station, with S16RN and S13LPN present, S23MHT verified that Patient #8 was supposed to be on "Line of Sight" observation precautions and he was assigned to monitor Patient #8. He reported he was "watching the whole unit because other MHTs were with patients outside and we are short-staffed."

Continuous observation on Unit 4000 on 04/16/19 from 10:10 a.m. to 11:35 a.m. revealed at 11:30 a.m. S29MHT unlocked the hall entrance door to the seclusion room and allowed Patient #7 to enter the ante area, unlocked the bathroom door, allowed Patient #7 to enter the bathroom, closed the bathroom door, exited the ante area, returned to the hall outside the seclusion entrance door, and locked the seclusion entrance door. S29MHT stood outside the seclusion entrance door in the hall for 3 minutes while Patient #7 was in the bathroom. Continuous observation revealed Patient #7 was not visible when standing in the hall outside the seclusion entrance door, and no sound could be heard from inside the bathroom. At 11:33 a.m. S29MHT unlocked the seclusion entrance door, walked into the ante area to the bathroom door, asked Patient #7 if she was alright, and Patient #7 exited the bathroom. There was no observation of Patient #7 being in LOS of any staff member while in the bathroom for 3 minutes.

An observation was made on 04/16/19 at 1:35 p.m. of Patient R4 lying on his bed in his room. No one else was observed in the room, or in the doorway. In an interview 04/16/19 at 1:38 p.m., S18MHT reported he was assigned to monitor Patient R4, but he had gone to look at the other patients and then was going to go back to Patient R4's room to watch him. He verified Patient R4 was LOS for suicide risk. S1Adm, present for the observation, verified the findings.

An observation made on 04/16/19 from 1:50 p.m. to 1:55 p.m. on Unit 3000 revealed an interview in progress at the nurses station with S19RN and S20LPN, no MHTs were observed in the 2 hallways of the unit, and 1 MHT was in the activity room and out the door as patients were outside. Patient R2 was observed walking up and down one of the hallways. At 1:55 p.m. S19RN and S20LPN were asked if any patients were on LOS observation level, and they answered Patients R2 and R5 were on LOS. When asked where these patients were at that time, the nurses had to look around, identified Patient R2 as walking at the end of the hallway, and said R5 might be in his room. Further observation, accompanied by S1Adm, revealed R5 was alone in his room with no staff within LOS of the patient. S19RN reported that S22MHT was on break, but could not say how long he had been off the unit, or how long Patients R2 and R5 had been without constant LOS observation. The observation was verified by S1Adm who was present for the observation.

Review of the policy titled "Observations, Patient", presented as a current policy by S1Adm, revealed the three levels of observation were 15 minute, LOS, and one-to-one. Further review revealed a patient was placed on LOS if their behavior was unpredictable, and there was a potential risk for harm to self and others, yet behavior was not at the point requiring constant one-to-one observation. The patient was to be kept in visual range of assigned staff at all times. During times of personal hygiene, toileting, and other self-care needs, staff should be in visual and hearing range of the slightly opened bathroom door. The Interdisciplinary Treatment Plan will include or be revised to include LOS observation.

Review of the March 2019 Nursing Meeting Agenda, presented by S2CNO, revealed the following: "Remember to time and date all documentation correctly. Night nurses make sure that there is an observation sheet for each patient present on the unit. Make sure all sheets have appropriate observation level checked off at the top of each sheet... Nurses are to required to round on all patients and initial the observation sheet every two hours."

Patient #7
Review of Patient #7's medical record revealed she was admitted on 04/13/19 with diagnoses of Mood Disorders and Bipolar Disorder, most recent episode manic, severe with psychotic features. Further review revealed a physician order by S31MD on 04/13/19 at 10:47 p.m. for LOS.

Review of Patient #7's "Interdisciplinary Treatment Plan" revealed no documented evidence that the ordered LOS observation was included.

Patient #8
Review of Patient #8's medical record revealed he was admitted 04/15/19 for Suicidal Ideations. Further review revealed a physician order 04/15/19 at 1:37 a.m. for LOS observation. Further review revealed a physician's order on 04/15/19 at 11:00 a.m. to change Patient #8's observation status to every 15 minutes, after the observation had been made of Patient #8 not being maintained on LOS at 10:30 a.m.

Patient R2
Review of the medical record for Patient R2 revealed he was admitted 04/2/19 with suicidal ideation and Schizoaffective Disorder, depressed type. Further review revealed a physician's order dated 04/16/19 at 2:33 p.m. to discontinue LOS observation and change to every 15 minute observation, 30 minutes after Patient R2 was observed with no LOS observation and staff reporting that the patient was on LOS observation.

Patient R4
Review of the medical record for Patient R4 revealed he was admitted 04/15/19 for Suicidal Ideation. Further review revealed a physician's order for LOS Observation dated 04/16/19 at 7:30 a.m.

Patient R5
Review of the medical record for Patient R5 revealed he was admitted 04/16/19 at 12:08 a.m. due to suicidal ideation and suicide attempt. Further review of the medical record revealed a physician's order for LOS observation dated 04/16/19 at 3:14 a.m.

Review of S29MHT's personnel file revealed she was hired on 04/01/19. Review of her "MHT Clinical Skills Competency Checklist" revealed competency in patient safety that included observation levels (routine, LPS, one-to-one), patient rounds documentation, precautions (suicide, seizure, choking, cheeking, fall, elopement), safety rounds every shift / contraband rounds, hand-off communication, and toileting were evaluated by "verbalized understanding" and not by "direct observation" on 04/04/19.

In an interview on 04/16/19 at 11:34 a.m., S29MHT indicated Patient #7 was on LOS which meant she needed to be kept in her (S29MHT) eyesight at all times. S29MHT confirmed Patient #7 was not in her eyesight or hearing range when she (Patient #7) was in the bathroom. S29MHT confirmed she was supposed to keep Patient #7 in her eyesight and within hearing range while Patient #7 was in the bathroom.

In an interview on 04/17/19 at 5:10 p.m., S2CNO indicated the treatment plan should reflect the increase in observation when a patient was placed on LOS. She confirmed the MHT's competency should be evaluated by a return demonstration and not just a verbal understanding.

2) Failing to ensure a patient with physician orders for Q 15 minutes observation was observed as ordered:
Continuous observation from on 04/16/19 from 10:00 a.m. to 11:35 a.m. on Unit 4000 revealed at 10:10 a.m. S6AC was conducting a recreational group in the Noisy Activity Room with 17 patients in attendance. Patient R1 was not observed to be in the room during the observation from 10:10 a.m. to 10:40 a.m. At 11:15 a.m. Patient R1 was observed to be asleep in his bed in Room "a".

Review of Patient R1's medical record revealed he was admitted on 04/16/19 at 1:43 a.m. with a diagnosis of Schizophrenia. Further review revealed an order on 04/16/19 at 1:43 a.m. from S27MD for Q 15 minutes psychiatric observation.

In an interview on 04/16/19 at 11:00 a.m., S30MHT indicated she was assigned to observe Patient #7 who was on LOS and 5 other patients on Q 15 minute observation. When asked how she observes 5 other patients while she's observing a patient on LOS, S30MHT indicated she has to keep the other patients (those on Q 15 minute observation) out their room. She indicated she was assigned to observe Patient R1 who did not attend group and was in his room. When the surveyor reviewed S30MHT's observation record for Patient R1 at 11:00 a.m., it was noted that S30MHT had documented her observation of Patient R1 in his room at 10:15 a.m., 10:30 a.m., and 10:45 a.m. When S30MHT was informed by the surveyor that she (S30MHT) was observed in the group room from 10:10 a.m. until she left the room at approximately 10:40 a.m., S30MHT indicated S28MHT had made the observations of Patient R1 at 10:15 a.m., 10:30 a.m., and 10:45 a.m., but since he (S28MHT) was in orientation, he wasn't allowed to document on the observation record.

In an interview on 04/16/19 at 11:05 a.m., S28MHT indicated he didn't go into any patient room to make observations and was only observing Patient #7 who was on LOS and was in the hall. When asked specifically if he had made an observation of Patient R1 in his room at 10:15 a.m., 10:30 a.m., and 10:45 a.m., S28MHT confirmed he did not go in Patient R1's room to make any observations.

3) Failing to ensure staff did not allow patients to enter other patients rooms without their permission:
Review of Patient #2's medical record revealed an admission date of 03/12/19 with admission diagnoses of suicidal ideation and effects of combination of Wellbutrin and alcohol. Patient #2 was discharged on 03/14/19.

In an interview on 04/15/19 at 12:23 p.m. with S2CNO, she reported she had spoken with Patient #2 and the patient's son because of concerns they had expressed regarding other patients coming into the patient's room at night. She further reported Patient #2's son had called their affiliate hospital and had complained that his mother had reported men had come into her room and had gotten into her bed. S2CNO indicated she had questioned all of the nurses and MHTs on the unit, and they reported they had seen other female patients going in and out of Patient #2's room, requiring redirection of those patients on the Geri-Psychiatric Unit. S2CNO indicated when she had spoken to staff on the Geri-Psychiatric Unit, they reported there were no men going into the patient's room.

In a telephone interview on 04/17/19 at 8:06 a.m. with Patient #2, she reported two different patients had come into her room, one patient who was 91 years old with true dementia and another patient who had been psychotic who had gotten into her bed and then came back into her room at 1:00 a.m. and 5:00 a.m. Patient #2 reported she had provided written notes to S2CNO regarding other patients coming into her room while she was hospitalized, as well as other concerns related to her care. Patient #2 reported S2CNO had told her she had received a complaint and had talked to her regarding her concerns about other patients coming into her room.

In an interview on 04/17/19 at 3:01 p.m. with S31MD, he reported Patient #2 had told him a couple of demented patients had come into her room at night but she had not seemed too distraught about it.





30420




30984

Based on record reviews, interviews, and observation, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care for each patient as evidenced by failure of the RN to ensure oral nutritional supplement intake or refusal, as ordered by the provider, was documented in the patient's record for 3 of 3 (#1, #R2, #R3) patients' records reviewed for nutritional supplementation from a total sample of 8 patients and 5 random patients.
Findings

Patient #1
Review of Patient #1's medical record revealed she was admitted on 03/17/19 at 2:37 a.m. with diagnoses of Bipolar II Disorder, most recent episode depressed, severe and Stimulant Use disorder, amphetamine type. Further review revealed an order on 03/17/19 at 2:37 a.m. for an adult regular diet by S27MD. Further review revealed an order was received from S4PMHNP on 03/18/19 at 11:33 a.m. to administer the dietary nutrition supplement Boost at all meals.

Review of Patient #1's medical record revealed no documented evidence that Boost was provided at all meals from admission on 03/17/19 through the time of her discharge on 03/23/19.

In an interview on 04/15/19 at 3:18 p.m., S15HIMD confirmed there was no documented evidence in Patient #1's medical record that Boost was administered with each meal.

Patient #R2
Review of the EMR of Patient R2 revealed he was a current patient, admitted on 04/02/19 due to suicidal ideation and Schizoaffective Disorder, depressed type. Review of a census generated from the EMR system revealed Patient R2 had an order for Boost-Plus Strawberry. Further review revealed the order comment included "Encourage patient to drink Strawberry boost if not eating at meal times. Have MHT monitor and report amount of meal consumed daily."

In an interview 04/16/19 at 1:50 p.m., S20LPN reported she was the medication nurse for Patient R2. S20LPN reported Patient R2 had not received any Boost that day on her shift, as the patient had eaten. She reported she had not documented the patient's intake or that he had not received the supplement. She reported she did not always document dietary supplements given to patients. After reviewing Patient R2's EMR, S20LPN reported the last documentation of the patient getting the supplement was 04/07/19. She further verified there were no entries as to the amount eaten by the patient since 04/07/19. S19RN, charge nurse present during the interview, reported they (the nurses) just ask the MHT's, when they return from the dining room with patients assigned to their unit, about the patient's intake, if there is a reason to do so. Both nurses confirmed they do not usually document patient meal intake.

Patient R3
Review of the medical record for Patient R3 revealed an admission date of 04/09/19 with a diagnosis of Depression. Further review revealed other diagnoses included, in part, Hyponatremia, Stage 3 Chronic Kidney Disease, and Anemia. Review of physician orders revealed a verbal order entered into the electronic medical record on 04/10/19 at 7:12 p.m. for Boost Breeze Dietary nutrition supplement-any flavor twice a day from S39FNP and electronically signed on 04/12/19 at 8:08 a.m. by S27MD. Further review of the orders revealed the order was continued and current at the time of the record review on 04/17/19 at 10:45 a.m. Further review of the electronic medical record with S15HIMD revealed no documented administration of the dietary supplement, any refusal by the patient, or any reason for omission of the ordered supplement.

In an interview 04/16/19 at 1:30 p.m., when asked for documentation of Patient R3's Boost Breeze having been provided to her, S17RN reported she didn't give anyone any supplements that day and didn't think any patient was on them. Review of Patient R3's dietary orders by S17RN revealed she had an order for Boost Breeze -any flavor BID. S17RN reported that supplements were given by the nurse and documented on the "I & O" section of the EMR. She verified there was no documentation of a supplement given to Patient R3 on 04/15/19 or 04/16/19. S17RN confirmed she was the only nurse on the unit during this shift and was responsible for giving medications and supplements to patients. S17RN reported the patient had not refused the dietary supplement, but offered no explanation why the patient had not received the Boost Dietary Supplement as ordered.

In an interview 04/17/19 at 4:20 p.m., S36LPN reported she had not given any Boost to Patient R3 on her (day) shift. She reported the patient had eaten well and she had given it before, but only if the patient had not eaten well. S37RN, charge nurse who joined the interview, reported she was assigned to Patient R3, but had not given her any Boost that day. She reported the patient had the Boost ordered, because she wasn't eating too well, but had eaten well that day. After reviewing Patient R3's order for Boost Breeze on the EMR, S37RN confirmed the order was for twice a day and did not indicate only if the patient was not eating well. Further review revealed no documentation of the patient's meal intake or administration of Boost Breeze. S37RN confirmed that she had not documented the patient's meal intake or that she had not received her Boost supplement. S37RN verified she had not offered the supplement to the patient.

In an interview on 04/17/19 at 5:17 p.m., S2CNO reported provider orders for patients were to be carried out as ordered. The CNO reported that it was her expectation that all treatments and orders should be documented in the patient's record, and if not carried out or administered, then documentation should include that the order was not carried out and why. She reported that until the EMR can be configured to have a specific area in the I & O section, nurses should be documenting in the nursing notes if a supplement is given, and how much of a meal a patient consumes.

An observation was conducted on Unit 1000 on 04/16/19 at 1:30 p.m. which revealed no Boost in the supplement cabinet. This observation was verified by S17RN, Charge Nurse.

An observation of the dietary supplement cabinets in the locked medication room for Units 3000 and 4000 was conducted 04/16/19 at 2:05 p.m. with S13LPN. The cabinets contained Ensure dietary supplements only and no Boost. This observation was verified by S13LPN, who reported that dietary supplements were stocked in the medication room by central supply staff.



30420

Based on record reviews and interview, the hospital failed to ensure the RN assigned the nursing care of each patient to other nursing personnel in accordance with the specialized qualifications and competence of the available nursing staff as evidenced by failure to have documented evidence of a demonstrated competency evaluation to perform the skills required of the MHT for 2 (S28MHT, S29MHT) of 2 MHT personnel files reviewed for competency from a total of 54 employed MHTs.
Findings:

Review of the personnel files of S28MHT and S29MHT revealed each MHT was hired on 04/01/19. Review of the "MHT Clinical Skills Competency Checklist" for S28MHT and S29MHT revealed the following MHT skills were evaluated by verbalized understanding and not direct observation: observation levels (routine, LOS, one-to-one), patient rounds documentation, precautions (seizure, choking, suicide, cheeking, fall, elopement), safety rounds every shift / contraband rounds, hand-off communication, patient escort, toileting, showering, hall monitoring, laundering.

In an interview on 04/17/19 at 5:10 p.m., S2CNO indicated the competency of a MHT should be evaluated by demonstration and not just an expression of verbal understanding.

Based on record reviews and interviews, the hospital failed to ensure an accurate discharge planning evaluation, to be used in the development of an appropriate discharge plan, was included in the patient's record for 3 (#1, #2, #7)of 5 (#1, #2, #3, #5, #7) patient records reviewed for discharge planning from a total patient sample of 8 patients.

Findings:

Review of the policy titled "Discharge Planning", presented as a current policy by S1Adm, revealed hospital discharge planning was a process that involved determining the appropriate post-hospital discharge destination for a patient, identifying what the patient required for a smooth and safe transition from the hospital to his/her discharge destination, and beginning the process of meeting the patient's identified post-discharge needs. The development of the plan begins on admission with active involvement of the patient and his/her representative. In developing discharge aftercare plans, financial needs, benefits needs, housing needs and/or placement issues, and transportation problems related to aftercare treatment should be assessed.

Patient #1
Review of Patient #1's medical record revealed she was admitted on 03/17/19 with diagnoses of Bipolar II Disorder, most recent episode depressed, severe and Stimulant Use Disorder, amphetamine type. Further review revealed she was discharged on 03/23/19. Further review revealed she was admitted by PEC that was signed on 03/16/19 at 7:41 p.m. due to being brought to the emergency department by the police after experiencing erratic behavior including slamming her head against the wall and attempting to stab her mother and threatening her brother and cousin. She was assessed to be homicidal and a danger to others. Her CEC was signed on 03/17/19 at 9:55 a.m. due to being a danger to self and others.

Review of her Psychiatric Evaluation conducted by S9PMHNP on 03/17/19 at 1:52 p.m. revealed Patient #1 reported feeling a little depressed and endorsed depressive symptoms of sleep problems with decreased energy, worthlessness, low mood, anhedonia, and isolating from others. She reported she was not able to go to store and fill her prescriptions and had not taken medications in 2 weeks. She indicated she was not interested in going to rehab hospital for substance abuse. Further review revealed the discharge plan was to assist the patient with finding a follow-up psychiatrist and therapist.

Review of Patient #1's Psychosocial Assessment conducted on 03/18/19 at 3:23 p.m. by S3LMSW revealed the information was obtained from the patient. Further review revealed Patient #1 lived with her mother and desired to return to the same placement. Further review revealed she was unemployed but able to work. The treatment issue to be addressed was outpatient services. She indicated transportation at discharge would be by Medicaid or family.
Potential dispositional issues that need to be addressed prior to discharge were none. S3LMSW documented that Patient #1 had the ability to obtain medications as ordered and had the capacity to follow discharge planning instructions. The social worker's role in discharge planning was to arranging transportation. There was no documented evidence the discharge planning evaluation reflected information related to Patient #1 having attempted to stab her mother and threatening her brother and cousin as documented in the PEC to determine if could return to same placement from which she came. There was also no documented evidence the evaluation accurately assessed her ability to obtain medications after discharge while S9PMHNP's evaluation reflected she had not been able to go to the store to fill her prescriptions and had not taken medications for 2 weeks (didn't determine if this was due to lack of money since she was not employed or due to lack of transportation).

In an interview on 04/17/19 at 9:22 a.m., S4PMHNP, when asked how the patient would be able to get medications if she didn't have a job or income, she indicated she didn't know, because she doesn't deal with that. She indicated they have treatment team meetings, but the patient doesn't come to the meeting. When asked if the team discusses how patients will get medications, she indicated she doesn't discuss how they would get medications but do discuss discharge.

In an interview on 04/17/19 at 10:30 a.m., S7Ther indicated she reviewed the collateral information before she did the discharge and realized the family was afraid of her but didn't want her to be homeless. She asked the patient where she wanted to go, and she hoped the patient would have said a shelter, but the patient was adamant about going home, so she could "get her stuff." When asked if they call the landlord (if documentation showed they were evicted) to see if the patient was allowed back, she indicated she doesn't do that. She indicated she requests the patient to make the call to the landlord.

In an interview on 04/17/19 at 11:00 a.m., S3LMSW indicated she vaguely remembered Patient #1. She indicated she had little contact with her. She indicated she and the nurse practitioner "tag team" the patient, and while S4PMHNP asks the questions, she (S2LMSW) completes the psychosocial assessment. She indicated after completing the psychosocial assessment, she didn't have any more contact with the patient, because she went on vacation. She indicated when she does the psychosocial assessment based on information the patient gives her. She indicated she then turns over the assessment S5LPC to obtain follow-up collateral. If the patient's mother indicated she couldn't go home, they would have set her up to go to a female shelter. She indicated she does the discharge planning when she initially sees the patient. If the patient has no follow-up care person, she sets it up and documents it in the computer and calls transportation when they discharge. She indicated the day of discharge the patient's follow-up is documented, and she asks if the patient has someone to pick them up or if they need transportation.

Patient #2
Review of Patient #2's medical record revealed an admission date of 03/12/19 with admission diagnoses of suicidal ideation and effects of combination of Wellbutrin and alcohol. Patient #2 was discharged on 03/14/19 at 4:38 p.m.

Review of Patient #2's social services documentation for discharge planning revealed a Psychosocial Assessment had been conducted by S10Ther on 03/14/19 at 12:38 p.m. (4 hours prior to Patient #2's discharge). Further review revealed the following entries, in part:
Discharge Planning/Clinical Summary: Treatment issues to be addressed following discharge: Major Depression.
Where will patient go upon discharge: Home, transported by Significant Other.
Specific community resources/support systems for utilization in discharge planning: (housing, living arrangements, financial aid, and aftercare treatment sources): Referral to Outpatient Behavioral Health Provider "A".
Clinical Summary /Conclusions and Recommendations: What are necessary steps for a discharge to occur: Attend group, take medications, meet with Psychiatrist, and comply with treatment.
What are anticipated social work roles in treatment and discharge planning: PSA ( Psychosocial Assessment), Master Treatment Plan, Psychiatric Treatment, Collateral, and Follow-up.

Further review of the patient's entire medical record, assisted by S2CNO chart navigator, revealed no documented evidence that follow-up appointments had been made for Patient #2. Additional review revealed no other Social Services entries related to Patient #2's Discharge Planning/Discharge.

In an interview 04/17/19 at 11:45 a.m. with S10Ther, she reported she had seen Patient #2 once or twice, because she was not at the hospital for very long before being discharged. S10Ther further reported Patient #2 was a LCSW (licensed clinical social worker). S10Ther indicated Patient #2 had told her she had a friend who was a Psychologist (S34Psych), and he would be assisting her with her follow-up after discharge. S10Ther reported Patient #2 had taken it upon herself to arrange her own follow-up and that was understandable, because she was a LCSW who had understood the process.

Patient #7
Review of Patient #7's medical record revealed she was admitted on 04/13/19 with diagnoses of Mood Disorders, and Bipolar Disorder, most recent episode manic with severe with psychotic features. Further review revealed she was PEC's on 04/13/19 at 5:35 p.m. as violent and a danger to others after hitting people at a department store, being evicted from her apartment and refusing to leave and not bathing and not taking her medications. She was CEC'd on 04/14/19 at 12:00 p.m. due to being gravely disabled.

Review of Patient #7's Patient Care Conference documented by S7Ther on 04/15/19 at 10:02 a.m. revealed contact was made with Patient #1's family member who reported that Patient #7 cannot work the way she is, but she was denied social security benefits. The family member reported that Patient #7 lived alone, and she needed a therapist and psychiatrist to come visit her and give her medication and treatment.

Review of Patient #7's Psychosocial Assessment documented by S3LMSW on 04/15/19 at 10:32 a.m. revealed Patient #7 lived alone in her own home and desired to return to the same place after discharge. Review of the discharge planning summary revealed the following questions and answers:
Where will the patient go upon discharge - home;
How will the patient be transported home - Medicaid or family;
Specific community resources/support systems - aftercare treatment;
Potential dispositional issues that need to be addressed prior to discharge/risk for homelessness/unable to return to current placement - none;
Does the patient have the ability to obtain medications and take medications as ordered without supervision - yes.
There was no documented evidence the discharge planning evaluation accurately evaluated the disposition at discharge as evidenced by S3LMSW not addressing the fact that Patient #7 had been evicted from her apartment as documented on the PEC. There was no documented evidence the evaluation accurately addressed whether Patient #7 could obtain medications and take them as ordered as evidenced by S3LMSW not addressing that she had not been taking her medications as reflected in the PEC and that the family member reported Patient #7 possibly needed assistance (home health) at home with treatment and medication administration.

In an interview on 04/17/19 at 9:22 a.m., S4PMHNP indicated she was a psychiatric nurse practitioner. She indicated her note of 04/15/19 (documented after the psychosocial assessment had been done but based on the patient care conference documented by S7Ther on 04/15/19 at 10:02 a.m. before the psychosocial assessment was documented) was based on her review of the social worker's collateral note. She indicated she wasn't aware that Patient #7 was evicted from her apartment. She indicated she rarely reviews the intake coordinator's documentation which is where it was documented that the patient was evicted from her apartment. She indicated she reviews the PEC where it was documented that she was evicted from her apartment, but she didn't know how she missed it. S4PMHNP was asked if they discussed in treatment team at discharge whether patients had money for medications, and she answered "no." When asked if that would affect the patient's medication compliance after discharge, she indicated "I see your point."

In an interview on 04/17/19 at 10:30 a.m., S7Ther indicated her collateral contact information is entered in the computer database, so it's accessible to the physician, nurse practitioner, and the social worker. She indicated she didn't see in Patient #7's record that the patient had been evicted from her apartment, and she indicated that's probably due to her lack of seeing it.

In an interview on 04/17/19 at 11:00 a.m., S3LMSW indicated indicated Patient #7 came into the room covered with a blanket and was calm and cooperative. When they got to the part about discharge, Patient #7 indicated she signed a 72 hour hold and "I'm getting out of here today." They informed her that she was PEC'd, and she began asking to see her chart. She became upset because she couldn't get the chart. S3LMSW indicated she reviewed the PEC and saw that Patient #7 was evicted from her apartment. She indicated the patient kept saying her being evicted wasn't true. S3LMSW indicated she documents the psychosocial assessment based on what the patient tells her regardless of knowing that she couldn't return home. When asked if the discharge plan was accurate, she indicated it is based on what the patient says. She indicated she would then need to do a follow-up note. She confirmed the initial discharge planning doesn't have the answers that are accurate based on what she knows about the patient.

Based on record reviews and interviews, the hospital failed to ensure the patient and family members were counseled to prepare them for post-hospital care as evidenced by failure to have an aftercare appointment arranged for 2 (#1, #2) of of 5 (#1, #2, #3, #5, #7) patient records reviewed for discharge planning from a total patient sample of 8 patients.
Findings:

Review of the policy titled "Discharge Planning", presented as a current policy by S1Adm, revealed hospital discharge planning was a process that involved determining the appropriate post-hospital discharge destination for a patient, identifying what the patient required for a smooth and safe transition from the hospital to his/her discharge destination, and beginning the process of meeting the patient's identified post-discharge needs. The development of the plan begins on admission with active involvement of the patient and his/her representative. In developing discharge aftercare plans, financial needs, benefits needs, housing needs and/or placement issues, and transportation problems related to aftercare treatment should be assessed.

Patient #1
Review of Patient #1's medical record revealed she was admitted on 03/17/19 with diagnoses of Bipolar II Disorder, most recent episode depressed, severe and Stimulant Use Disorder, amphetamine type. Further review revealed she was discharged on 03/23/19. Further review revealed she was admitted by PEC that was signed on 03/16/19 at 7:41 p.m. due to being brought to the emergency department by the police after experiencing erratic behavior including slamming her head against the wall and attempting to stab her mother and threatening her brother and cousin. She was assessed to be homicidal and a danger to others. Her CEC was signed on 03/17/19 at 9:55 a.m. due to being a danger to self and others.

Review of her "Discharge Care Plan Info" documented by S7Ther on 03/22/19 at 5:46 p.m. revealed she was being assigned to Provider B where she will be assigned a physician and therapist after follow-up has been initiated by Patient #1. Further review revealed patient #1 will go to provider B "Monday at 9:15 a.m." and will present as a walk-in aftercare appointment. Further review revealed the following note: "Remember: Mental Health Clinics DO NOT count as valid follow-up, so avoid referring to clinics if at all possible.

In an interview on 04/17/19 at 10:30 a.m., S7Ther indicated she faxed Patient #1's info to Provider B where she was receiving care prior to discharge. She indicated some of the staff was out, and she remembered she came in to help with the discharge. She confirmed an appointment was not made with a specific therapist and psychiatrist prior to discharge for Patient #1.

Patient #2
Review of Patient #2's medical record revealed an admission date of 03/12/19 with admission diagnoses of suicidal ideation and effects of combination of Wellbutrin and alcohol. Patient #2 was discharged on 03/14/19 at 4:38 p.m.

Review of Patient #2's entire medical record, assisted by S2CNO chart navigator, revealed no documented evidence that follow-up appointments had been made for Patient #2.

In an interview 04/17/19 at 11:45 a.m. with S10Ther, she reported she had seen Patient #2 once or twice, because she was not at the hospital for very long before being discharged. S10Ther further reported Patient #2 was a LCSW (licensed clinical social worker). S10Ther indicated Patient #2 had told her she had a friend who was a Psychologist (S34Psych), and he would be assisting her with her follow-up after discharge. S10Ther reported Patient #2 had taken it upon herself to arrange her own follow-up and that was understandable, because she was a LCSW who had understood the process.

Based on observations, record reviews, and interviews, the hospital failed to ensure the requirements of the Condition of Participation of Patient Rights were met as evidenced by failing to ensure suicidal patients with physician orders for LOS on 3 separate units were observed as ordered for 2 (#7, #8) of 2 current inpatients with physician orders for LOS from a sample of 8 patients and 3 (R2, R4, R5) of 4 (R2, R3, R4, R5) random inpatients with physician orders for LOS from a sample of 5 random patients. Observations were made on 04/15/19 at 10:30 a.m. on Unit 4000 (#8), on 04/16/19 from 10:10 a.m. to 11:35 a.m. on Unit 4000 (#7), on 04/16/19 at 1:35 p.m. on Unit 1000 (R4), and on 04/16/19 at 1:55 p.m. on Unit 3000 (R2, R5) (see findings in tag A0144).
Findings:

An Immediate jeopardy situation was identified on 04/16/19 at 3:50 p.m. and reported to S1Adm. The Immediate Crisis was that suicidal patients with physician orders for LOS observation (defined as the patient being in visual range of assigned staff at all times and during times of toileting, the staff should be in visual and hearing range of the slightly opened bathroom door) on 3 separate units were not observed as ordered. At the time of the observation, there were 5 suicidal patients with LOS observation orders.

On 04/17/19 at 11:40 a.m. S1Adm presented the first plan for lifting the immediacy of the Immediate Jeopardy situation, and the plan included the following:
1) Beginning at 6:00 p.m. on 04/16/19 training was completed with all direct care staff on the current day shift and continued into the night shift with signed attestation by each employee indicating that education had been received and the LOS policy had been reviewed. Each unit was met with individually and would continue with the arrival of the day shift on 04/17/19 with signed attestation after the training. Staff will not return to work any unit until training and signed attestation was complete.
2) Staffing Coordinator, CNO, House Supervisors, and charge nurses will ensure that one staff is assigned specifically to each patient on LOS monitoring. Should there arise a staffing issue that would prevent proper monitoring, the charge nurse will immediately notify the Staffing Coordinator, CNO, and/or House Supervisor to obtain correct staffing. Staffing Coordinator, MHT Supervisor, House Supervisor, and CNO will provide direct care duties (LOS or other) as needed until additional staff can be called in. Effective 04/17/19 all assigned LOS will be clearly indicated on the daily schedules and assignment sheets, and a clean copy of the assignment sheet will be rebuilt by the end of the day on 04/18/19.
3) Edited Leadership and Supervisor Observation Rounds to include specific monitoring of LOS and additional immediate action for non-compliance. Increasing frequency of rounds, going from once per shift to 3 times per shift. Leadership will complete three rounds per day shift Monday through Friday, House Supervisors will complete rounds three times per shift on evening and weekends. Two rounds per shift will focus exclusively on observation checks, one-to-one, and LOS compliance.
4) Round sheets to be turned in daily to Risk Manager (to Administrator while the Risk Manager position is vacant) who will double check and follow-up on any "no" answers.
5) Multiple monitors will be implemented for Rounding and reported as PI data including compliance with number of rounds completed, number of "no" answers checked for the question "Is the staff member conducting LOS monitoring in visual range of the patient at all times and only monitoring one patient?", and appropriate actions taken for "no" answers.
6) Current policy requires an assessment of the LOS in the shift nursing notes two times per day. Implement monitor for number/percentage of nursing notes that assess patient LOS status and report as monthly PI data. CNO or designee will monitor 100% of nursing progress notes for patients on LOS.
The "Daily Staffing Sheet", "Leadership Rounds" checklist, "Educational Attendance Roster", and "Line of Sight Training Attestation" for each employee who had received education thus far were submitted for review by the surveyors.

In an interview on 04/17/19 at 11:57 a.m., the surveyors informed S1Adm that the plan of removal was not accepted due to the following reasons:
1) The daily shift assignment sheet needed to be addressed as having the list of patients assigned to each nurse and MHT;
2) Leadership needs to be defined as to the specific leader title;
3) Round sheets reviews need to include the time frame that they will be monitored; and
4) Monitoring (number 5 and 6 listed above in the plan) needed to have the timeframe for monitoring.

S1Adm presented the revised second plan of removal on 04/17/19 at 1:50 p.m. with the following revisions:
1) No revisions made or required.
2) Revised to add that effective 04/17/19 all assigned LOS will be clearly indicated on the assignment sheets including the staff responsible. The assignment sheet will also indicate which staff are responsible for monitoring all other patients. Daily schedules will indicated which staff are assigned to LOS and will not include patient information.
3) Revised to add that current leadership rounding calendar will be followed and includes the CEO, CFO, DON, DCS, HRD, Director of Recreational Therapy, Director of Plant Operations, Director of Business Development, and HIM Director. Observation rounds are a permanent process, however the increased frequency of rounds will continue for at least 3 months or until compliance can be demonstrated.
4) No revisions made or required.
5) Revised to add that data will be reported daily Monday through Friday in flash meeting with reporting of weekend performance in Monday's meeting. Daily reporting will continue for at least 3 months and until compliance can be demonstrated. Once compliance is demonstrated, data reporting will continue as a permanent monthly monitor.
6) revised to add that data will be reported daily Monday through Friday in flash meeting with reporting of weekend performance in Monday's meeting. Daily reporting will continue for at least 3 months and until compliance can be demonstrated. Once compliance is demonstrated, data reporting will continue as a permanent monthly monitor.

In an interview on 04/17/19 at 1:50 p.m., the surveyors informed S1Adm that the second plan of removal was not accepted due to monitoring addressed in numbers 5 and 6 not having compliance defined, such as a percentage or measure.

S1Adm presented the third plan of removal on 04/17/19 at 3:42 p.m. with the following revisions to numbers 5 and 6:
5) Revised to add that daily reporting will continue for at least 3 months and until 100% compliance can be consistently demonstrated. Once 100% compliance is demonstrated, data reporting will continue as a permanent monthly monitor.
6) Revised to add that daily reporting will continue for at least 3 months and until 100% compliance can be consistently demonstrated. Once 100% compliance is demonstrated, data reporting will continue as a permanent monthly monitor.

Observations were conducted on 04/17/19 at 3:40 p.m. on Unit 1000. Patients R3 and R4 were no longer ordered to be on LOS. S37RN indicated the patients were all currently on Q 15 minute observation. 12 patients were observed in the television room watching a science fiction movie, and 2 patients were observed walking the halls. All patient observation sheets were reviewed and were all current.

In an interview on 04/17/19 at 3:45 p.m., S37RN confirmed she had received training regarding LOS Patient Supervision and a refresher on hospital policies regarding levels of observation and staff supervision according to orders by the physician. She indicated she had to sign an attestation verifying she had received the referenced training. She reported LOS was essentially like patients being on 1:1 Supervision, except the patient did not have to be within arm's reach, but had to be within the assigned staff member's direct line of sight, including when the patient went to the bathroom. She reported the patient had to be handed off if the MHT assigned had a break or otherwise was unable to observe the patient LOS, and whomever took over the patient had to observe that patient only and could not perform any other tasks.

In an interview on 04/17/19 at 3:50 p.m.. S36LPN confirmed she had received training regarding Line of Sight Patient Supervision and a refresher on hospital policies regarding levels of observation and staff supervision according to orders by the physician. She reported LOS was having the patient in her direct line of sight, like a 1:1, but not having to have the patient within arm's reach, but had to be within the assigned staff member's direct line of sight at all times, including when the patient went to the bathroom. She reported the patient had to be handed off if the MHT assigned had a break or otherwise was unable to observe the patient LOS, and whomever took over the patient had to observe that patient only and could not perform any other tasks. She confirmed she had to fill out an attestation indicating she had received education regarding patient levels of observation and Line of Sight.

In an interview on 04/17/19 at 4:37 p.m., S35MHT confirmed she had received training regarding Line of Sight Patient Supervision and a refresher on hospital policies regarding levels of observation and staff supervision according to orders by the physician. She reported LOS was having the patient in her direct line of sight, like a 1:1, but not having to have the patient within arm's reach, but had to be within the assigned staff member's direct line of sight at all times, including when the patient went to the bathroom. She reported the patient had to be handed off if the MHT assigned was unable to observe the patient LOS. She reported the patient's observation sheets had to be handed off directly to the staff who took over the patient, and the MHT could not perform any other tasks. She confirmed she had to fill out an attestation indicating she had received education regarding patient levels of observation and Line of Sight.

Observation on 04/17/19 at 4:05 p.m. on Unit 3000 revealed S40MHT was seated inside the open doorway to Room "b" observing Patient R5 who was lying in bed and was ordered to be on LOS. S40MHT indicated when Patient R5 goes to the bathroom, he (S40MHT) lowers the bathroom door that was attached by Velcro to a position that allows him (S40MHT) to be able to visualize Patient R5 while he's in the bathroom. He indicated he had received education on the LOS policy before he started his shift this day by his supervisor. He indicated LOS meant he had to keep the patient on LOS in his eyesight at all times.

In an interview on 04/17/19 at 4:10 p.m., S41LPN showed the surveyor the physician order for LOS for Patient R5 that was received on 04/16/19 at 3:14 a.m. She indicated she had received education on LOS by S2CNO this day before starting her shift. She indicated LOS meant the assigned staff had to keep the patient ordered to be on LOS within their eyesight at all times.

In an interview on 04/17/19 at 5:48 p.m., S1Adm was informed that the Immediate Jeopardy Plan of Removal was accepted. He was informed that, since there was not enough evidence to determine sustainability of the plan, the Condition of Participation of Patient Rights would remain at the condition level.

Based on record reviews and interview, the hospital failed to ensure each patient received a psychiatric evaluation that estimated intellectual functioning, memory functioning, and orientation as evidenced by failure to have documented evidence of how concentration, attention span, recent and remote memory, intelligence, judgment, and insight were tested and assessed as required by the Medical Staff Rules and Regulations for 1 (#7) of 5 (#1, #2, #3, #4, #7) patient records reviewed for completion of the psychiatric evaluation from a sample of 8 patients.
Findings:

Review of the "Rules and Regulations of the Medical Staff of River Place Behavioral Health", presented as the current rules and regulations by S1Adm, revealed the psychiatric evaluation and mental status examination shall be completed by the physician within 24 hours after admission of the patient. Further review revealed a list of items to be included in the evaluation that included an estimation of intellectual functioning, memory functioning and how tested, and orientation.

Review of the "Psychiatric Evaluation" conducted for Patient #7 on 04/14/19 at 12:02 p.m. by S9PMHNP revealed no documented evidence of how concentration, attention span, recent and remote memory, intelligence, judgment, and insight were tested and assessed as evidenced by the choices to select for each item being void of a check mark.

In an interview on 04/17/19 at 2:47 p.m., S9PMHNP indicated she used the paper form to document the psychiatric evaluation, because the computer system was down. She indicated the computer system usually has drop-down box for how the above-listed areas were tested, but she probably forgot to document how she did it on the paper form.

Based on record review and interview, the hospital failed to ensure each patient had a comprehensive, individualized treatment plan. This deficient practice was evidenced by:
1) Failing to initiate a treatment plan for 1 (#3) of 5 (#1, #2, #3, #4, #5) patient records reviewed for treatment planning from a sample of 8 patients.
2) Failing to update a patient's treatment plan (#4) with changes in level of observation due to behavior changes (aggressive toward peers and staff and sexually acting out) and increased suicide risk scores for 2 (#4, #7) of 5 (#1, #2, #3, #4, #5) patient records reviewed for treatment plan revision from a sample of 8 patients.

Findings:

Review of the policy titled "Treatment Planning", presented as a current policy by S1Adm, revealed each patient's treatment plan shall be guided by the interdisciplinary treatment plan. The treatment plan is the tool used by the physician and interdisciplinary treatment team to implement the physician ordered services and move the patient toward the expected outcomes and goals. The nursing staff is responsible for developing the Initial Treatment Plan no later than 8 hours of admission. The Treatment Plan shall be completed no later than the third day after admission. Treatment plan updates shall be documented at least weekly, as the physician and treatment team assesses the patient's current clinical status, review progress toward treatment plan goals, and make necessary modification. A review of the patient's Treatment Plan following any major clinical change shall be conducted, and appropriate modifications made.

1) Failing to initiate a treatment plan:
Review of Patient #3's medical record revealed an admission date of 04/13/19 with admission diagnoses of Bipolar Disorder with bizarre behavior and medication non-compliance. Further review revealed the patient's legal status was PEC. .

Review of Patient #3's medical record on 04/16/19 revealed the patient's Interdisciplinary Master Treatment Plan, dated 04/13/19, was blank.

In an interview on 04/17/19 at 11:45 a.m. with S10Ther, she confirmed Patient #3's Interdisciplinary Master Treatment Plan had not been completed at the time of the surveyor's review on 04/16/19 and further confirmed the plan had been blank.

2) Failing to update a patient's treatment plan:

Review of Patient #4's medical record revealed an admission date of 03/12/19 with admission diagnoses of
Bipolar Disorder with mania and agitation. Further review the patient's legal status was PEC on 03/12/19 due to being currently a danger to self and gravely disabled. Patient #4's legal status on 03/27/19 was Formal Voluntary.

Review of Patient #4's nurses notes revealed the following entries:
03/12/19 at 11:09 p.m.: Pt yelling and screaming, combative, verbally abusive, threatening staff, unable to redirect, Geodon injection given to decrease agitation.
03/13/19 at 2:07 p.m.: Sister called to inform us pat is very hypersexual when she is manic, pt. also steals from other patients when she is manic. Pt. had to be redirected from male patients.
03/13/19 at 00:28: Placed on LOS ( line of sight) due to SRA (suicide risk assessment) score of 30.
03/15/19 at 8:32 a.m.: Placed 1:1 for assault. .

Review of Patient #4's Interdisciplinary Master Treatment plan, dated 03/12/19, revealed the patient's hypersexual behavior, increased suicide risk resulting in patient being placed on LOS level of observation, and being placed on 1:1 level of observation due to assault were not addressed as identified problems on the patient's plan of care.

In an interview on 04/17/19 at 3:01 p.m. with S31MD, he confirmed Patient #4's treatment plan should have been updated with changes in level of observation and changes in behavior. S31MD reported the Interdisciplinary Master Treatment Plan was viewed, by staff, as a necessary piece of paper and not as an actual plan for treatment.

In an interview on 04/17/19 at 5:17 p.m. with S2CNO, she confirmed Patient #4's Interdisciplinary Master Treatment Plan should have included updates related to patient behavior changes and the required level of observation changes to manage those behaviors.

Patient #7
Review of Patient #7's medical record revealed she was admitted on 04/13/19 with diagnoses of Mood Disorders and Bipolar Disorder, most recent episode manic, severe with psychotic features. Further review revealed a physician order by S31MD on 04/13/19 at 10:47 p.m. for LOS.

Review of Patient #7's Interdisciplinary Treatment Plan Master Sheets and Psychiatric and medical Problem Sheets, signed by nursing and social services on 04/15/19 and by the activity therapist and the physician on 04/16/19, revealed no documented evidence that the increased suicide risk score and subsequent physician-ordered LOS was addressed in the treatment plan.

In an interview on 04/17/19 at 5:10 p.m., S2CNO indicated the treatment plan should reflect the patient's increase in the level of observation.

Based on record review and interview, the hospital failed to ensure treatment received by the patient was documented in such a way to assure all active therapeutic efforts were included. This deficient practice was evidenced by failure of the staff responsible for providing therapeutic treatment modalities/interventions to document provision of, and patient's response to, a specific modality for 2 (#2,#3) of 5 (#1, #2, #3, #4, #5) patient records reviewed for documentation of therapy from a sample of 5 patients.
Findings:

Patient #2
Review of Patient #2's medical record revealed an admission date of 03/12/19 with admission diagnoses of suicidal ideation and effects of combination of Wellbutrin and alcohol. Patient #2 was discharged on 03/14/19.

Review of Patient #2's medical record revealed only one Activity Therapy note in the patient's record. Further review revealed no documented notes for scheduled Psycho-Ed Group, Nursing Group, and Process Group.

In an interview on 04/15/19 at 12:33 p.m. with S2CNO (who was navigating the patient's electronic medical record), she confirmed there were no documented Psycho-Ed Group, Nursing Group, and Process Group notes in the patient's record. S2CNO further confirmed all patients were expected to attend all groups on their units. S2CNO verified staff providing specific modalities should have documented when patients attended group, their response to group,and when they did not attend group, including the reason for not attending.

Patient #3
Review of Patient #3's medical record revealed an admission date of 04/13/19 with admission diagnoses of Bipolar Disorder with bizarre behavior and medication non-compliance. Further review revealed the patient's legal status was PEC. .

Review of Patient #3's medical record on 04/16/19 revealed there were no daily social services therapeutic group notes documented in Patient #3's record.

In an interview on 04/17/19 at 11:45 a.m. with S10Ther, she confirmed she conducted therapeutic groups on the Geri-Psychiatric Unit. S10Ther further confirmed Patient #3 had attended one or two of her meetings since her admission. S10Ther confirmed there were no daily notes regarding whether or not Patient #3 had attended and her response to group activities in the record. S10Ther reported she was only one of two social services staff on the unit, and she had not documented any notes "due to it being a lot on her."

In an interview on 04/17/19 at 3:01 p.m. with S31MD, he confirmed staff who were conducting therapeutic groups should have been documenting patient attendance, patient participation in group, and failure to attend group, with the reason for not attending, in the patients' medical records. S31MD indicated patients who decline group therapy participation should be offered an alternative activity. S31MD reported failure to chart patient progress was unacceptable.