HospitalInspections.org

30984


Based upon reviews of medical records and interviews, the Governing Body failed to ensure the members of the Medical Staff were held accountable to the Governing Body for the quality of care provided to patients as evidenced by:
a.failing to ensure the physician assessed, in a timely matter, a patient (Patient #E1) who had been repeatedly reported by the Registered Nurse to have significant changes in his physical condition.
b. failing to ensure a Medical Staff member pronounced a deceased patient for 2 of 2 deaths (Patient #E1 and #E2) reviewed.

Findings

a. failing to ensure the physician assessed, in a timely matter, a patient (Patient #E1) who had been repeatedly reported by the Registered Nurse to have significant changes in his physical condition.


Patient #E1
Review of Patient #E1's medical record revealed he was a 70 year old male admitted on 8/18/14 with a diagnosis of Recurring Depression with Psychotic symptoms. His past medical history was listed as Huntington's Disease and Diabetes Mellitus II. His chief complaint was listed as he was having "Disruptive Behavior in the Nursing Home." Review of his History and Physical Examination, dated 8/20/14, revealed he had chorea form movements. His plan of care was to observe and adjust treatment as needed.

Review of Patient #E1's Psychiatric Evaluation, dated 8/19/2014, revealed the chief complaint was, "The nursing home reports an increase in aggressive behavior as well as weight loss." Reason for Admission: 1. The patient presents as a danger to self. 2. The patient presents as a danger to others. 3. Decreased appetite with weight loss. 4. Inappropriate outburst. 5. The patient needs medication stabilization...The nursing home reported that he has become more aggressive toward other staff members and that he has even been resisting them to assist him with all of his needs. It was observed by some of the staff that he was attempting to kick people as they passed by or even if they got too close. His wife reported that there were multiple medication changes starting at the beginning of this month and that he has had significant decrease in appetite since the beginning of the month. Reportedly, he lost 16 lbs (pounds) in the past 11 days...Patient #E1 does have Huntington's disease and does have some spastic movements. During the interview, they did appear to be slightly worse than when he left in July. He also seemed to be more verbal and his voice seemed to be a lot louder than when he left as well. He was more impulsive and when asking a question he would shout it out rather than speaking in a normal tone... The patient was oriented X 3 (person, place and time).

Review of the patient's Louisiana Physician Orders for Scope of Treatment (La Post) revealed the patient had Huntington's Disease and he had decided to have a DNR (Do not attempt Resuscitation) (Allow Natural Death) status. He did agree to the option that he would do a trial period of artificial nutrition by a tube and IV (Intravenous) fluids for 30 days.

Review of the Physician Orders revealed an order for a CBC (Complete Blood Count) and CMP (Complete Metabolic Profile) on 9/2/14 at 1745 (5:45 p.m.).

Review of the CBC collected on Patient #E1 revealed his White Blood Count (WBC) was 17.4 (high). The reference range was listed as 4.0-11.0. The print date and time was listed as 9/3/14 at 8:03:57 a.m.

Review of the Multi-Disciplinary Notes revealed the following:
9/2/14 1615 (4:15 p.m.)- Pt (Patient) sweating, (Arrow up) increased movements, Restlessness, CGB (Capillary Blood Glucose) 93, B/P (blood pressure) 118/66, T (temperature) 98.4, APRN1 notified, Orders given to monitor few hours if sweating continues notify MD1 (psychiatrist). Will continue to monitor. RN1

9/2/14 at 1745 (5:45 p.m.)- Pt sweating to the point that his shirt had to be changed. MD1(psychiatrist) notified CBG 93 and B/P and temp (temperature) WNL (within normal limits). Increased (arrow up) movements reported to dr (doctor) no orders noted. Do CMP (Complete Metabolic Profile) and CBC (Complete Blood Count) in a.m.; Hold Geodon until MD1 sees the pt tomorrow. RN1

9/3/14 8:15 a.m.- Evaluated pt's condition, pt very restless, anxious, unable to sit in w/c (wheelchair), slipping out, also pt is very clammy, sweaty. B/P 154/64, P (pulse)120, T 98.9 Instructed MHTs (Mental Health Technicians) to put pt in bed to rest, pt able to communicate with staff at this point. Notified DON and CEO on the unit. Will continue to monitor. RN3

9/3/14 8:15 a.m.- Charge Nurse, RN3, informed myself and CEO of condition of patient. Observed patient in bed, MHT changing incontinent diaper. Pt. alert, restless, moving legs constantly. Advised RN3 to notify MD1, which he planned to do. DON

9/3/14 8:20 a.m. - MD1 notified of pt's condition, informed MD1of pt's constant jerking restlessness, perfuse sweating and his inability to get comfortable, Pt sill able to make needs known at this point. MD1 ordered Ativan 1 mg (milligram) po (by mouth) now x 1 (1 dose) for increase anxiety r/t (related to) disease process. Will continue to monitor. RN3

9/3/14 9:00 a.m.- Went to pt's room to assess, pt still sweating, decrease (arrow down) jerking, but breathing has become labored. O2 (oxygen) sat (saturation) 95%, put pt on O2 at this point to supplement. 2 L (liters) per NC (nasal cannula) administered. O2 dipped to 88% then went back to 95%. Will continue to monitor.RN3.

9/3/14 9:30 a.m. -Went to pt's room , O2 sats (saturation) still fluctuating b/t (between) high 80's and low to mid 90's. Remains with labored breathing O2 at 2 L/min (Liters per minute) per NC (nasal cannula) Checked pt's CBG (Capillary Blood Glucose) was 84. Will continue to monitor. RN3

9/3/14 10:00 a.m.- Pt's condition unchanged, O2 sats still fluctuating b/t 80's and low to mid 90's Will notify MD1 of pt's condition, will continue to monitor. RN3

9/3/14 10:04 a.m. -Walked to the adult unit to notify MD1 of pt's condition, explained to him that he's still sweating profusely, his breathing is still labored, beginning to become hard to stimulate, and could we send him out to get medically cleared. He explained to me that he was having an acute ataxia episode, and that he will see him soon. Walked back to the unit. Will continue to monitor. RN3.

9/3/14 10:47 a.m.- MD1 contacted me to give pt 2.5 mg (milligrams) po (by mouth) of Zyprexa due to his increase(arrow up) anxiety, at this point pt was found unresponsive, not breathing, no b/p, no code called, pt DNR (Do not Resuscitate). RN3

9/3/14 11:00 a.m.- 911 called. RN3

9/3/14 11:02 a.m.- MD1 notified pt not responding. RN3

9/3/14 11:13 a.m. - Ambulance arrived on the unit performed EKG (Electrocardiogram) with flat line as the result. RN3

9/3/14 11:14 a.m.- Notified coroner of results of Ambulance's EKG and therefore lack of V/S(Vital Signs). Instructed to release body to family's choice of Funeral Home. RN3


In an interview conducted on 7/7/15 at 10:57 a.m. with RN3, he reported he was the nurse assigned to care for Patient #E1, when he died (9/3/14). He went on to state it was the patient's third admit to the facility and every time he was readmitted his disease process had progressed. RN3 reported he remembered Patient #E1 vividly because he had nightmares about that situation for months. He said after breakfast, on 9/3/14, a MHT told him Patient #E1 was very uncomfortable. RN3 reported he went to assess the patient.. He reported the patient had involuntary movements, which were typical for him, but he reported Patient #E1's breathing was different. He reported he called MD1 (psychaitrist) to notify him of Patient #E1's condition and he ordered Ativan for the patient. RN3 reported he placed oxygen on the patient because something was different about him. RN3 reported the patient was still talking and able to answer questions at this time. RN3 indicated the CEO was making rounds so he reported Patient #E1's declining status to her. RN3 further reported he discussed the patient with the DON and she told him to keep monitoring the patient. RN3 reported he went next door (to the adult unit) and spoke face to face with MD1 and described his assessment of the patient to MD1 and asked if the patient could be sent out for medical clearance. RN3 reported MD1 told him it was just the symptoms of the patient's Huntington's Disease. RN3 went on to report he went to the next unit to get MD1 to examine the patient because that was the immediate resource available to him to obtain assistance for his patient. He also went on to explain to MD1 the patient's behavior at breakfast. MD1 reported to RN3 it was the patient's disease process, but he would be over shortly to look at the patient. RN3 reported he thought the physician would be over to examine the patient in about 15 -20 minutes, the psychiatrist was in a treatment team meeting, but MD1 never came to examine the patient. RN3 reported himself and the MHT never left the patient's side. He further reported 40 minutes later MD1 called him with an order to administer 2.5 mg of Zyprexa to the patient and when he went to administer the medication the patient had expired. He said he knew the patient was a DNR (Do not Resuscitate), but he wanted to make the patient as comfortable as possible. EMS (Emergency Medical Services) were called and came to the hospital and obtained an EKG on the patient and EMS pronounced the patient, the hospital then called the coroner's office.

An interview was conducted on 7/7/15 at 1: 28 p.m. with MD1(psychiatrist). MD1 indicated he was very familiar with Patient #E1. He had treated the patient many times. He went on to report on 9/2/14 the patient had increased agitation, shaking, his vital signs were stable, he had hyperventilation, which continued through 9/3/14 (the next day). The patient's vital signs remained stable, most of the symptoms which were described to him were related to the patient's Huntington's Disease. MD1 reported he was called on evening of 9/2/14 due to the patient having increased sweating and his vital signs were stable. RN3 called him at 8:00 a.m. the next morning because the patient was sweating and hyperventilating (labored breathing). MD1 reported the patient was having an ataxic attack. He further reported he was trying to relieve his symptoms with medications. MD1 reported the medical physician saw the patient initially on admission to perform the H&P (History and Physical). MD1 reported the patient was receiving treatment for stabilization of his psychiatric symptoms. He reported there was no treatment for Huntington's Disease, but the involuntary movements were part of the psychiatric issue. He indicated treatment for late Huntington's Disease was to place the patient on antipsychotic medications. Psychiatric symptoms were being treated at this hospital. When questioned on what kept him from assessing the patient when the patient had a deteriorating condition since he was physically in the building; he reported he was seeing another patient and he knew Patient #E1 had these ataxia symptoms previously. He reported he also knew the patient had a DNR status (a code was not called) so he didn't come as quickly. When questioned on how he determines if he needs to assess a patient or not, he reported it depended on the presentation of the patient's symptoms. MD1 was given the results of the CBC (Complete Blood Count) and CMP (Complete Metabolic Profile) he had ordered on Patient #E1 on the evening of 9/2/14. He reported he had not seen the lab results and if he had seen the results he would have ordered a Medical Doctor consult due to a possible infectious process. Review of the lab result documentation revealed they had been faxed to the hospital on 9/3/14 at 8:00 a.m.
An interview was conducted with the Medical Director on 7/8/15 at 10:05 a.m. He reported he had reviewed Patient #E1's death. He understood the patient had about a 12- 14 hour decline in condition prior to his death. The Medical Director reported MD1 (psychiatrist)should have assessed the patient on the morning of 9/3/14 especially since he was physically present in the building. He went on to report he should have ordered stat labs, not routine labs, on the evening of 9/2/14 and reviewed the results immediately. The Medical Director reported, it is basic that if a physician orders labs, he is responsible for following up on the labs.

b. failing to ensure a medical staff member pronounced dead a deceased patient for 2 out of 2 deaths (Patient #E1 and #E2) reviewed.


Patient #E1
Review of Patient #E1's medical record revealed he was a 70 year old male admitted on 8/18/14 with a diagnosis of Recurring Depression with Psychotic symptoms. His past medical history was listed as Huntington's Disease and Diabetes Mellitus II. He had a DNR status and expired on 9/3/14 at the hospital.

An interview was conducted with RN3 on 7/7/15 at 10:55 a.m. He reported he was the nurse assigned to care for Patient #E1 on 9/3/14 when the patient expired. After the patient expired, EMS (Emergency Medical Services) were called and came to the hospital and obtained an EKG on the patient (flat EKG). The EMS pronounced the patient, the hospital then called the coroner and was told the hospital could release the body to the family's funeral home of choice.

Patient #E2
Review of Patient #E2's medical record revealed she admitted on 5/28/14 with a diagnosis of Major Depressive Disorder. She was full code status and expired on 5/30/14 at the hospital. Review of the discharge (death) summary, dated 5/30/14, revealed the following: The patient had continuous cessation of all vital signs and was pronounced deceased by ER (emergency room) physician, via telephone with EMS EMT (emergency medical technician).

In an interview on 7/7/15 at 9:40 a.m. with the CEO, she indicated that she had not known patients could not be pronounced by ER physicians who had been notified of a patient death by responding paramedics.

In an interview on 7/7/15 at 4:14 p.m. with MD3, he indicated that if a death occurred in the hospital, the paramedics could pronounce death and the physician could certify it later.

30984


Based on observations and interviews, the hospital failed to ensure that patients received care in a safe setting as evidenced by failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality for acute care psychiatric patients on the adult psychiatric unit and the geriatric psychiatric unit. There were currently 38 patients receiving treatment at the time of the observations.

Findings:

On 7/6/15 from 10:00 a.m. until 10:40 a.m., the following observations were made in patients' rooms:
a. Lever style door handles (not anti-ligature) positioned in a downward fashion.
b. Room entry door, interior bathroom door and closet hinges separated widely enough to facilitate potential ligature risk;
c. Crank beds with cranks attached on the beds on the geriatric unit and all rooms on the adult unit except for room "a";
d. Gooseneck faucets in bathroom sinks (non-anti-ligature) on both of the units;
e. Drawer pulls on chest of drawers not flush, facilitating potential ligature anchor in room "c" .
f. All of the patient beds contained springs which had sharp points and could potentially be
removed;
g. Room "b" had exposed pipes under the bathroom sink which posed a ligature risk.

In an interview on 7/8/15 at 10:00 a.m. with Corporate Quality, she verified the above mentioned safety hazards in the patients' rooms.

Based on record review, observation and interview, the hospital failed to meet the Condition of Participation for Quality Assurance Performance Improvement (QAPI) as evidenced by:

1. Failing to set priorities for high-risk, high volume and problem prone areas as evidenced by the failure to identify and implement corrective action relative to the need for establishment of protocols for guidance of RN (registered nurse) staff in the management of patients with decline/deterioration of medical status (Patient #E1) when the patient is not seen by a licensed practitioner/not transferred to a higher level of care; the failure to identify and implement corrective action relative to errors in administration of insulin (Patient #B8); and the failure to identify and implement corrective action relative to deficiencies in Infection Control practices related to Isolation Precautions/Practices (Patient #B7,#B8). (See findings at A-0283)

2. Failing to formulate an action plan aimed at performance improvement as evidenced by the failure to identify and implement corrective action relative to the need for establishment of protocols for guidance of RN (registered nurse) staff in the management of patients with decline/deterioration of medical status (Patient #E1) when the patient is not seen by a licensed practitioner/not transferred to a higher level of care. (See findings at A-0308).

Based on record review, interview and observation, the hospital failed to set priorities for high-risk, high volume and problem prone areas as evidenced by:
1) Failure to identify and implement corrective action relative to the need for establishment of protocols for guidance of RN (registered nurse) staff in the management of patients with decline/deterioration of medical status (Patient #E1) when the patient is not seen by a licensed practitioner/not transferred to a higher level of care;
2) Failure to identify and implement corrective action relative to errors in administration of insulin (Patient #B8);
3) Failure to identify and implement corrective action relative to deficiencies in Infection Control practices related to Isolation Precautions/Practices (Patient #B7,#B8).
Findings:
1) No protocols for RN management of a patient (Patient #E1) with declining/deteriorating medical status, not seen by a licensed practitioner/transferred to a higher level of care.
Review of the root cause analysis conducted by the hospital, after the death of Patient #E1 in 9/2014, (patient with declining /deteriorating condition not seen by a licensed practitioner/not transferred to a higher level of care ) revealed the committee found no deficient practice and no further actions needed.
An Immediate Jeopardy situation was identified on 7/7/15 at 7:10 p.m. regarding failure of the hospital to have a system in place to address the physician assessing patients, in a timely manner, with deteriorating medical conditions that are not transferred to a higher level of medical care. Specifically, the physician failed to assess in a timely manner, a patient (Patient #E1) who was repeatedly reported by the RN to have significant changes in his physical condition. The hospital also failed to implement processes to provide guidance for RN staff to prevent further occurrences related to deteriorating conditions for patients that are not transferred to a higher level of medical care.

2) Medication errors related to insulin administration
Review of the medical record for Patient #B8 from his admission on 6/25/15 through 7/7/15 revealed 6 documented errors in insulin administration, identified during the survey process, by the survey team.

In an interview on 7/6/15 at 3:02 p.m. with the DON, she indicated the nursing staff on the night shift had to double check their own insulin doses because there was only one nurse (RN) in the adult and geriatric units at night. She said the nurses could not leave their units because that would leave the unit unattended by a RN. She said there was no LPN staff on the night shift after 11:00 p.m.

In an interview on 7/8/15 at 2:53 p.m. with Corporate Quality, she verified the above documented insulin administration errors. She verified there were different staff members on different shifts making different errors. She said the staff needed training on insulin administration.

3) Failure to identify and implement corrective action relative to deficiencies in Infection Control practices related to Isolation Precautions/Practices (Patient #B7,#B8).

Review of a Microbiology Culture Reports for Patient #B8 dated 6/28/15 and Patient #B7 dated 6/30/15 revealed the following footnote: This organism (MRSA) is a multi-drug resistant organism and potential pathogen that mandates the institution of contact isolation.

Review of Patient #B10's medical record revealed she did not have positive cultures of any kind.

On 7/7/15 and 7/8/15 during multiple observations, the following infection control issues were noted:
Patients (#B7 and #B8) with MRSA (Methicillin-resistant Staphylococcus aureus) had no signage indicating contact precautions on their room doors, no orders for contact precautions placed in their medical records, and no indications were noted on their Kardex that they were on contact precautions as per the hospital's policies and procedures for MRSA;

Patient #B7 (positive for MRSA) was placed in a room with another patient who was not positive for MRSA;

Proper hand hygiene and accepted standards of practice for infection control were not followed during blood glucose monitoring and insulin administration on a patient (#B8) with MRSA. During observations on 7/7/15 at 11:05 a.m. and 7/8/15 at 11:00 a.m., LPN1 was observed performing blood glucose monitoring and administering insulin. During the observations the following breaches were noted: cross contamination of patients with contact precautions, improper hand hygiene and glove usage, failing to properly disinfect a glucometer, and improper sharps disposal.

In an interview on 7/6/15 at 3:30 p.m. with the DON, she indicated there were no patients on any type of isolation precautions on either the adult or geriatric-psychiatric unit.

In an interview on 7/7/15 at 10:00 a.m. with Quality/ICO, she verified Patient #B10's door was incorrectly marked for contact precautions. She confirmed Patient #B10 did not have positive cultures for any type of infection. She also stated Patient #B7 and Patient #B8 did not have contact precautions but should have. She also verified Patient #B7 and Patient #B8 did not have their Kardex flagged or the order in their charts.

In an interview on 7/7/15 at 10:11 a.m. with Quality/ICO, she verified Patient #B7 should have been in a private room or in a room with another patient with an MRSA infection but was not.

In an interview on 7/8/15 at 2:00 p.m. with RN3 (who had observed LPN1), he verified there had been several breaches in infection control when LPN1 had done the blood glucose check and insulin injection on Patient #B8 (on contact isolation for MRSA).

Review of the Quality Improvement Report presented by Quality/ICO as the hospital 's QAPI documentation revealed no documented evidence of data collection/analysis related to a need for revision of protocols for RN management of patients with decline/deterioration of medical status when the patient is not seen by a licensed practitioner/not transferred to a higher level of care. Further review revealed no documented evidence of indicators specifically addressing medication errors involving insulin administration. Additional review revealed breaks in Infection Control practices related to appropriate use of PPE (personal protective equipment), utilization of appropriate signage for isolation precautions, placement of isolation precaution orders on patient charts, updating of patient Kardex with isolation information, and timely initiation of isolation precautions after receipt of positive culture reports were not identified as areas of deficient practice in need of performance improvement.

In an interview on 7/8/15 at 2:00 p.m. with Quality/ICO she indicated appropriate use of PPE (personal protective equipment) for isolation precautions, utilization of appropriate signage for isolation precautions, and timely initiation of isolation precautions were not currently identified as problems to be addressed through QAPI in the form of performance improvement projects. She also indicated the hospital had not identified lack of protocols for RN management of patients with decline/deterioration of medical status when the patient is not seen by a licensed practitioner/not transferred to a higher level of care as a problem area. Quality/ICO confirmed the QAPI plan currently had no indicators specific to medication errors involving insulin administration. She said corporate usually designated the indicators for the hospital to focus on for performance improvement. She confirmed they were not hospital specific.

Based on record review, observation and interview, the hospital failed to implement preventive actions after an adverse patient event and failed to identify medical errors as evidenced by:
1) Failure to identify and implement corrective action relative to the need for establishment of protocols for guidance of RN (registered nurse) staff in the management of patients with decline/deterioration of medical status (Patient #E1) when the patient is not seen by a licensed practitioner/not transferred to a higher level of care;
2) Failure to identify and implement corrective action relative to errors in administration of insulin (Patient #B8).

Findings:
1) No protocols for RN managment of a patient (Patient #E1) with declining/deteriorating medical status, not seen by a licensed practitioner/transferred to a higher level of care.
Review of the root cause analysis conducted by the hospital, after the death of Patient #E1 in 9/2014, (patient with declining /deteriorating condition not seen by a licensed practitioner/not transferred to a higher level of care ) revealed the committee found no deficient practice and no further actions needed.
An Immediate Jeopardy situation was identified on 7/7/15 at 7:10 p.m. regarding failure of the hospital to have a system in place to address the physician assessing patients, in a timely manner, with deteriorating medical conditions that are not transferred to a higher level of medical care. Specifically, the physician failed to assess in a timely manner, a patient (Patient #E1) who was repeatedly reported by the RN (RN3) to have significant changes in his physical condition. The hospital also failed to implement processes to provide guidance for RN staff to prevent further occurrences related to deteriorating conditions for patients that are not transferred to a higher level of medical care.

2) Medication errors related to insulin administration
Review of the medical record for Patient #B8 from his admission on 6/25/15 through 7/7/15 revealed 6 documented errors in insulin administration identified during the survey process.
In an interview on 7/8/15 at 2:53 p.m. with Corporate Quality, she verified the above documented insulin administration errors. She verified there were different staff members on different shifts making different errors. She said the staff needed training on insulin administration.

Review of the Quality Improvement Report presented by Quality/ICO as the hospital 's QAPI documentation revealed no documented evidence of data collection/analysis related to a need for revision of protocols for RN management of patients with decline/deterioration of medical status when the patient is not seen by a licensed practitioner/not transferred to a higher level of care. Further review revealed no documented evidence of indicators specifically addressing medication errors involving insulin administration.

In an interview on 7/6/15 at 3:02 p.m. with the DON, she indicated the nursing staff on the night shift had to double check their own insulin doses because there was only one nurse (RN) in the adult and geriatric units at night. She said the nurses could not leave their units because that would leave the unit unattended by a RN. She said there was no LPN staff on the night shift after 11:00 p.m.

In an interview on 7/8/15 at 2:00 p.m. with Quality/ICO she indicated the hospital had not identified lack of protocols for RN management of patients with decline/deterioration of medical status when the patient is not seen by a licensed practitioner/not transferred to a higher level of care as a problem area. Quality/ICO confirmed the QAPI plan currently had no indicators specific to medication errors involving insulin administration. She said corporate usually designated the indicators for the hospital to focus on for performance improvement. She confirmed the indicators were not hospital specific.

Based on QAPI (quality assurance performance improvement) documentation review and interview, the hospital failed to formulate an action plan aimed at performance improvement as evidenced by:
1) Failure to identify and implement corrective action relative to the need for establishment of protocols for guidance of RN (registered nurse) staff in the management of patients with decline/deterioration of medical status (Patient #E1) when the patient is not seen by a licensed practitioner/not transferred to a higher level of care;
2) Failure to identify and implement corrective action relative to errors in administration of insulin (Patient #B8);
3) Failure to identify and implement corrective action relative to deficiencies in Infection Control practices related to Isolation Precautions/Practices (Patient #B7,#B8).

Findings:

1) Failure to identify and implement corrective action relative to the need for establishment of protocols for guidance of RN (registered nurse) staff in the management of patients with decline/deterioration of medical status (Patient #E1) when the patient is not seen by a licensed practitioner/not transferred to a higher level of care.
Review of Root Cause Analysis for the event on 9/3/14 (Patient #E1's death) revealed in part the patient's change of condition was identified and steps were taken as directed in Policy Treatment-Spec-11 Early Response Intervention to Deteriorating Patient Condition/change in condition. No staff related issues identified. No uncontrollable external factor influenced this outcome. Patient's medical history of Huntington's Disease directly affected the patient's condition. No communication issue identified in this event. Several types of communication were utilized; verbal, telecommunication, and hand-off communication. No barriers to communication were identified in this event. Charge nurse effectively communicated with the patient's physician and leadership staff regarding a change in the patient's condition. No actions were identified as needing to be changed due to this patient's death.

An Immediate Jeopardy situation was identified on 7/7/15 at 7:10 p.m. regarding failure of the hospital to have a system in place to address the physician assessing patients, in a timely manner, with deteriorating medical conditions that are not transferred to a higher level of medical care as evidenced by the hospital failing to have a system in place to address patients with deteriorating medical condition. Specifically, the physician failed to assess in a timely manner, a patient (Patient #E1) who was repeatedly reported by the RN to have significant changes in his physical condition. The hospital also failed to implement processes to provide guidance for RN staff to prevent further occurrences related to deteriorating conditions for patients that are not transferred to a higher level of medical care.

An interview was conducted with the DON on 7/6/15 at 2:00 p.m. She reported with review of the Root Cause Analysis, the hospital felt there were no identifiable systems that needed to be reviewed or changed. She reported no changes had been made to the process since the death of Patient #E1.

2) Failure to identify and implement corrective action relative to errors in administration of insulin (Patient #B8).

Review of the medical record for Patient #B8 from his admission on 6/25/15 through 7/7/15 revealed 6 documented errors in insulin administration.

In an interview on 7/6/15 at 3:02 p.m. with the DON, she indicated the nursing staff on the night shift had to double check their own insulin doses because there was only one nurse (RN) in the adult and geriatric units at night. She said the nurses could not leave their units because that would leave the unit unattended by a RN. She said there was no LPN staff on the night shift after 11:00 p.m.

In an interview on 7/8/15 at 2:53 p.m. with Corporate Quality, she verified the above documented insulin administration errors. She verified there were different staff members on different shifts making different errors. She said the staff needed training on insulin administration.

3) Failure to identify and implement corrective action relative to deficiencies in Infection Control practices related to Isolation Precautions/Practices (Patient #B7,#B8).

On 7/7/15 and 7/8/15 during multiple observations, the following infection control issues were noted:
Patients with MRSA (Methicillin-resistant Staphylococcus aureus) had no signage indicating contact precautions on their room doors, orders for contact precautions were not placed in the medical records of Patients #B7 and #B8 and no indications were noted on their Kardex that they were on contact precautions as per the hospital's policies and procedures for MRSA;

Patient #B7 (positive for MRSA) was placed in a room with another patient who was not positive for MRSA;
Proper hand hygiene and accepted standards of practice for infection control were not followed during blood glucose monitoring and insulin administration on a patient (#B8) with MRSA. During an observation on 7/7/15 at 11:05 a.m. and 7/8/15 at 11:00 a.m., LPN1 was observed performing blood glucose monitoring and administering insulin. During the observation the following breaches were noted: cross contamination of patients with contact precautions, improper hand hygiene and glove usage, failing to properly disinfect a glucometer, and improper sharps disposal.

Review of a Microbiology Culture Reports for Patient #B8 dated 6/28/15 and Patient #B7 dated 6/30/15 revealed the following footnote: This organism (MRSA) is a multi-drug resistant organism and potential pathogen that mandates the institution of contact isolation.

In an interview on 7/6/15 at 3:30 p.m. with the DON, she indicated there were no patients on any type of isolation precautions on either the adult or geriatric-psychiatric unit.

In an interview on 7/7/15 at 10:00 a.m. with Quality/ICO, she verified Patient #B10's door was incorrectly marked for contact precautions. She also stated Patient #B7 and Patient #B8 did not have contact precautions but should have. She also verified Patient #B7 and Patient #B8 did not have their Kardex flagged or the order in their charts as per policy.

In an interview on 7/7/15 at 10:11 a.m. with Quality/ICO, she verified Patient #B7 should have been in a private room or in a room with another patient with an MRSA infection but was not.

In an interview on 7/8/15 at 2:00 p.m. with RN3, he verified there had been several breeches in infection control when LPN1 had done the blood glucose and insulin injection on Patient #B8.

Review of the Quality Improvement Report presented by Quality/ICO as the hospital 's QAPI documentation revealed no documented evidence of data collection/analysis related to protocols for RN management of patients with decline/deterioration of medical status when the patient is not seen by a licensed practitioner, medication errors involving insulin administration, appropriate use of PPE for isolation precautions, utilization of appropriate signage for isolation precautions, and audits of charts for timely initiation of isolation precautions.



In an interview on 7/8/15 at 2:00 p.m. with Quality/ICO she indicated the hospital had not identified lack of protocols for RN management of patients with decline/deterioration of medical status when the patient is not seen by a licensed practitioner/not transferred to a higher level of care as a problem area. Quality/ICO confirmed the QAPI plan currently had no indicators specific to medication errors involving insulin administration. She said corporate usually designated the indicators for the hospital to focus on for performance improvement. She also confirmed appropriate use of PPE for isolation precautions, utilization of appropriate signage for isolation precautions, and timely initiation of isolation precautions were not currently identified as problems to be addressed through QAPI in the form of performance improvement projects. She confirmed they were not hospital specific.

Based on record reviews and interviews, the hospital failed to meet the Condition of Participation of Medical Staff as evidenced by:

1) Failing to have a system in place to address the physician assessing patients, in a timely manner, with deteriorating medical conditions that are not transferred to a higher level of medical care as evidenced by:

An Immediate Jeopardy situation was identified on 7/7/15 at 7:10 p.m. due to the hospital:
a.) Failing to ensure the physician assessed, in a timely manner, a patient who had been repeatedly reported by the RN to have significant changes in his physical condition. (See findings at tag A-0347).
b.) Failing to implement processes to provide guidance for RN staff to prevent further occurrences related to deteriorating conditions for patients that are not transferred to a higher level of medical care. (See findings at tag A-0347).

a) The physician failed to assess in a timely manner, a patient who was repeatedly reported by RN to have significant changes in his/her physical condition:

On 9/2/14 at 4:15 p.m. the patient was assessed by RN1 to have increased movements, sweating and restlessness. APRN1 (Advanced Practice Registered Nurse) was notified of these findings. She told nursing staff to notify Psychiatrist if sweating continued.

On 9/2/14 at 5:45 p.m. MD1 (psychiatrist) was notified that patient was sweating to the point that his shirt had to be changed and his movements had increased. No new orders noted. RN1

A comprehensive metabolic panel was ordered for the a.m. (9/3/15) and the Geodon dose was held until MD1(psychiatrist) could assess the patient in the a.m. Review of the patient 's medical record revealed no assessment of the patient by MD1 (psychiatrist) or any physician.

On 9/3/14 at 8:10 a.m.: patient very restless, anxious, unable to sit in wheelchair, slipping out, patient very clammy and sweaty. MHTs instructed by RN3 to put patient to bed to rest. Patient able to communicate with staff at this point. DON and hospital administrator (CEO)notified. RN3

9/3/14 at 8:15 a.m.: entry by DON: Notified of change of condition of patient. Observed the patient in bed. Patient alert, restless, moving legs constantly. Advised nurse to notify psychiatrist.

9/3/14 at 08:20 a.m.: MD1 (psychiatrist) notified for the 2nd time of patient 's condition. MD1 (psychiatrist) informed by telephone of constant jerking, restlessness, profuse sweating and inability to get comfortable. MD1(psychiatrist) ordered Ativan 1 milligram.RN3

9/3/14 at 09:00 a.m.: Patient still sweating decreased jerking, but breathing has become labored. Oxygen saturation 95% at this time, supplemental oxygen (2 liters) started by RN3 due to patient's difficulty breathing. RN3

9/3/14 at 09:30 a.m.: Oxygen saturation still fluctuating between high 80's and low to mid 90's. Remains with labored breathing. Oxygen at 2 Liters. Checked patient's blood glucose= 84. RN3

9/3/14 at 10:00 a.m.: patient's condition unchanged, oxygen saturations still fluctuating between high 80's and low 90's. Will notify MD1 (psychiatrist) of patient's condition. RN3.

9/3/14 at 10:04 a.m.: RN3 walked to adult unit to notify MD1 (psychiatrist) of patient's condition. Explained to him (MD1-psychiatrist) that he (patient) is still sweating profusely, his breathing is still labored, beginning to become hard to stimulate. Could we send him out to get him medically cleared? He explained to me he was (the patient) in an acute ataxia episode and he (MD1-psychiatrist) will see him soon. RN3.

9/3/14 at 10:47 a.m. MD1 (psychiatrist) contacted the nurse (RN3) to give patient Zyprexa 2.5 mg po (by mouth) due to the patient's increased anxiety at this point. Patient was found unresponsive, not breathing, no blood pressure.RN3

b. The hospital failed to implement processes to provide guidance for RN staff to prevent further occurrences related to deteriorating conditions for patients that are not transferred to a higher level of medical care.

Review of the hospital's protocols and policies revealed no process for managing patients with conditions deteriorating that are not assessed by a physician who are not transferred to a higher level of care.

A corrective action plan to lift the Immediate Jeopardy was presented by the CEO, on 7/8/15 at 8:42 a.m.:

Review of the hospital's Corrective Action Plan documentation for lifting of the Immediate Jeopardy revealed the following:
DON informed charge RN and LPNs on the 7p.m. shift on 7/7/15 at 8:00 p.m. of her presence in the hospital and the need to be notified of any deterioration of patient condition for further directives until new protocol could be implemented within the next couple of hours.
8:55 p.m. - Deteriorating/Emergent Medical and/or Psychiatric Condition Action was completed;
9:00 p.m. - Deteriorating/Emergent Medical and/or Psychiatric Condition Action was approved by the CW (committee of the whole) and the Medical Director;
9:15 p.m.- Deteriorating/Emergent Medical and/or Psychiatric Condition Action was approved by the Governing Body (the CEO and Senior Vice President of Compliance & Outcomes);
9:15 p.m.- Approved action was implemented via education by the DON to the Charge RN and LPNs on both the adult and geriatric units. The Action Plan was also posted at each nurses station for easy reference.
On 7/8/15, during routine observations, performed by surveyors, on the units (geriatric and adult) the Action Plan was noted to be posted in the units ' nurses ' stations.
7/8/15-2:40 a.m.; Revisions of PC-13: Provision of Emergency Services, AS-07: Medical Consultation, Requests for and TX-SPEC-11: Early Response Intervention to Deteriorating Patient Condition/Change in Condition were completed as well as Reviews of TX-SPEC 13:Code Blue Response and LD-08: Chain of Command, Authority Delegation for Administration on Call, Physician Supervision;
7/8/15- 2:45 a.m. - Revised policies were reviewed and approved by the CW- Medical Director with no further recommendations made.
7/8/15- 2:53 a.m. - Revised policies were reviewed and approved by CW.
7/8/15 - 3:00 a.m. - Revised policies were reviewed and approved by the Governing Body, the CEO and Senior Vice President of Compliance & Outcomes with no further recommendations made.
7/8/15- 5:30 a.m.: Roll out Education Plan and Outline of PI (Performance Improvement) monitors were completed.
PI Monitoring:
The following 2 PI monitors will be tracked for 90 days on 100% of applicable patients. The DON will be responsible for completing these monitors and reporting results to PI, CW and GB Committees. The DON will be responsible for plan of corrections as needed for deficient practices identified.
#1- Response to Deteriorating/Emergent Medical and/or Psychiatric Condition/Provision of Emergency Services: 100% monitoring for 90 days of all patients identified with a deteriorating or emergent medical and/or psychiatric condition and were provision of emergency services were provided.
#2- Medical Consultations: 100% of all MD ordered, time specified on-site assessments/consults for 90 days.

The revised policies, staff education materials and sign in rosters indicating staff completion of education on new policies/procedures were reviewed by the survey team on 7/8/15 (prior to lifting of Immediate Jeopardy).
The 2 RNs working the day shift on 7/8/15, S9RN and S17RN, were interviewed regarding training on the new policies and procedures referenced above. They were both knowledgeable of the new policies and procedures to follow regarding management of deteriorating patients and the proper notification of the chain of command at the administrative level. They both indicated after 2nd notification of staff they were to call a Code Blue or 911.

The CEO confirmed, in interview, on 7/8/15, during presentation of the plan of lifting, that staff would not be allowed to work until they had been trained on the new policies and procedures referenced above.

After review of the Action Plan for lifting of the Immediate Jeopardy Situation, the team held a meeting, discussed the actions taken by the hospital and decided the Immediacy of the Immediate Jeopardy situation had been removed. The Immediate Jeopardy situation was lifted on 7/8/15 at 9:09 a.m. The Immediacy has been lifted though there was not enough evidence to determine sustainability of Compliance for the Condition of Medical Staff to be cleared. Non-compliance remains at the Condition Level.

Based on record review and interview, the hospital failed to ensure the medical staff was accountable for the quality of medical care provided to a patient as evidenced by:
a. failing to ensure the physician assessed, in a timely matter, a patient (Patient #E1)who had been repeatedly reported by the Registered Nurse to have significant changes in his physical condition.
b. failing to implement processes to provide guidance for RN staff to prevent further occurrences related to deteriorating conditions for patients that are not transferred to a higher level of medical care.
c. failed to ensure the members of the Medical Staff were held accountable for the quality of care provided to patients as evidenced by a medical staff member not pronouncing dead 2 (# E1,#E2) out of a total of 2 deceased patients in the last year.

Findings:

a. failing to ensure the physician assessed, in a timely matter, a patient (Patient #E1)who had been repeatedly reported by the Registered Nurse to have significant changes in his physical condition.

Review of the hospital's policy on Early Response Interventions to Deteriorating Patient Conditions/Change in Condition, Policy TX-SPEC-11 revealed in part, It is the policy of the facility to improve recognition and response to changes in a patient condition. This facility identifies unexpected acute illnesses which pose life threatening situations for our patients. This facility identifies (1) for situation in which an individual's psychological health is deteriorating and they are becoming a threat to themselves and others. (2) respiratory/cardiopulmonary arrest and (3), response to abnormal changes/fluctuation in a patients status; I & O (Input and Output), CBG (capillary blood glucose) levels and Vital signs...It is policy that an MD/DO (onsite or on call) may directly provide appraisals of emergency, provide medical direction/oversight of onsite staff conducting appraisal or provide initial treatment directly...II. Early Intervention Plan/Criteria for Calling Additional Response Assistance/Assessment.
Early recognition and response to early warning signs prior to a cardiopulmonary or respiratory arrest may assist in reducing patient mortality.
A. Early Warning Signs: Cardiopulmonary/Respiratory Arrest...
Discomfort in other areas of the upper body. Can include pain or discomfort in one or both arms, the back, neck, jaw or stomach. Shortness of breath. Often comes alone with chest discomfort. But it can also occur before chest discomfort. Other symptoms. May include breaking out in a cold sweat, nausea, or light headedness.
B. Early Warning Signs: Respiratory Arrest: agitation, confusion, struggling to breath, tachycardia and diaphoresis are present, there may be intercostal or sternoclavicular retractions. Patients with CNS (Central Nervous System) impairment or respirations and paradoxical breathing movements. Patients with a foreign body in the airway may choke and point to their necks. Early Intervention Plan-Staff: Should a patient be experiencing these symptoms seek additional assistance by: Tell nurse who will provide immediate assessment, intervention & identify need for immediate referral as necessary.
Nursing
A. Call the physician on site or on call to provide appraisal/oversight initial treatment
B. Call attending psychiatrist and apprise of situation
C. Should a medical emergency exist, follow Provision of Emergency Services policy and implement physician orders.

Review of the hospital's policy on Provision of Emergency Services, Policy # PC-13, revealed in part, Procedure/Inpatient- Nurse- All patients are assessed daily by a RN (Registered Nurse) to ensure all psychiatric and medical needs are being identified. The attending physician is notified of any medical needs. Medical consults are ordered and provided based on the assessments and physician's orders. If the medical condition is deemed emergent, the nurse may call the Physician on-call for consultation, direction and/or transfer order to the emergency department.

Patient #E1
Review of Patient #E1's medical record revealed he was a 70 year old male admitted on 8/18/14 with a diagnosis of Recurring Depression with Psychotic symptoms. His past medical history was listed as Huntington's Disease and Diabetes Mellitus II. His chief complaint was listed as he was having "Disruptive Behavior in the Nursing Home." Review of his History and Physical Examination, dated 8/20/14, revealed he had chorea form movements. His plan of care was to observe and adjust treatment as needed.

Review of Patient #E1's Psychiatric Evaluation, dated 8/19/2014, revealed the chief complaint was, "The nursing home reports an increase in aggressive behavior as well as weight loss." Reason for Admission: 1. The patient presents as a danger to self. 2. The patient presents as a danger to others. 3. Decreased appetite with weight loss. 4. Inappropriate outburst. 5. The patient needs medication stabilization...The nursing home reported that he has become more aggressive toward other staff members and that he has even been resisting them to assist him with all of his needs. It was observed by some of the staff that he was attempting to kick people as they passed by or even if they got too close. His wife reported that there were multiple medication changes starting at the beginning of this month and that he has had significant decrease in appetite since the beginning of the month. Reportedly, he lost 16 lbs (pounds) in the past 11 days...Patient #E1 does have Huntington's disease and does have some spastic movements. During the interview, they did appear to be slightly worse than when he left in July. He also seemed to be more verbal and his voice seemed to be a lot louder than when he left as well. He was more impulsive and when asking a question he would shout it out rather than speaking in a normal tone... The patient was oriented X 3 (person, place and time).

Review of the patient's Louisiana Physician Orders for Scope of Treatment (La Post) revealed the patient had Huntington's Disease and he had decided to have a DNR (Do not Attempt Resuscitation) (Allow Natural Death) status. He did agree to the option that he would do a trial period of artificial nutrition by a tube and IV (Intravenous) fluids for 30 days.

Review of the Nursing Initial Interview and Assessment, dated 8/18/14, revealed the patient had dysphagia with choking, gurgling on liquids and malnutrition (greater than 10 lb (pound)lost in 3 months).

Review of the Physician Orders revealed an order for a CBC (Complete Blood Count) and CMP (Complete Metabolic Profile) on 9/2/14 at 1745 (5:45 p.m.).

Review of the CBC collected on Patient #E1 revealed his White Blood Count (WBCs) were 17.4 (high). The reference range was listed as 4.0-11.0. The print date and time was listed as 9/3/14 at 8:03:57 a.m.

Review of the Nutrition Assessment, dated 8/21/14, by the Clinical Dietician revealed the patient was assessed as being currently on a diet of chopped meat and nectar thick liquids. Patient #E1 had lost 16 lbs recently and he had mild protein storage depletion. He was started on Two Cal 4 oz (ounces) BID (twice a day) po (by mouth) for protein and calories. He was identified as a choking risk.

Review of the Multi-Disciplinary Notes revealed the following:
9/2/14 1615 (4:15 p.m.) - Pt. (Patient) sweating, (Arrow up) increased movements, Restlessness, CBG (Capillary Blood Glucose) 93, B/P (blood pressure) 118/66, T (temperature) 98.4, APRN1 notified, Orders given to monitor few hours if sweating continues notify MD1 (psychiatrist). Will continue to monitor. RN1

9/2/14 1745 (5:45 p.m.)- Pt. sweating to the point that his shirt had to be changed. MD1 (psychiatrist) notified CBG 93 and B/P and temp (temperature) WNL (within normal limits). Increased (arrow up) movements reported to dr. (doctor) no orders noted. Do CMP (Complete Metabolic Profile) and CBC (Complete Blood Count) in a.m. and Hold Geodon until MD1(psychiatrist) sees the pt. tomorrow. RN1.

9/3/14 8:15 a.m. Evaluated pt's condition, pt very restless, anxious, unable to sit in w/c (wheelchair), slipping out, also pt. is very clammy, sweaty. B/P 154/64, P (pulse)120, T 98.9 Instructed MHTs (Mental Health Technicians) to put pt. in bed to rest, pt. able to communicate with staff at this point. Notified DON and CEO on the unit. Will continue to monitor. RN3

9/3/14 8:15 a.m. Charge Nurse, RN3, informed myself and CEO of condition of patient. Observed patient in bed, MHT changing incontinent diaper. Pt. alert, restless, moving legs constantly. Advised RN3 to notify MD1 (psychiatrist), which he planned to do. DON

9/3/14 8:20 a.m. MD1 (psychiatrist) notified of pt's condition, informed MD1 of pt.'s constant jerking restlessness, perfuse sweating and his inability to get comfortable, Pt. sill able to make needs known at this point. MD1 (psychiatrist) ordered Ativan 1 mg (milligram) po (by mouth) now x 1 (1 dose) for increased anxiety r/t (related to) disease process. Will continue to monitor. RN3

9/3/14 9:00 a.m.- Went to pt.'s room to assess, pt. still sweating, decrease (arrow down) jerking, but breathing has become labored. O2 (oxygen) sat (saturation) 95%, put pt on O2 at this point to supplement. 2 L (liters) per NC (nasal cannula) administered. O2 dipped to 88% then went back to 95%. Will continue to monitor. RN3.

9/3/14 9:30 a.m. -Went to pt.'s room , O2 sats (saturation) still fluctuating b/t (between) high 80's and low to mid 90's. Remains with labored breathing O2 at 2L/min (Liters per minute) per NC (nasal cannula) Checked pt.'s CBG (Capillary Blood Glucose) was 84. Will continue to monitor. RN3;

9/3/14 10:00 a.m.- Pt.'s condition unchanged, O2 sats still fluctuating b/t 80's and low to mid 90's Will notify MD1(psychiatrist) of pt.'s condition, will continue to monitor. RN3;

9/3/14 10:04 a.m.-Walked to the adult unit to notify MD1(psychiatrist) of pt.'s condition, explained to him that he's still sweating profusely, his breathing is stilled labored, beginning to become hard to stimulate, and could we send him out to get medically cleared. He explained to me that he (the pt.) was having an acute ataxia episode, and that he will see him soon. Walked back to the unit. Will continue to monitor. RN3

9/3/14 1047- MD1( psychiatrist) contacted me to give pt. 2.5 mg (milligrams) po (by mouth) of Zyprexa due to his increased (arrow up) anxiety, at this point pt. was found unresponsive, not breathing, no b/p, no code called, pt. DNR (Do not Resuscitate). RN3

9/3/14 11:00 a.m.- 911 called. RN3

9/3/14 11:02 a.m.- MD1(psychiatrist) notified pt. not responding. RN3

9/3/14 11:13 a.m.-Ambulance arrived on the unit performed EKG (Electrocardiogram) with flat line as the result. RN3

9/3/14 11:14 a.m.-Notified coroner of results of Ambulance's EKG and therefore lack of V/S(Vital Signs). Instructed to release body to family's choice of Funeral Home. RN3


An interview conducted on 7/7/15 at 10:57 a.m. with RN3, he reported he was the nurse assigned to care for Patient #E1 when he died (9/3/14). He went on to state it was the patient's third admit to the facility and every time he was readmitted his disease process had progressed. RN3 reported he remembered Patient #E1 vividly because he had nightmares about that situation for months. He said after breakfast, on 9/3/14, a MHT told him Patient #E1 was very uncomfortable. RN3 reported he went to assess the patient.. He reported the patient had involuntary movements, which were typical for him, but he reported Patient #E1's breathing was different. He reported he called MD1(psychiatrist) and notified him of the patient's condition and he ordered Ativan for the patient. RN3 reported he placed oxygen on the patient because something was different about the patient. RN3 reported the patient was still talking and able to answer questions at this time. RN3 reported the CEO was making rounds so he reported Patient #E1's declining status to her. RN3 further reported he discussed the patient with the DON and she told him to keep monitoring the patient. RN3 reported he went next door (to the adult unit) and spoke face to face with MD1 (psychiatrist) and described his assessment of the patient to MD1 (psychiatrist) and asked if the patient could be sent out for medical clearance. RN3 reported MD1(psychiatrist) told him it was just the symptoms of the patient's Huntington's Disease. RN3 went on to report he went to the next unit to get MD1(psychiatrist) to examine the patient because that was the immediate resource available to him to obtain assistance for his patient. He also went on to explain to MD1(psychiatrist) the patient's behavior at breakfast. MD1 (psychiatrist) reported to RN3 it was the patient's disease process, but he would be over shortly to look at the patient. RN3 reported he thought the physician would be over to examine the patient in about 15 -20 minutes. MD1 (psychiatrist) was in a treatment team meeting and never came to examine the patient. RN3 reported he and the MHT never left the patient's side. He further reported 40 minutes later MD1 (psychiatrist) called him with an order to administer 2.5 mg of Zyprexa to the patient and when he went to administer the medication the patient had expired. He said he knew the patient was a DNR (Do Not Resuscitate), but he wanted to make the patient as comfortable as possible. EMS (Emergency Medical Services) were called and came to the hospital and obtained an EKG on the patient and EMS pronounced the patient, the hospital then called the coroner's office.

An interview was conducted on 7/7/15 at 1:28 p.m. with MD1 (psychiatrist). MD1 (psychiatrist) indicated was very familiar with Patient #E1. He had treated the patient many times. He went on to report on 9/2/14 the patient had increased agitation, shaking, his vital signs were stable, he had hyperventilation, which continued through 9/3/14 (the next day). The patient's vital signs remained stable, most of the symptoms which were described to him was related to the patient's Huntington's Disease. MD1 (psychiatrist) called on the evening of 9/2/14 due to the patient having increased sweating and his vital signs were stable. RN3 called him at 8:00 a.m. the next morning because the patient was sweating and hyperventilating (labored breathing). MD1(psychiatrist) reported the patientwas having an ataxic attack. He further reported he was trying to relieve his symptoms with medications. MD1 reported the medical physician saw the patient initially on admission to perform the H&P (History and Physical). MD1 reported the patient was receiving treatment stabilization of his psychiatric disorder symptoms. He reported there was no treatment for Huntington's Disease, but the involuntary movement were part of the psychiatric issue. Treatment for late Huntington's Disease is to place the patient on antipsychotic medications. Psychiatric symptoms were being treated at this hospital. When questioned on what kept him from assessing the patient when the patient had a deteriorating condition since he was physically in the building; he reported he was seeing another patient and he knew Patient #E1 had these ataxia symptoms previously. He reported he also knew the patient had a DNR status (a code was not called) so he didn't come as quickly. When questioned on how he determines if he needs to assess a patient or not, he reported it depended on the presentation of the patient's symptoms. MD1 was given the results of the CBC (Complete Blood Count) and CMP(Complete Metabolic Profile) he had ordered on Patient #E1 on the evening of 9/2/14. He reported he had not seen the labs results and if he had seen the results he would have ordered a Medical Doctor consult due to a possible infectious process. Review of the lab results revealed the lab results had been faxed to the hospital on 9/3/14 at 8:00 a.m.

An interview was conducted with the Medical Director on 7/8/15 at 10:05 a.m. He reported he had reviewed Patient #E1's death. He understood the patient had about a 12- 14 hour decline in condition prior to his death. The Medical Director reported MD1 (psychiatrist) should have assessed the patient on the morning of 9/3/14 especially since he was physically present in the building. He went on to report he should had ordered stat labs, not routine labs, on the evening of 9/2/14 and reviewed the results immediately. Medical Director reported, it is basic that if a physician orders labs, he is responsible for following up on the labs.

b. failing to implement processes to provide guidance for RN staff to prevent further occurrences related to deteriorating conditions for patients that are not transferred to a higher level of medical care.

Review of Root Cause Analysis for the event on 9/3/14 (Patient #E1's death) revealed in part the patient's change of condition was identified and steps were taken as directed in Policy Treatment-Spec-11 Early Response Intervention to Deteriorating Patient Condition/change in condition. No staff related issues identified. No uncontrollable external factor influenced this outcome. Patient's medical history of Huntington's Disease directly affected the patient's condition. No communication issue identified in this event. Several types of communication were utilized; verbal, telecommunication, and hand-off communication. No barriers to communication were identified in this event. Charge nurse effectively communicated with the patient's physician and leadership staff regarding a change in the patient's condition. No actions were identified as needing to be changed due to this patient's death.

An interview was conducted with the DON on 7/6/15 at 2:00 p.m. She reported with review of the Root Cause Analysis, the hospital felt there were no identifiable systems that needed to be reviewed or changed. She reported no changes had been made to the process since the death of Patient #E1.


c. failed to ensure the members of the Medical Staff were held accountable for the quality of care provided to patients as evidenced by a medical staff member not pronouncing the death for 2 (# E1,#E2) of 2 (#E1,#E2) deceased patients reviewed in the last year.

Patient E1
Review of Patient #E1's medical record revealed he was a 70 year old male admitted on 8/18/14 with a diagnosis of Recurring Depression with Psychotic symptoms. His past medical history was listed as Huntington's Disease and Diabetes Mellitus II. He had a DNR status and expired on 9/3/14 at the facility.

An interview was conducted with RN3 on 7/7/15 at 10:55 a.m. He reported he was the nurse assigned to care for Patient E1 on 9/3/14 when the patient expired. After the patient expired, EMS (Emergency Medical Services) were called and came to the hospital and obtained an EKG on the patient (flat EKG). The EMS pronounced the patient, the hospital then called the coroner and was told the hospital could release the body to the family's funeral home of choice.

Patient #E2
Review of Patient #E2's medical record revealed she admitted on 5/28/14 with a diagnosis of Major Depressive Disorder. She was full code status and expired on 5/30/14 at the facility. Review of the discharge (death) summary, dated 5/30/14, revealed the following: The patient had continuous cessation of all vital signs and was pronounced deceased by ER (emergency room) physician, via telephone with EMS EMT.

In an interview on 7/7/15 at 9:40 a.m. with the CEO, she indicated that she had not known patients could not be pronounced by ER physicians who had been notified of a patient death by responding paramedics.

In an interview on 7/7/15 at 4:14 p.m. with MD3 he indicated that if a death occurred in the hospital, he said paramedics can pronounce death and the physician can certify it later.

30364




30984


Based on record review, observation and interview, the registered nurse failed to supervise and evaluate the care provided to patients as evidenced by:
1. failing to ensure vital signs were obtained as ordered by the practitioner for 1 (#B8) of 3 (#B8,#B9,#E2) patients whose medical record was reviewed for the assessment of vital signs being obtained as ordered.
2. failing to ensure the accuracy of documentation (initiating precautions as ordered by the physician) relating to a patient assessed to be a danger to self and aggressive toward others and a patient assessed to be a moderate suicide risk, who are placed on close observation q (every) 15 minutes for 2 ( #B8,#D8) of 10 patients sampled for observations.
3. failing to ensure registered nurses performed observations of the patients every 2 hours as per hospital policy for 2 (#A7,#D8) of 10 patients sampled for observations.


Findings:

1. Failing to ensure vital signs were obtained as ordered by the practitioner for 2 of 2 patients whose medical record was reviewed for the assessment of vital signs being obtained as ordered.

Patient # B8:
Review of the medical records for Patient #B8 revealed he was admitted to the Geri-Psychological Unit on 6/25/15 with diagnoses which included a Stage IV Sacral Ulcer, lower back ulcer, Neurogenic Bladder, Anemia, Paraplegia, Diabetes Mellitus-Type II, Hypothyroidism, Deep Vein Thrombosis and Cerebrovascular Accident. Further review revealed the patient had a colostomy and an indwelling Foley catheter.
Review of the admission orders revealed orders dated 6/25/15 indicating that routine vital signs were to be obtained three times daily. Review of the record revealed that Patient #B8's vital signs were not obtained as ordered. Documentation in the medical record revealed that Patient #B8's vital signs were obtained on the following dates and times:
6/25/15 - patient admitted at 3:30 p.m.: vital signs on admission. No documented evidence of vital sign assessments for evening shift or night shift;
6/28/15 - No documented evidence of vital sign assessments on the day or evening shift;
6/29/15 - no documented evidence of vital sign assessments on the night shift;
7/2/15 - no documented evidence of vital sign assessment on the night shift.

In an interview on 7/6/15 at 3:02 p.m. with the DON, she indicated the TID vital signs on the geriatric psychiatric unit were obtained as follows: 2 sets on the day shift and one set on the night shift. The DON confirmed, after review of Patient #B8 ' s vital sign record, that the patient ' s vital signs had not been obtained as ordered by the physician.


2. Failing to ensure the accuracy of documentation (precautions documented as ordered by the physician) relating to a patient assessed to be a danger to self and aggressive toward others and a patient assessed to be a moderate suicide risk, who are placed on close observation q (every) 15 minutes.

Patient #B8
Review of Patient #B8's medical record revealed that the patient was admitted on a Formal Voluntary Commitment due to being a "danger to self" and aggressive toward others. Review of the physician's orders revealed an order dated 6/25/15 indicating that the patient was to be placed on close observation - q 15 minute observational level with the following precautions: elopement, falls, assault and bleeding. Review of the "observation check sheet" completed by the mental health technicians revealed the following:
6/25/15: Observation level: q 15 minute observations; precautions: falls;
6/26/15: Observation level: q 15 minute observations; precautions: falls, bleeding;
6/27/15: Observation level: q 15 minute observations; precautions: falls, bleeding;
6/28/15: Observation level: q 15 minute observations; precautions: falls, bleeding;
6/29/15: Observation level: q 15 minute observations; precautions: blank, observations stopped at 11:15 p.m.: patient sleeping;
7/1/15: Observation level: q 15 minute observations; precautions: falls, observations began at 4:45 p.m. on 7/1/15;
7/2/15: Observation level: q 15 minute observations; precautions: falls;
7/3/15: Observation level: q 15 minute observations; precautions: falls, bleeding;
7/4/15: Observation level: q 15 minute observations; precautions: falls, bleeding.

In an interview on 7/7/15 at 3:25 p.m. with the CEO, she indicated the q 2 hour charge RN signature on the observation flow sheet was an attestation, by the RN, that the mental health technicians (MHTs) had been performing q 15 minute observations as ordered. She agreed the RN charge nurse, at the time of review, should have been verifying that the observation level and precautions were documented as ordered.

In an interview on 7/6/15 at 3:02 p.m. with DON, she confirmed, after review of Patient #B8's "observation check sheet" that the staff failed to consistently indicate that the patient was on elopement, fall, assault and bleeding precautions.

Patient #D8
Review of Patient #D8 medical record revealed she was a 35 year old femaled admitted to the facility on 3/25/15 for Bipolar disorder without Psychosis. Reveiw of her Admit Orders/Initial Plan of Care dated 3/25/15 revelaed she was placed on sucide precautions and an observation level of close observation every 15 minutes. Review of her Suicide Assessment,dated 3/35/15, revealed she was assessed as being a moderate suicide risk
Review of Close Observation Sheets dated 3/25/15 through her discharge date from the faciltiy on 4/6/15 (12 days) revealed she was on an observation level of every 15 minutes, but no precautions were documented as being monitored through Patient #D8's entire hospitalization.
An interview was conducted with DON on 7/6/15 at 2:30 p.m. She reported there should had been documentation on the observation level sheet of the precautions the patient was ordered to be on by the physician.

3. Failing to ensure registered nurses performed observations of the patients every 2 hours as per hospital policy for 2 (#A7 and #D8) of 10 patients sampled for observations.

Review of the hospital policy titled Level of Observations revealed in part:
The Registered Nurse must perform observations in addition to the other assigned staff. The RN will initial their rounds in the column indicating RN rounds.

Patient #A7
Review of the Close Observation Check Sheets for Patient #A7 revealed a notation at the top of the pages for the RN to perform nurse checks every 2 hours and initial in the right hand column. Review of the sheets revealed the following times had not been initialed:
6/24/15- 6/25/15: 6:00 a.m.
6/25/15- 6/26/15: 6:00 a.m.
6/29/15- 6/30/15: 6:00 a.m.
6/30/15- 7/1/15: 6:00 a.m.
7/2/15- 7/3/15: 12:00 a.m., 2:00 a.m., 4:00 a.m., and 6:00 a.m.
7/3/15- 7/4/15: 6:00 p.m. and 6:00 a.m.
7/4/15- 7/5/15: 6:00 p.m. and 6:00 a.m.

Patient #D8
Review of the Close Observation Check Sheets for Patient #D8 revealed a notation at the top of the pages for the RN to perform nurse checks every 2 hours and initial in the right hand column. Review of the sheets revealed the following times had not been initialed:

3/27/15- 3/28/15: 6:00 p.m. and 6:00 a.m.
3/28/15-3/29/15: 6:00 p.m.
3/29/15-3/30/15: 6:00 p.m.
4/1/15-4/2/15: 6:00 p.m.and 6:00 a.m.
4/2/15-4/3/15: 6:00 p.m.
4/5/15-4/6/15: 8:00 p.m.

In an interview on 7/6/15 at 2:40 p.m. with the CEO, she viewed Patient #A7 ' s observation sheets and verified the RN had not documented 2 hour checks as per expectations.

Based on record review and interview, the hospital failed to ensure the nursing staff developed, and kept current individualized and comprehensive nursing care plans for 3 (#B8, #B11, #A7) of 3 (#B8, #B11, #A7) patients sampled for care planning.
Findings:
Review of the hospital's policy for Treatment Planning; Integrated/Multidisciplinary,Policy Tx-Gen-02, revealed in part, The multi-disciplinary treatment team,under the direction and supervision of the attending physician, shall develop an integrated written, comprehensive Treatment Plan with specific goal and objectives necessary to address deficits identified in the assessment process... Admitting nurse: Formulates the initial treatment plan based on physician's orders/initial plan and findings and conclusions from the Pre-admission Assessment, Nursing Assessment, and family/significant other information within 8 hours of admit or sooner if patient's needs warrants immediate action. Initiates individualized treatment problem/nursing diagnosis list as identified in the assessment. Revises and develops nursing and medical components of the treatment plan based on additional findings from patient assessments, problems, needs, strengths and limitations and physician's orders. Revises plan based on changes in condition and physician's orders received. All physician order will be added to the treatment plan.
Patient #B8
Review of the medical records for Patient #B8 revealed he was admitted on 6/25/15 with diagnoses which included a Stage IV Sacral Ulcer, lower back ulcer, Neurogenic Bladder, Anemia, Paraplegia, Diabetes Mellitus-Type II, Hypothyroidism, Deep Vein Thrombosis and Cerebrovascular Accident. Further review revealed the patient had a colostomy and an indwelling Foley catheter. .
Review of Care Plans for Patient #B8 revealed no specific interventions identifying the type of isolation precautions (contact precautions) and PPE (personal protective equipment) required for isolation of a patient with a positive urine culture for Methicillin Resistant Staphylococcus Aureus (MRSA) which was a Multi Drug Resistant Organism (MDRO). Further review revealed the patient's sliding scale insulin was not addressed on the plan of care. Additional review of care plans for Patient # B8 revealed colostomy care and foley catheter care were not addressed. The care plans were documented on a pre-printed form with various choices for nursing diagnosis, interventions, goals and outcomes. The care plans were not specific or individualized.

In an interview on 7/6/15 at 3:02 p.m. with DON, she said the hospital care plans were "bland" and were not individualized to each patient.


Patient #B11
Patient #B11 was an 84 year old female admitted to the facility on 7/6/15 for Major Depressive Disorder. She also had Parkinson's Disease, Hypertension, Chronic Back Pain, Chronic Kidney Disease, and Lower Leg Edema. The plan was to adjust her medications and evaluate her feet for edema.

Review of her Plan of Care revealed no specific interventions for her medical issues including Hypertension, Chronic Back Pain, Chronic Kidney Disease, Parkinson's Disease and the chronic leg and foot edema.

An interview was conducted with the DON on 7/8/15 at 2:50 p.m. With review of the patient's plan of care, the DON acknowledged the care plan was not specific for the patient's medical issues and the plan of care was not individualized.

Patient #A7
Review of the medical record for Patient #A7 revealed she was admitted on the Adult unit
On 6/23/15 with diagnosis which included hypertension, legal blindness, and partial left foot amputation.

Review of the treatment plans for Patient #A7 revealed she had no problems identified for the above mentioned medical problems.



30364




30984

Based on record review and interview, the hospital failed to ensure drugs and biologicals were administered in accordance with the orders of the practitioner responsible for the patient's care for 1 (#B8) of 2 (#B8, #B9) patients reviewed for insulin administration.

Findings:
Review of the medical record for Patient #B8 revealed he had been admitted on 6/25/15 with diagnosis which included Major Depression, Generalized Anxiety and Diabetes Type I.
Further review revealed physician ' s orders dated 6/27/15 at 12:00 p.m. for Levemir (long acting insulin) 60 units at hour of sleep and 7 units of Novolin R (short acting insulin) before each meal. Patient #B8 also had an order for sliding scale insulin before meals.

Review of the MAR (medication administration record) for Patient #B8 dated 7/3/15 revealed the 6:30 a.m. scheduled dose of 7 units of Regular insulin was circled indicating it had been held.

Review of the physician ' s orders for Patient #B8 dated 7/3/15 revealed no orders to hold the 7/3/15 dose of insulin. Review of the medical record revealed no documentation as to why the dose had not been given.

Review of the MAR for Patient #B8 dated 7/3/15 revealed the 9:00 p.m. blood glucose was documented as 201 mg/dL (milligrams/deciliter). Review of the sliding scale orders revealed Patient #B8 should have received 2 units of Regular insulin. No documentation of insulin administration was recorded.

Review of the MAR for Patient #B8 dated 7/4/15 revealed at 6:30 a.m. the blood glucose was recorded as 117 mg/dL. The scheduled dose of insulin was circled to indicate it had been held. No physician's orders or nurse ' s notes were documented as to why the 6:30 a.m. dose had been held.

Review of the MAR for Patient #B8 dated 7/5/15 revealed the blood glucose was documented as 68 mg/dL. The scheduled dose of 7 units of Regular insulin was documented as having been given. No documentation could be located that the physician had been notified of the decreased blood glucose level before the 7 units of insulin had been given.

Review of the MAR for Patient #B8 dated 7/7/15 revealed the scheduled dose of 7 units of Regular insulin was documented as being held at 6:30 a.m. There were no physician's orders documented to hold the dose of insulin.

In an interview on 7/6/15 at 3:02 p.m. with the DON, she indicated the nursing staff on the night shift had to double check their own insulin doses because there was only one nurse (RN) in the adult and geriatric units at night. She said the nurses could not leave their units because that would leave the unit unattended by a RN. She said there was no LPN staff on the night shift after 11:00 p.m.

In an interview on 7/8/15 at 2:53 p.m. with Corporate Quality, she verified the above documented insulin administration errors. She verified there were different staff members on different shifts making different errors. She said the staff needed training on insulin administration.

Based on record review and interview, the hospital failed to ensure all patients medical record entries were timed by the person responsible for providing or evaluating the service provided for 3 (#A7,#A8,#B8 ) of 3 (#A7,#A8,#B8) patients sampled.

Findings:

Review of the Medical and Professional Staff Organizational Bylaws revealed in part:
Medical Records and Orders:
7. All clinical entries and summaries in the patient ' s medical record shall be accurately dated, timed and authenticated.

Patient #A7
Review of the medical record for Patient #A7 revealed the verbal orders dated 6/23/15 for Admission Orders/Initial Plan of Care and the Admission Medication Reconciliation orders had been authenticated by the physician, but the authentication had not been timed.

Patient #A8
Review of the medical record for Patient #A8 revealed the verbal order dated 7/1/15 to discontinue Adderall had been authenticated by the physician, but the authentication had not been timed.

Review of the admission orders for Patient#A8 revealed the orders had been taken verbally by a registered nurse on 7/1/15 at 7:15 p.m. The physician had authenticated the order on 7/3/15 but had not timed his authentication.

Patient #B8

Review of the admission orders for Patient#B8 revealed the orders had been taken verbally by a registered nurse on 6/25/15 at 3:00 p.m. The physician had authenticated the order on 6/26/15 but had not timed his authentication.

Review of the Psychaiatric Evaluation, completed on 6/26/15, revealed the evaluation had benn authenticate and signed, but not dated.

Further review revealed the following orders that had been authenticated, dated, but not signed:
Discharge orders, dated 6/29/15, transferring the patient to the emergency room for evaluation and treatment were authenticated and dated, but not signed.
7/1/15 4:45 pm verbal order taken by an RN for Sliding scale insulin. The order was signed by the ordereing physician on 7/6/15, but was not timed.

In an interview on 7/6/15 at 3:02 p.m. with the DON, she said there was a problem with the physician's timing their signatures.









Surveyor: DYER, JAMIE



30984

Based on interview and record reviews, the hospital failed to develop policies and procedures that addressed safety precautions against radiation hazards to provide for the safety of staff and patients during radiological procedures performed in the hospital.

Findings:
A review of the contracts provided by Corporate Quality revealed the hospital had a contract with a mobile medical service to provide mobile radiology services for in-patients.

A review of the hospital's Policy and Procedure Manual provided by Corporate Quality as the most current manual, revealed no documented evidence of any policies and procedures related to radiology services that addressed safety precautions against radiation hazards for the safety of staff and patients during radiological procedures performed in the hospital.


In an interview on 07/08/15 at 2:10 p.m., Corporate Quality, indicated the hospital had no policies and procedures in place that addressed safety precautions against radiation hazards for staff and personnel during radiology procedures.

Based on observation, interview and record review, the hospital failed to ensure the infection control officer developed a system for controlling infections and communicable diseases of patients and personnel. This deficient practice is evidenced by:

1) failing to ensure patients with MRSA (Methicillin-resistant Staphylococcus aureus) had correct signage indicating contact precautions on their room doors, orders for contact precautions placed in their medical records and indications on their Kardex that they were on contact precautions as per the hospital's policies and procedures for 2 (#B8, #B7) of 2 patients with MRSA;

2) failing to ensure patients with MRSA were in a single occupancy room or shared a room with another patient with the same infection for 1 (#B7) of 2 patients (#B7, #B8) with a known MRSA infection;

3) Failing to ensure hand hygiene and accepted standards of practice for infection control were followed during blood glucose monitoring and insulin administration on a patient with MRSA for 1 (#B8) of 1 patients observed. This deficient practice is evidenced by cross contamination of patients with contact precautions, improper hand hygiene and glove usage, failing to properly disinfect a glucometer, and improper sharps disposal.

Findings:

1) Failing to ensure patients with MRSA (Methicillin-resistant Staphylococcus aureus) had correct signage indicating contact precautions on their room doors, orders for contact precautions placed in their medical records and indications on their Kardex that they were on contact precautions as per the hospital's policies and procedures.

Review of the hospital policy and procedure titled IC-04: Transmission Based Precautions: Contact; Droplet; Airborne Precautions Protocol to Identify Pathogen/Organism/Infection, revealed in part:
Protocol instructions for Contact Precautions:
3. A sign will be posted outside of the patient's door indicating contact precautions.
5. The plan of care will reflect appropriate protocol interventions.
6. A sticker will be placed on the chart and the patient's Kardex indicating the precautions.
7. The patient observation sheet will reflect all precautions the patient is on.

Review of the hospital policy titled IC-13: Methicillin Resistant Staphylococcus Aureus (MRSA) revealed in part:
Procedure:
3. If a patient is diagnosed with active MRSA after admission has occurred, the nurse will notify the IC nurse and implement contact precautions.
4. The patient will be placed in a private room, if private room available, or roomed with another patient with known MRSA only as a last resort.
6. A copy of the protocol for precautions placed in chart/Kardex (written communication tool of patient information) flagged.
Contact Protocol Instructions:
3. Obtain and carry out Contact Precautions Protocol and place a copy in the orders section of the chart.

Review of a Microbiology Culture Reports for Patient #B8 dated 6/28/15 and Patient #B7 dated 6/30/15 revealed the following footnote: This organism (MRSA) is a multi-drug resistant organism and potential pathogen that mandates the institution of contact isolation.

In an observation on 7/7/15 at 8:00 a.m. on the geriatric unit, the only door sign indicating a patient was on contact precautions was outside of Patient #B10's room (Patient #B10 did not have MRSA or contact precautions). Further review revealed Patient #B7 and Patient #B8 did not have contact precaution signs outside of their rooms.

Review of the Kardex and the medical record for Patient #B7 and Patient #B8 revealed no copy of the contact precaution protocols were placed in the patients ' charts and the patients' kardex had not been flagged.

In an interview on 7/6/15 at 3:30 p.m. with the DON, she indicated there were no patients on any type of isolation precautions on either the adult or geriatric-psychiatric unit.

In an interview on 7/7/15 at 8:10 a.m. with LPN1, he was asked why patient B10 had a contact precaution sign on her door and he said Patient #B10 was on contact precautions because she had MRSA (sign was incorrectly placed outside of her room). Review of Patient #10 ' s medical record revealed she did not have MRSA.
In an interview on 7/7/15 at 10:00 a.m. with Infection Control Nurse, she verified Patient #B10 ' s door was incorrectly marked for contact precautions. She also stated Patient #B7 and Patient #B8 did not have contact precautions but should have. She also verified Patient #B7 and Patient #B8 did not have their Kardex flagged or the order in their charts as per policy.

2) Failing to ensure patients with MRSA were in a single occupancy room or shared a room with another patient with the same infection.

Review of the hospital policy and procedure titled IC-04: Transmission Based Precautions: Contact; Droplet; Airborne Precautions Protocol to Identify Pathogen/Organism/Infection, revealed in part:
Protocol instructions for Contact Precautions:
2. The patient will be assigned a private room. When a private room is not available, the patient will be placed with a patient who has an active infection with the same organism only as a last resort.

Review of the patients' room assignments on the Geriatric Unit revealed Patient #B7 was sharing a room with Patient #B12. Review of the patients ' medical records revealed Patient #B7 was positive for MRSA and Patient #B12 did not have MRSA.

In an interview on 7/7/15 at 10:11 a.m. with InfectionControlNurse, she verified Patient #B7 should have been in a private room or in a room with another patient with an MRSA infection but was not.

3) Failing to ensure hand hygiene and accepted standards of practice for infection control were followed during blood glucose monitoring and insulin administration on a patient with MRSA. This deficient practice is evidenced by cross contamination of patients with contact precautions, improper hand hygiene and glove usage, failing to properly disinfect a glucometer, and improper sharps disposal.

Review of the hospital policy titled IC-09: Hand Hygiene revealed in part:
Purpose:
Inadequate hand hygiene is the leading cause of infectious outbreaks in healthcare facilities. Scrupulous hand hygiene practices clearly reduce the spread of infectious microorganisms.
Glove removal:
How to perform hand washing:
Thoroughly wet hands with warm-never hot-running water. Apply soap and lather. Vigorously rub lathered hands together for 20 to 30 seconds, including all parts of hands and wrists.

In an observation on 7/7/15 at 11:05 a.m., LPN1 was obtaining a blood glucose reading on Patient #B8 who was positive for MRSA. He pushed Patient #B8's wheelchair into Patient #B13's (not positive for MRSA) room and obtained the blood glucose reading. He left Patient #B8 in the room and went to the medication room to obtain insulin to administer. He returned, administered the insulin, removed his gloves and put them on Patient #B13's bed. He sanitized his hands and then picked up the used gloves off of the bed with his bare hands. He then pushed Patient #B8 ' s wheelchair into a common area without sanitizing his hands.

In an observation on 7/8/15 at 11:00 a.m., LPN1 was obtaining a blood glucose level on Patient #B8. He pushed Patient #B8's wheelchair into Patient #B14's room (not positive for MRSA). He wiped Patient #B8's finger and began to stick it with a lancet when RN3 intervened and told him to move Patient #B8 to his own room to draw the blood. After moving Patient #B8 to his own room and performing the finger stick for the blood glucose, he removed his gloves, picked up the glucometer with his bare hands and placed the glucometer on the bathroom sink. He washed his hands for approximately 7 seconds, picked up the dirty glucometer with his clean hands and placed it on top of the medication cart. He did not sanitize the glucometer before or after use. When he returned to Patient #B8's room to administer an insulin injection, he wiped Patient #B8's arm with an alcohol prep without wearing gloves. He then pulled gloves out of his pocket and donned them to give the injection. After the injection, he removed his gloves and then placed the used insulin syringe into his pocket. He then washed his hand for 10 seconds and exited the room.

In an interview on 7/8/15 at 2:00 p.m. with RN3, he verified there had been several breeches in infection control when LPN1 had done the blood glucose and insulin injection on Patient #B8.









30984

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

I. Provide comprehensive Master Treatment Plans that reflected appropriate active treatment to be given to patients and provided by the facility staff. Specifically, the facility failed to:

A. Provide comprehensive Master Treatment Plans (MTPs) that were individualized with all necessary components to provide active treatment. The MTPs were missing the following components:

1. Behaviorally descriptive psychiatric problem statements to be used as the basis for developing MTPs for eight (8) of eight (8) active sample patients (A5, A6, A10, A13, B4, B6, B7 and B15) identified in clinical assessments. (Refer to B119)

2. Individualized and specific active treatment interventions for eight (8) of eight (8) active sample patients (A5, A6, A10, A13, B4, B6, B7 and B15). (Refer B122)

Failure to develop master treatment plans with all the necessary components hampers the staff's ability to provide coordinated interdisciplinary care; potentially resulting in patients' active treatment needs not being met.

B. Ensure that appropriate treatment plan revision occurred for the care and treatment of two (2) of eight (8) active sample patients (A6 and B7). Specifically, the treatment plans for these patients were not updated to reflect appropriate interventions based on their presenting needs and current level of functioning. This failure results in patients being without a plan with appropriate interventions to provide guidance for staff to assist them, potentially resulting in patients' active treatment needs not being met. (Refer to B118)

II. Ensure that active treatment measures, such as individual treatment and other therapeutic activities, were available for two (2) of eight (8) active sample patients (A6 and B7) who were unwilling or unable to attend group therapies or benefit from the groups provided. Specifically, these patients spent many hours on the unit without appropriate alternative structured therapy or activities. Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered to them in a timely fashion, potentially delaying their improvement. (Refer to B125 I)

III. Assess and treat the medical problems of one (1) of one (1) patient (Patient E1) reviewed because of the death of Patient E1 in the facility. Failure to address and respond to medical issues results in a potential risk to the health and lives of patients. (Refer to B125 II)

IV. Ensure that patients received sufficient hours of active treatment, including groups, individual sessions, and therapeutic activities especially on evening hours and weekends for all patients in the facility with a census of 38 patients. For the Geriatric Unit patients, there was only one hour of Psychotherapy Group and one hour of Recreational Therapy scheduled for each weekday, and one hour of Psychotherapy Group for each weekend day. For the Adult Unit patients, there was only one hour of Psychotherapy or Relapse Prevention Group, one hour of Life Skills or Psychotherapy Group, and one hour of Recreational Therapy scheduled for each weekday, and one hour of Psychotherapy Group for each weekend day. No active treatment groups or therapeutic activities were scheduled for evenings. Failure to provide sufficient active treatment potentially results in patients being hospitalized without the level and intensity of treatment needed to achieve their optimum level of functioning prior to discharge. (Refer to B125-III)

Based on record review and interview, there was a systematic failure by the facility to provide comprehensive Master Treatment Plans that reflected appropriate active treatment to be given to patients and provided by the facility staff. Specifically, the facility failed to:

I. Provide comprehensive Master Treatment Plans (MTPs) that were individualized with all necessary components to provide active treatment. The MTPs were missing the following components:

A. Behaviorally descriptive psychiatric problem statements to be used as the basis for developing MTPs for eight (8) of eight (8) active sample patients (A5, A6, A10, A13, B4, B6, B7 and B15) identified in clinical assessments. (Refer to B119)

B. Individualized and specific active treatment interventions for eight (8) of eight (8) active sample patients (A5, A6, A10, A13, B4, B6, B7 and B15). (Refer B122)

Failure to develop master treatment plans with all the necessary components hampers the staff's ability to provide coordinated interdisciplinary care; potentially resulting in patients' active treatment needs not being met.

II. Ensure that appropriate treatment plan revision occurred for the care and treatment of two (2) of eight (8) active sample patients (A6 and B7). Specifically, the treatment plans for these patients were not updated to reflect appropriate interventions based on their presenting needs and current level of functioning. This failure results in patients being without a plan with appropriate interventions to provide guidance for staff to assist them, potentially resulting in patients' active treatment needs not being met.

Findings include:

A. Document Review

1. The facility's policy titled, "TX-GEN-02: Treatment Planning; Integrated/ Multidisciplinary" had the following statements regarding revision of the MTP. The policy stipulated that, "The Treatment Plan shall be initiated as a component of the admission process with continual development and formulation by the attending physician and multidisciplinary treatment team..." "Admitting Nurse: Revises plan based on changes in condition and physician orders received..." "Therapist/Primary RN: Reevaluates goals and objectives and revises same as needed." The facility failed to follow its policy to revise the plan based on changes in each patient's condition.

2. The team did not collaborate to formulate the MTP as an interdisciplinary team to make decisions about care and determine an appropriate treatment focus and target behaviors that would be addressed during the patient's hospitalization. Each discipline formulated his/her own plan using preprinted forms with long and short-term goals and clinical interventions. The Registered Nurse (RN) was responsible for initiating the treatment plan within eight (8) hours "based on findings from patient assessment, problems, needs, strengths and limitations, and physician orders." The RN completes the section of the MTP for nursing and the physician. The social worker and recreational therapists selects from a preprinted list of goals and interventions.

3. The MTPs of two (2) patients (A6 and B7), who were unable or unwilling to participate in active treatment as assigned on their MTP, were not revised to reflect their current level of functioning. (Refer to B125)

B. Staff Interviews

1. In an interview on 7/7/15 at 11:10 a.m., RT 1 stated, "All patients are expected to attend all groups. We don't change the treatment plan when patient are not attending groups. We just do an one-to-one." However, a review of the "Inpatient Group Documentation" Forms for the active sample patients revealed that when the "mini 1:1" was checked, limited information was documented regarding topics discussed or information provided. Therefore, it was difficult to determining what active treatment clinical staff actually provided.

2. During an interview with the Medical Director on 7/8/15 at 9:45 a.m., he acknowledged that the MTP's for Patient A6 and Patient B7 had not been revised to include alternative interventions for these patients who were not participating in group therapy. He acknowledged that no specific individual therapies were ordered for these patients.

Based on record review and interview, the facility failed to ensure that each patient had individualized psychiatric problem statements written in behavioral and descriptive terms on the Master Treatment Plans (MTPs). Instead, the stated problems on the treatment plans included diagnostic and/or generalized psychiatric terms rather than behaviorally descriptive psychiatric problems based on clinical assessment data and/or how presenting symptoms were specifically manifested by each of eight (8) of eight (8) active sample patients (A5, A6, A10, A13, B4, B6, B7 and B15). This failure results in fragmented treatment plans that are not comprehensive or individualized to patients' presenting psychiatric problems.

Findings include:

A. Record Review:

The MTPs for the following patients were reviewed (dates of plans in parentheses): A5 (6/19/15), A6 (6/19/15), A10 (6/26/15), A13 (6/29/15), B4 (6/23/15), B6 6/27/15), B7 (6/26/15) and B15 (7/3/15). This review revealed that MTPs had the following psychiatric problem statement with global psychiatric terms and/or generalized symptoms, selected from a preprinted list, that did not have behaviorally descriptive and supporting documentation to reflect how presenting symptoms and/or problems were precisely manifested by each patient.

1. Patient A5's MTP included the following psychiatric problem statement on the problem list: "Alt [Alteration] of Mood R/T [related to]: Depression, As Evidenced by: Death Wishes, [decreased] energy, [decreased] ADLs, [decreased] Sleep pattern, [decreased] Self-worth, isolative Bx. [Behavior],...Disorganized Thought." These were global and generalized psychiatric problem statements rather than specific behavioral descriptions of how each patient individually manifested these problems.

2. Patient A6's MTP included the following psychiatric problem statement on the problem list: "Alt [Alteration] of Mood R/T [related to]: Depression, As Evidenced by: [Decreased] energy, [decreased] Sleep pattern, [decreased] Appetite, Delusions, [increased Anxiety], Excessive Worry, Anhedonia, Irritability, Disease process that interferes with ability to function..." These were global and generalized psychiatric problem statements rather than specific behavioral descriptions of how each patient individually manifested these problems. The Psychiatric Evaluation dated 6/19/15 noted, "...was seeing and talking to demons in the house...responding to internal stimuli at times...has had some up and down sleep disturbance..." There was no description of the internal stimuli or sleep disturbance.

3. Patient A10's MTP included the following psychiatric problem statement on the problem list: "Alt [Alteration] of Mood R/T [related to]: Depression, As Evidenced by: Death Wishes, [decreased] energy, [decreased], [decreased] Sleep pattern, [decreased] Sleep pattern, [decreased] eye contact, [increased] Anxiety,...Disturbed affect, Excessive worry, Poor self/confidence/concept." These were global and generalized psychiatric problem statements rather than specific behavioral descriptions of how each patient individually manifested these problems.

4. Patient A13's MTP included the following psychiatric problem statement on the problem list: "Alt [Alteration] of Mood R/T [related to]: Depression, As Evidenced by: [Decreased] energy, [Decreased] ADLs, [decreased] Sleep pattern, [decreased] Appetite, [Decreased] Self-worth, isolative Bx [behavior]... [increased] Anxiety... Disorganized thoughts, Anhedonia, Unhealthy use of leisure time ... lack of interest in activities and/or hobbies..." These were global and generalized psychiatric problem statements rather than specific behavioral descriptions of how each patient individually manifested these problems. The Psychiatric Evaluation dated 6/29/15 noted, "...would hang [him/herself] if [s/he] continued to drink this way...started drinking heavily from the moment [spouse] passed away...states [s/he] averages from a 6-pack a day...drinks until passing out. "

5. Patient B4's MTP included the following psychiatric problem statement on the problem list: "Alt [Alteration] of Mood R/T [related to]: Depression, As Evidenced by: [Decreased] ADLs, [Increased] Anxiety, [decreased] Ability to focus, Irritability, Poor anger control." These were global and generalized psychiatric problem statements rather than specific behavioral descriptions of how each patient individually manifested these problems. The Psychiatric Evaluation dated 6/23/15 noted, "...increasing weakness and difficulty responding... talks nonstop, difficult to redirect, shaky all over...reported that [s/he] was experiencing both auditory and visual hallucinations [These were not described]...sees a house on fire, sees people walking in front of [him/her]...easily becomes tearful..."

6. Patient B6's MTP included the following psychiatric problem statement on the problem list: "Alt [Alteration] of Mood R/T [related to]: Depression, As Evidenced by: [Decreased] ADLs, [decreased] Sleep pattern, [decreased] Appetite, isolative Bx [behavior], [increased] Anxiety...[Decrease] Ability to focus, Irritability, paranoia, [increased agitation, [increased] aggression." There was no documentation on the MTP that provided behavioral descriptions of how this patient individually manifested any of these problems.

7. Patient's B7's MTP included the following psychiatric problem statement on the problem list: "Alt [Alteration] of Mood R/T [related to]: Depression, As Evidenced by: Delusions, [increased Anxiety], Excessive Worry, Anhedonia, Irritability." These were global and generalized psychiatric problem statements rather than specific behavioral descriptions of how each patient individually manifested these problems.

8. Patient B15's MTP included the following psychiatric problem statement on the problem list: "Alt [Alteration] of Mood R/T [related to]: Elevated/Manic Mood, As Evidenced by: [Decreased] energy, [Decreased] ADLs, [decreased] Sleep pattern, [decreased] Appetite, Delusional, Paranoid Bx. [Behavior], [Decreased] Ability to focus." These were global and generalized psychiatric problem statements rather than specific behavioral descriptions of how each patient individually manifested these problems. The Psychiatric Evaluation dated 7/3/15 noted, "...[Patient's name] has not slept over the past 48 hours...constantly pacing up and down the hallways...has been verbally aggressive..."

B. Staff Interviews

1. In an interview on 7/7/15 at 10:30 a.m., with RN1, the psychiatric problem statements on the MTPs were discussed. RN1 acknowledged that these statements did not contain behavioral descriptions regarding each patient's presenting symptoms.

2. In an interview on 7/7/15 at 2:25 p.m. with the Chief Executive Officer (CEO) and Director of Social Work, the Master Treatment Plan process was discussed. The CEO stated, "I understand the need to individualize the treatment plan."

3. During an interview with the Medical Director on 7/8/15 at 9:45 a.m., he acknowledged that the psychiatric problem statements on the MTPs for these patients were generic and not specific to the individual patients.

Based on record review and interview, the facility failed to consistently develop Master Treatment Plans (MTPs) that evidenced sufficient individualized planning of interventions with specific focus based on individual needs and abilities of eight (8) of eight (8) active sample patients (A5, A6, A10, A13, B4, B6, B7 and B15). Specifically, interventions were stated as generic discipline functions written as active treatment interventions. Some MTPs also failed to consistently state the specific focus for interventions, and whether interventions would be delivered in group or individual sessions. These deficiencies result in treatment plans that fail to reflect an individualized approach to interdisciplinary treatment and also fail to provide guidance to staff regarding the specific interventions and purpose for each. These failures also potentially result in inconsistent and/or ineffective treatment.

Findings include:

A. Record Review

The MTPs for the following patients were reviewed (dates of plans in parentheses): A5 (6/19/15), A6 (6/19/15), A10 (6/26/15), A13 (6/29/15), B4 (6/23/15), B6 6/27/15), B7 (6/26/15) and B15 (7/3/15). This review revealed that the MTPs contained a preprinted form for each category of problem. These forms included preprinted problem, long and short-term goals, and identical clinical interventions. These forms contained routine and generic discipline functions such as monitoring, assessing, prescribing, evaluating, encouraging, etc. written as active treatment interventions. Interventions for one of the psychiatric problems listed included the following findings.

1. Psychiatrist Interventions: For the problem "Alt [Alteration] of Mood R/T [related to]: Depression," for seven (7) active sample patients (A5, A6, A10, A13, B4, B6 and B7) and Related to: "Elevated Manic Mood" for one patient (B15), all had the following identical non-individualized and generic interventions despite different presenting symptoms for each patient.

"Complete Psychiatric Evaluation within 24 hours of admit." "Direct treatment plan & team x 1 per week." "Meet with the patient at least (handwritten entry) x per wk to assess status, evaluate effectiveness of medication & prescribe medication as needed throughout the duration of tx [treatment]." "Monitor risk level and direct team as needed to keep patient safe." "Complete H & P exam/medical consult within 24 hours of admit per [MD ' s name]."

These interventions were generic physician tasks instead of specific treatment intervention statements that included a modality (group or individual sessions), a frequency of contact, and a focus of treatment that would assist each patient to accomplish his/her treatment goals and improve specific presenting problems.

2. Registered Nurse Interventions: For the problem "Alt [Alteration] of Mood R/T [related to]: Depression," for seven (7) active sample patients (A5, A6, A10, A13, B4, B6 and B7) and Related to: "Elevated Manic Mood" for one patient (B15), all had the following identical non-individualized and generic interventions despite different presenting symptoms for each patient. .

"Complete Nursing Assessment & formulate plan on admit." "Provide safe, structure environment daily for the duration of tx [treatment]." "Communicate to TX [Treatment] team the patient's status." "Assess mood, behavior & effectiveness of intervention(s) daily for duration of treatment." "Implement close q 15 observation for duration of Tx [Treatment]." "Assess physical status, vital signs, appetite & sleep daily for duration of TX [treatment]." "Administer medications as prescribed for duration of treatment."

These interventions were actually generic nursing tasks instead of specific treatment intervention statements that included a modality (group or individual sessions), a frequency of contact, and a focus of treatment that would assist each patient to accomplish his/her treatment goals and make improvements in presenting problems.

The following nursing interventions were the only treatment intervention included on the preprinted list:

"Provide education on disease process and alternative to self-harm via nursing group x45-60 min daily x (left blank) weeks." This intervention statement was very broad in that it did not a specific focus of treatment related to "disease process" that would direct targeted information based on each patient's needs and/or presenting symptoms.

"Educate on medication prescribed x 1 per wk [week]." "Provide nursing groups x45-60 min [minutes] (Number of weeks) per week for duration of TX [treatment]." These intervention statements failed to include a focus of treatment based each patient's need and/or presenting symptoms. In addition, the intervention statement regarding medication education did not include whether the intervention would be conducted in group or individual sessions.

3. Social Work Interventions: For the problem "Alt [Alteration] of Mood R/T [related to]: Depression," for seven (7) active sample patients (A5, A6, A10, A13, B4, B6 and B7) and Related to: "Elevated Manic Mood" for one patient (B15), all had the following identical non-individualized and generic interventions despite different presenting symptoms.

"Meet with patient 1:1 to complete Psychosocial/ Multidisciplinary Treatment Integration within 72 hours." "Develop and establish rapport with patient daily and ongoing within 5 days." "Engage patient's family/significant others in continued support within 48 hours of admit & via wkly [weekly] collatera1 contracts throughout the duration tx [treatment]."

These interventions were actually generic social work and not specific treatment intervention statements reflecting what would be done by the social worker to assist the patient to make improvement in the specific and descriptive presenting symptom(s).

The following social work interventions were the only treatment intervention included on the preprinted list:

"Provide Group Psychotherapy to process issues & address tx [treatment] goals x 45-60 min [minutes] x 1 sessions per day for 1-2 weeks." This intervention statement was very broad in that it failed to include specific information regarding issues to be addressed based on each patient's presenting symptoms. "Provide individual/Family Therapy sessions as ordered by MD." This intervention statement did not include a focus of treatment or a frequency of contact.

4. Activity Therapist Interventions: For the problem "Alt [Alteration] of Mood R/T [related to]: Depression," for seven (7) active sample patients (A5, A6, A10, A13, B4, B6 and B7) and Related to: "Elevated Manic Mood" for one patient (B15), all had the following identical non-individualized and generic intervention despite different presenting symptoms.

"Complete Activity Assessment within 72 hours and formulate treatment plan."

This intervention was a generic recreational therapist function and was not an intervention to assist the patients to accomplish treatment goals and improve presenting problems.

The following statement was a treatment intervention statement included on the preprinted list and selected for all eight active sample patients. "Provide groups x45-60 min [minutes] 4 per week for duration of TX [treatment]." However, the intervention statement was very broad and failed to name the groups to be implement and did not include a focus of group treatment based each patient's need and/or presenting symptoms.

B. Staff Interviews

1. In an interview on 7/7/15 at 10:30 a.m., the medical records for B4 and B15 were reviewed with RN1. RN 1 acknowledged that interventions on the MTPs were not individualized and were routine nursing functions. She agreed that intervention statements regarding medication education did not include the modality (group or individual sessions) and focus of treatment such as side effects of specific medication(s), benefits of medications, specific medication compliance issues, etc. She also agreed that nursing groups assigned on MTPs did not contain a focus of treatment

2. In an interview on 7/7/15 at 9:30 a.m., the medical records for A6 and A13 were reviewed with RN 2. RN 2 agreed that interventions reflected routine nursing functions instead of specific and individualized treatment interventions to assist these patients to improve presenting problems and/or symptoms.

Based on record review, and interview, the facility failed to ensure that the nursing interventions listed on the Master Treatment Plans (MTPs) were documented by registered nurses for eight (8) of eight (8) active sample patients (A5, A6, A10, A13, B4, B6, B7 and B15). Specifically, there was no documentation showing the topic(s) discussed and/or information provided during nursing treatment interventions. In addition, there was limited documentation regarding the response to the treatment interventions provided. This failure potentially hampers the treatment team's ability to determine patients' response to treatment interventions, evaluate whether there are measurable changes in patients' condition, and revise the treatment plan if/when needed.

A. Record Review:

The MTPs for the following patients were reviewed (dates of plans in parentheses): A5 (6/19/15), A6 (6/19/15), A10 (6/26/15), A13 (6/29/15), B4 (6/23/15), B6 6/27/15), B7 (6/26/15) and B15 (7/3/15) and revealed the following findings:

1. Eight (8) patients (A5, A6, A10, A13, B4, B6, B7, B15) all had the following nursing interventions for the problem "Alt [Alteration] of Mood R/T [related to]....(List of presenting symptoms)."

"Educate on medication prescribed x 1 per wk [week]." "Provide nursing groups x45-60 min [minutes] (Number of weeks) per week for duration of TX [treatment]." There was no documentation found in "Daily Nursing Note" Forms or "Inpatient Group Documentation" Forms that included the topic and/or medication(s) discussed during these interventions. When documented, there was only limited information documented about the patient's response to the intervention such as the patient's level of understanding and behavior(s) exhibited during the intervention.

2. Three (3) patients (A5, A10, and B15) had the following nursing interventions for the problem "Potential for Self-Harm Related to:...(List of presenting symptoms)."

"Provide education on disease process and alternatives to self-harm via nursing group x 45-60 min daily x (handwritten entry) weeks." There was no documentation found in "Daily Nursing Note" Form and "Inpatient Group Documentation" Forms that included the topic regarding depression and issues related to self-harm were discussed during nursing group interventions with these patients. When documented, there was only limited information documented about the patient's response to the intervention. There was no documentation regarding the patient's level of understanding and behavior(s) exhibited during the intervention.

3. Three (3) patients (A6, A13, and B15) had the following nursing interventions for the problem "Alteration in Health Maintenance R/T [Related to]:...(List of presenting symptoms)." "Educate on S&S [signs and symptoms] of disease weekly for duration of treatment." "Educate on importance of diet/exercise/health issues to improve health weekly as indicated." The following health issues were checked: [(Patient A6), Asthma, hypertension and fluid retention, (Patient A13) hypertension and diabetes and (Patient B15), hypertension, History of Diabetes, and C/O [complaints of] pain. There was no documentation found in "Daily Nursing Note" Forms and "Inpatient Group Documentation" Forms that included the topic regarding health maintenance issues associated with each of these patients were discussed during group and/or 1:1 interventions with these patients. There was actually no documentation that these nursing interventions were provided at all. There was no documentation about the patient's response to the intervention or the patient's level of understanding and behavior(s) exhibited during the intervention.

B. Staff Interviews

1. In an interview on 7/7/15 at 9:30 a.m., the medical records for A6 and A13 were reviewed with RN 2. RN 2 agreed that the topic of the group was not included in the documentation of the patients' attendance in group sessions.

2. In an interview on 7/7/15 at 10:30 a.m., the medical records for B4 and B15 were reviewed with RN1. RN 1 agreed that the documentation of groups held by registered nurses did not include topics discussed with patients and/or what information was provided. She acknowledged that the information regarding the patient's response was limited to whether the patient participated or not and did not include the patient's level of understand and/or behaviors exhibited during the group intervention.

3. During interview on 7/7/15 at 3:45 p.m. with the Director of Nursing, she acknowledged that documentation related to nursing interventions showed that the topics discussed (such as specific medications) and/or information provided during nursing interventions were missing. In addition, the Director of Nursing acknowledged that the level of participation documented in the notes was general and did not contain the patient's level of understanding or behaviors exhibited during group sessions attended.

4. During an interview with the Medical Director on 7/8/15 at 9:45 a.m., he acknowledged that the interventions on the MTPs for these patients were generic and not specific to the individual patients.

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

I. Ensure that active treatment measures, such as individual treatment and other therapeutic activities were available for two (2) of eight (8) active sample patients (A6 and B7) who were unwilling or unable to attend group therapies or benefit from the groups provided. Specifically, these patients spent many hours on the unit without appropriate alternative structured therapy or activities. Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered to them in a timely fashion, potentially delaying their improvement.

II. Assess and treat the medical problems of one (1) of one (1) patient (Patient E1) reviewed because of the death of Patient E1 in the facility. Failure to address and respond to medical issues results in a potential risk to the health and lives of patients.

III. Ensure that patients received sufficient hours of active treatment, including groups, individual sessions, and therapeutic activities especially on evening hours and weekends for all patients in the facility with a census of 38 patients. For the Geriatric Unit patients, there was only one hour of Psychotherapy Group and one hour of Recreational Therapy scheduled for each weekday, and one hour of Psychotherapy Group for each weekend day. For the Adult Unit patients, there was only one hour of Psychotherapy or Relapse Prevention Group, one hour of Life Skills or Psychotherapy Group, and one hour of Recreational Therapy scheduled for each weekday, and one hour of Psychotherapy Group for each weekend day. No active treatment groups or therapeutic activities were scheduled for evenings. Failure to provide sufficient active treatment potentially results in patients being hospitalized without the level and intensity of treatment needed to achieve their optimum level of functioning prior to discharge.

Findings include:

I. Active Treatment

A. Patient A6

1. Patient A6 was admitted to the unit on 6/23/15 with a diagnosis of "Schizoaffective Disorder, Bipolar Type..." Throughout the survey, the patient was observed to be in his/her room and not interacting with other patients or staff. The patient attended no therapeutic groups and isolated in his/her room.

2. A review of the "Close Observation Check Sheets" for each day from 6//2815 through 7/7/15 reflected that the patient mostly remained in his/her room when group treatment sessions were being held.

3. The Master Treatment Plan dated 6/19/15 identified five clinical problems: 1. "Altered thought processes..." 2. "Alteration in Mood..." 3. "Alteration in Health Maintenance..." 4. "Potential for relapse..." and 5. "Potential for Violence..." The interventions identified were primarily group treatment. There were no provisions made in the Master Treatment Plan to show that the current plan was not appropriate to the reality of the patient isolating in his/her room.

4. A review of the "Group Documentation" Forms from 6/27/15 to 7/6/15 revealed that Patient A6 attended groups inconsistently showing the patient's absence from group treatment 20 times. During the period from 7/1/15 - 7/7/15, Patient A6 rarely attended group but was isolating in his/her room when groups were being held. A review of the "Daily Nursing Note" Forms from 6/27 through 7/5/15 revealed a similar pattern of attendance. These notes showed the patient refusing to attend groups and "non-participation due to psychosis."

5. In patient and staff interviews, it was confirmed that the patient had not been attending groups and that no alternative or revised treatment plan had been developed to identify appropriate interventions for the patient.

6. The patient stated, in interviews on 7/6/15 at 10:30 a.m., "I stay away from people. I don't want to attend groups. I just want to go home."

7. In an interview with RN 2 on 7/7/15 at 9:30 a.m. acknowledged that Patient A6 had not recently been attending groups. She stated, "I do a one to one with the patient when [s/he] doesn't attend group." However, when the patient's medical record was reviewed, there no treatment notes that showed topics discussed, information provided, patient's response to intervention, and plan to ensure that active treatment would be provided to the patient despite refusal to attend the nursing group. Therefore, it was difficult to discern whether active treatment interventions, assigned on MTPs, were provided because the topics discussed and information given to assist with the patient's improvement in his/her level of functioning were not documented.

B. Patient B7

1. Patient B7 was admitted 6/26/15. The admission Psychiatric Evaluation dated 6/27/15 stated Patient B7 "has become aggressive, yelling, screaming, and paranoid" according to the nursing home where s/he resided. The admission diagnoses included "Schizoaffective disorder, depressed type" and "Dementia, early stages." A review of the MTP dated 6/29/15 stated the treatment interventions as follows: for the Problem of "Risk for Violence" interventions included "Explore alternative coping skills to effectively manage aggressive behavior via group psychotherapy x 15 min per session x 7 sessions per wk [week] for 1-2 wks(s)," for the Problem of "Alteration of Mood R/T Depression" interventions included "Provide Nursing Groups 45-60 min x 2 per day for 2 week(s)," "Provide Group Psychotherapy to process issues & address tx [treatment] goals x 45-60 min per session, x1 sessions (sic)," "Provide groups x 45-60 4 per week for duration of Tx," "Assist patient in making the connection between CD/mental illness symptoms and social/recreational deficits TR [therapeutic recreation] group 45-60 min 4 x per day for 1-2 weeks." "Provide RN Nursing Groups x 45-60 min 2 per day per 2 weeks," and for the Problem of "Alteration in Perception" interventions included "Explore basic coping strategies to improve reality based thinking and life management skills per supportive group psychotherapy x 45-60 min x 1 day for 1-2 week(s)," and "Assist patient in making the connection between CD/mental illness symptoms and social/recreational deficits TR group 45-60 min 4 per week per 1-2 weeks)." No individual therapy or alternative interventions were included on the MTP.

2. During an observation of the "Psychotherapy Group" on 7/6/15 at 10:00 a.m., Patient B7 was observed sitting at a table in the group room with her head down and eyes closed during the group.

3. During an observation of the Nursing Group on 7/7/15 at 8:27 a.m., Patient B7 was observed sitting at a table in the group room with her head down and eyes closed during the group.

4. A review of the nursing group notes from 6/27/15 to 7/6/15 indicated that Patient B7 attended only 12 of 20 groups provided. The nursing group notes for 11 of the 12 groups attended described Patient B7's responses to groups as "poor focus," "rambling speech," "poor response," "[decreased] concentration," "loud outburst," "confused," and "limited participation. "

5. A review of the "Group Documentation" notes from 6/27/15 to 7/6/15 indicated that Patient B7 attended only 14 of 18 groups provided. The "Group Documentation" for 12 of the 14 groups attended described Patient B7's responses to groups as refusing to participate, often sitting with his/her eyes closed.

6. In an interview on 7/7/15 at 10:30 a.m. with RN 1, the nursing group held from 8:27a.m. - 9:10 a.m. was discussed. RN 1 admitted that the group was not appropriate for many of the patients attending due to their low level of functioning.

7. During an interview with MD 1 on 7/7/15 at 1:30 p.m., he acknowledged that Patient B7 was not benefitting from group therapy. He acknowledged that the treatment for Patient B7 primarily consisted of "meds." MD 1 acknowledged that no other alternative treatments were provided for Patient B7.

8. During an interview with the Director of Social Work on 7/7/15 at 1:10 p.m., he stated that individual therapy was not provided as an intervention unless ordered by a psychiatrist. He did not identify any patients in the current census of 38 patients who were receiving individual therapy.

9. In an interview with SW 1 on 7/8/15 at 10:20 a.m., SW 1 acknowledged that group psychotherapy was not an appropriate group for most patients on the Geriatric Unit. She admitted that some patients did not participate during group sessions but just sat and observed. She noted that all patients were expected to attend the psychotherapy group.

10. During an interview with the Medical Director on 7/8/15 at 9:45 a.m., he acknowledged that the therapy groups being provided on the geriatric unit were not suitable for many of the patients functioning at a lower cognitive level. He acknowledged that no alterative treatments were provided for these patients who were unable to benefit from these groups.

II. Medical Care

Patient E1

A. Record Review

1. The Psychiatric Evaluation dated 8/20/14 stated Patient E1 was admitted on 8/18/14 because of "nursing home reports an increase in aggressive behavior, as well as weight loss." Admission diagnoses included "Axis I:" "Major depression, recurrent, severe with psychotic features" and "Dementia, secondary to Huntington's disease" and "Axis III:" "Diabetes mellitus type 2," "Hyperlipidemia," and "Huntington's disease." The only documentation of abnormal movements from Huntington's disease was "Patient E1] does have Huntington's disease and does have some spastic movements" and "Marked psychomotor retardation noted." The "Past Medical History" did not indicate that Patient E1 had a previous history of complications from Huntington's disease such as pneumonia, aspiration, or accidents.

2. The "Abnormal Involuntary Movement Scale (AIMS)" signed by MD 1 documented no abnormal movements were present in the face, mouth, extremities, or trunk.

3. The initial Medical History and Physical Exam for Patient E1 dated 8/20/15 documented "non-focal choreiform movements." The "Past History" did not indicate that Patient E1 had a previous history of complications from Huntington's disease such as pneumonia, aspiration, or accidents. A review of the medical record for Patient E1 did not document the involvement of a medical consultant in the assessment and management of Patient E1's Huntington's disease after this initial physical examination.

4. Physician Order/Admission Medication Reconciliation dated 8/14/14 at 5:30 p.m. indicated "Xenazine 12.5 mg [one] po [by mouth] Bid [twice daily]" had been prescribed prior to admission for the treatment of Patient E1's Huntington's disease. This medication was ordered at the time of admission but was not provided. The "Physician Progress Notes" by APRN 1 dated 8/21/14 at 3:45 p.m. stated "Xenazine was held due to it being a mail order - used to tx [treat] chorea for Huntington's - questionable mix [with] other meds - consult [medical consultant]." The medical record did not document a medical consultation was ordered or obtained for Patient E1 to evaluate the prescription of Xenazine or other medication for Patient E1's Huntington's disease.

5. The Master Treatment Plan dated 8/18/14 did not include a problem related to Patient E1's Huntington's disease except "Risk for Choking Related to: Neurologic Disorder." No interventions were documented for the physician to address this identified problem.

6. The psychiatric "Physician Progress Notes" completed by MD 1 dated 8/20/14 at 11:00 a.m., 8/21/14 at 3:45 p.m., 8/22/14 at 11:00 a.m., 8/25/14 at 11:00 a.m., 11/27/14 at 11:50 a.m., 8/29/14 at 11:00 a.m., 9/1/14 at 11:30 all stated the examination of Patient E1's "Motor Activity" was "average." None of these psychiatric notes described an assessment of Patient E's Huntington's disease or a plan for management.

7. A review of the medical record did not document that Patient E1 received an evaluation of the risk for aspiration.

8. The "Physician Progress Notes" completed by APRN 1 dated 9/2/14 at 11:00 a.m. stated that Patient E1 was "less anxious & less impulsive - more tolerant of [increased] stimulation - improved interactions."

9. The "Multi-Disciplinary Note" by RN 1 dated 9/2/14 at 4:15 p.m. stated "Pt [patient] sweating - [increased] movements. Restlessness. CBG [capillary blood glucose] 93. B/P [blood pressure] 118/66. T [temperature] 98.4.and APRN [advanced practice nurse] notified. Orders given to monitor few hrs [hours] if sweating continues notify [MD 1]. Will continue to monitor."

10. The "Multi-Disciplinary Note" by RN 1 dated 9/2/14 at 5:45 p.m. stated "Pt sweating to the point that his shirt had to be changed. [MD 1] notified. CBG 93 & B/P & Temp [temperature] WNL [within normal limits]. [increased] movements reported to the Dr [doctor]. NO [no order] noted. Do CMP [comprehensive metabolic panel] & CBC [complete blood count] in AM [morning] & hold Geodon till [until] [MD 1] sees the pt tomorrow."

11. The "Multi-Disciplinary Note" by RN 3 dated 9/3/14 at 8:10 a.m. stated "Evaluated Pt's condition, pt very restless anxious, unable to sit in w/c [wheel chair], slipping out, also pt is very clamy (sic), sweaty, BP 154/66 P [pulse] 120 T 98.9. Instructed MHTs [mental health technicians] to put pt in bed to rest, pt able to communicate [with] staff at this point. Notified DON [name] & administrator [name] on the unit. Will continue to monitor."

12. The "Multi-Disciplinary Note" by the DON dated 9/3/14 at 8:15 a.m. stated "Charge nurse, [RN 2], informed myself and [name], admin [administrator] of c/c [change in condition] for patient. Observed pt in bed. MHT, [name] changing incontinent diaper. Pt alert, restless, moving legs constantly. Advised [RN 2] to notify [MD 1] which he had planned to do."

13. The "Multi-Disciplinary Note" by RN 3 dated 9/3/14 at 8:20 a.m. stated "[MD 1] notified of pt's condition, informed [MD 1] of pt's constant jerking restlessness, perfuse sweating, and his inability to get comfortable. Pt still able to make needs known at this point. [MD 1] ordered Ativan 1 mg [milligram] po [by mouth] now x [one] for [increased] anxiety r/t disease process. Will continue to monitor."

14. The "Multi-Disciplinary Note" by RN 3 dated 9/3/14 at 9:00 a.m. stated "Went to pt's room to assess, pt still sweating, [decreased] jerking, but breathing has became (sic) labored. O2 [oxygen] sat [saturation] 95%, put pt on O2 @ this point to supplement, 2L [liters] per NC [nasal canulla] administered, O2 dipped to 88% then went back up to 95%. Will continue to monitor."

15. The "Multi-Disciplinary Note" by RN 3 dated 9/3/14 at 9:30 a.m. stated "Went to pt's room, O2 sat still fluctuating b/t [between] high 80's & low to mid 90's. Remains [with] labored breathing. O2 @ 2L per NC. Checked pt's CBG BS was 84. Will continue to monitor."

16. The "Multi-Disciplinary Note" by RN 3 dated 9/3/14 at 10:00 a.m. stated "Pt's condition unchanged, O2 sats still fluctuating b/t high 80's & low to mid 90's. Will notify [MD 1] of pt's condition, will continue to monitor."

17. The "Multi-Disciplinary Note" by RN 3 dated 9/3/14 at 10:04 a.m. stated "Walked to adult unit to notify [MD 1] of pt's condition, explained to him that he's still sweating profusely (sic), his breathing is still labored, beginning to become hard to stimulate, and could we send him out to get medically cleared. He explained to me that he was having an acute ataxia episode, and that he will see him soon. Walked back to the geri [geriatric] unit. Will continue to monitor."

18. The "Multi-Disciplinary Note" by RN 3 dated 9/3/14 at 10:47 a.m. stated "[MD 1] contacted me to give pt 2.5 mg of Zyprexa due to his anxiety, at this point pt was found unresponsive, not breathing, No BP, no code called, pt DNR [do not resuscitate]."

19. The "Multi-Disciplinary Note" by RN 3 dated 9/3/14 at 11:13 a.m. stated "...ambulance arrived on the unit performed EKG [electrocardiogram] [with] flat line as the result."

20. A review of the Laboratory Report, collected 9/3/14 at 5:40 a.m., included the following abnormal values: white blood cells = 17.4 1000/ul [reference range = 4.0-11.0], sodium = 153 mEq/L [miliequivalents per liter] [reference range = 136-145], chloride = 112 mEq/L [reference range = 100-109], glucose = 54 mg/dL [milligrams per deciliter] [reference range 70-100], blood urea nitrogen = 31 mg/dL] [reference range = 5-25], anion gap = 20 [reference range = 8.0-16.0]. The Laboratory Report indicated that these values were faxed to the facility on 9/3/14 at 8:04 a.m. A review of the medical record did not indicate that these laboratory values were reviewed and action taken prior to Patient E1 becoming unresponsive on 9/3/14 at 10:47 a.m.

B. Interviews

1. During an interview with RN 3 on 7/7/15 at 11:00 a.m., RN 3 stated that during breakfast on 9/3/14 Patient E1 "was not looking good." RN 3 stated that he instructed a mental health technician to "check on" Patient E1 more frequently than every 15 minutes. RN 3 stated that Patient E1's condition then "became something more." RN 3 stated that Patient E1's breathing became "different" and RN 3 administered oxygen. RN 3 acknowledged that he reported concerns to MD 1 twice before going to another unit where MD 1 was conducting a treatment team. RN 3 reported meeting "face to face" with MD 1 and told MD 1 that Patient E1's "breathing was not normal" and asked "if I could call an ambulance." RN 3 reported to MD 1 that Patient E1 was "not better with Ativan." RN 3 stated that MD 1 said that Patient E1's condition was a manifestation of Huntington's disease and that MD 1 would come to the unit to evaluate the patient "soon." RN 3 stated that "it took awhile. He was in treatment team." RN 3 stated that MD 1 did not come to the unit to evaluate Patient E1 before Patient E1 died.

2. During an interview with the DON on 7/6/15 at 4:20 p.m., she acknowledged that no physician assessed Patient E1 between 9/2/14 at 4:15 p.m. and 9/3/15 at 10:47 a.m. when Patient E1 was found unresponsive.

3. During an interview with MD 1 on 7/7/15 at 1:30 p.m., MD 1 stated that he had not involved a medical consultant in the treatment of Patient E1's Huntington's disease because he believed Huntington's disease was primarily a psychiatric disorder and was treated with psychotropic medications. MD 1 acknowledged that there was no documentation of an assessment of Patient E1's Huntington's disease other than the associated psychiatric symptoms. MD 1 was unaware of any formal assessment of Patient E1's risk for aspiration. MD 1 stated that he did not evaluate Patient E1 between 9/2/14 at 5:45 p.m. when he was first notified of Patient E1's change in medical condition and when Patient E1 became unresponsive on 9/3/14 at 10:47 a.m. MD 1 acknowledged that he had not reviewed the abnormal laboratory studies that he had ordered on 9/2/15 and were received by the facility on 9/3/15 at 8:04 a.m.

4. During an interview with APRN 1 on 7/7/15 at 10:10 a.m., she stated that Patient E1 was "not specifically being followed" for his Huntington's disease.

5. During an interview with the Medical Director on 7/8/15 at 9:45 a.m., he agreed that a physician should have assessed Patient E1 when notified by the nurse that the patient's medical condition was deteriorating. He stated that he expected physicians to examine a patient or send them to a emergency department when the medical condition of a patient deteriorated. The Medical Director stated that it was his expectation that psychiatrists at the facility involve medical consultants in the care of patients with complex medical conditions. He acknowledged that there was no documentation that a medical consultant was involved in the care of Patient E1 after the initial physical examination. The Medical Director acknowledged that Huntington's disease was considered a neurologic disorder with associated psychiatric problems. The Medical Director acknowledged that he participated in the Root Cause Analysis of this event and that there were no findings or action resulting from the review.

6. During an interview with MD 2, a medical services physician, on 7/8/15 at 9:45 a.m., MD 2 acknowledged that medical consultants do not follow patients with medical issues unless consulted by the psychiatrists. MD 2 stated that if a nurse reported a deterioration in condition, such as occurred with Patient E1, he would "come in immediately [to assess the patient]" or "send [him/her] to the ER [emergency room]." After reviewing the nursing notes and laboratory studies dated 9/3/15, MD 2 stated that Patient E1 may have had an infection and been dehydrated. MD 2 acknowledged that he would have considered treatment of Patient E1 with an antibiotic and fluids based on the symptoms and laboratory studies. MD 2 stated that it was the responsibility of the MD 1 to review the laboratory studies that MD 1 had ordered. MD 2 stated that he believed medical care was better provided when a single medical provider was assigned to the facility on a full-time basis to oversee the medical care for all patients rather than the medical consultation model that was used.

III. Sufficient Hours of Active Treatment

Findings include:

A. Geriatric Unit

1. During an observation on 7/6/15 at 10:00 a.m. during the "Psychotherapy Group" conduced by the social worker, a total of nine (9) of 18 patients were in the group. The remaining patients were either in bed, walking in the hallway, or sitting in another dayroom watching television.

2. During an observation on 7/7/15 at 8:27 a.m., RN 1 conducted a group titled "Nursing Community Group," a total of nine (9) of 18 patients was in the group. The remaining patients were either in bed or in the dayroom watching television. The patients were given a handout with a face on it and were asked to "draw a picture of how you feel today." Most patients did not complete the task. Active sample patient B4 was crying and said, "The doctor told me I could go home." Active Sample patient B7 had his/her head down through out the group session. Other non-sample patients did not pay attention when RN1 was speaking, and two of them were lying on the sofa and appeared to be sleeping.

B. Adult Unit

1. During an observation on 7/6/15 at 2:20 p.m. during the "Recreation Therapy" group conduced by the activities therapist, a total of 12 of 20 patients were in the group. The remaining patients were either in bed or walking in the hallway.

B. Document review

1. A review of the "Geriatric Unit Schedule" revealed that only one hour of Psychotherapy Group and one hour of Recreational Therapy was scheduled for each weekday, and one hour of Psychotherapy Group for each weekend day. No active treatment groups or therapeutic activities were scheduled for evenings.

2. A review of the "Adult Unit 1 Schedule" and "Adult Unit 3 Schedule" revealed that only one hour of Psychotherapy or Relapse Prevention Group, one (1) hour of Life Skills or Psychotherapy Group, and one hour of Recreational Therapy scheduled for each weekday, and one hour of Psychotherapy Group for each weekend day. No active treatment groups or therapeutic activities were scheduled for evenings.

C. Interviews

1. During an interview with the Director of Social Work on 7/7/15 at 1:10 p.m., he acknowledged that there was only two (2) hours of therapeutic group activities scheduled each weekday for the Geriatric Unit and three (3) hours of therapeutic group activities scheduled each weekday for the Adult Unit. He acknowledged that, for both units, there was only one hour of scheduled group activities on weekends and no activities scheduled during evening hours.

2. During an interview with the Medical Director on 7/8/15 at 9:45 a.m., he acknowledged that there was only two (2) hours of the scheduled group activities each day for the Geriatric Unit and three (3) hours of scheduled group activities for the Adult Unit. He acknowledged that, for both units, there was only one hour of scheduled group activities on weekends and no activities scheduled during evening hours.

I. Based on observation, interview, and medical record and document review, the facility failed to ensure that the Medical Director monitored and took the needed corrective actions to:

A. Ensure the provision of comprehensive Master Treatment Plans that reflected appropriate active treatment to be given to patients and provided by the facility staff. Failure to develop master treatment plans with all the necessary components hampers the staff's ability to provide coordinated interdisciplinary care and results in patients being without a plan with appropriate interventions to provide guidance for staff to assist them, potentially resulting in patients' active treatment needs not being met. (Refer to B118)

B. Ensure that each patient had individualized psychiatric problem statements written in behavioral and descriptive terms on the Master Treatment Plans (MTPs). Instead, the stated problems on the treatment plans included diagnostic and/or generalized psychiatric terms rather than behaviorally descriptive psychiatric problems based on clinical assessment data and/or how presenting symptoms were specifically manifested by each of eight (8) of eight (8) active sample patients (A5, A6, A10, A13, B4, B6, B7 and B15). This failure results in fragmented treatment plans that are not comprehensive or individualized to patients' presenting psychiatric problems. (Refer to B119)

C. Ensure the development of Master Treatment Plans (MTPs) that evidenced sufficient individualized planning of interventions with specific focus based on individual needs and abilities of eight (8) of eight (8) active sample patients (A5, A6, A10, A13, B4, B6, B7 and B15). Specifically, interventions were stated as generic discipline functions written as active treatment interventions. Some MTPs also failed to consistently state the specific focus for interventions, and whether interventions would be delivered in group or individual sessions. These deficiencies result in treatment plans that fail to reflect an individualized approach to interdisciplinary treatment and failed to provide guidance to staff regarding the specific interventions and purpose for each. These failures also potentially result in inconsistent and/or ineffective treatment.

Findings include:

1. Record Review

The MTPs for the following patients were reviewed (dates of plans in parentheses): A5 (6/19/15), A6 (6/19/15), A10 (6/26/15), A13 (6/29/15), B4 (6/23/15), B6 6/27/15), B7 (6/26/15) and B15 (7/3/15). This review revealed that the MTPs contained a preprinted form for each category of problem. These forms included preprinted problem, long and short-term goals, and identical clinical interventions. These forms contained routine and generic discipline functions such as monitoring, assessing, prescribing, evaluating, encouraging, etc. written as active treatment interventions. Interventions for one of the psychiatric problems listed included the following findings: Psychiatrist Interventions: For the problem "Alt [Alteration] of Mood R/T [related to]: Depression," for seven (7) active sample patients (A5, A6, A10, A13, B4, B6 and B7) and Related to: "Elevated Manic Mood" for one (1) patient (B15), all had the following identical non-individualized and generic interventions despite different presenting symptoms selected from a preprinted list of interventions: "Complete Psychiatric Evaluation within 24 hours of admit." "Direct treatment plan & team x 1 per week." "Meet with the patient at least (handwritten entry) x per wk to assess status, evaluate effectiveness of medication & prescribe medication as needed throughout the duration of tx [treatment]." "Monitor risk level and direct team as needed to keep patient safe." "Complete H & P exam/medical consult within 24 hours of admit per [MD's name]." These interventions were generic physician tasks instead of specific treatment intervention statements that included a modality (group or individual sessions), a frequency of contact, and a focus of treatment that would assist each patient to accomplish his/her treatment goals and improve specific presenting problems.

2. Staff Interview

During an interview with the Medical Director on 7/8/15 at 9:45 a.m., he acknowledged that the physician interventions on the MTPs for these patients were generic and not specific to the individual patients.

D. Ensure that active treatment measures, such as individual treatment and other therapeutic activities, were available for two (2) of eight (8) active sample patients (A6 and B7) who were unwilling or unable to attend group therapies or benefit from the groups provided. Specifically, these patients spent many hours on the unit without appropriate alternative structured therapy or activities. Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered to them in a timely fashion, potentially delaying their improvement. (Refer to B125 I)

E. Ensure the assessment and treatment of the medical problems of one (1) of one (1) patient (Patient E1) reviewed due to the death of Patient E1 in the facility as well as failure to identify factors that may have contributed to the death. Failure to address and respond to medical issues and failure to identify factors that may have contributed to the death of a patient result in a potential risk to the health and lives of patients.

1. Refer to B125II.

2. Document review

A review of the Root Cause Analysis dated 9/24/14 stated that the only "Root cause" identified was that the "Patient's medical history of Huntington's disease directly affected the patient's outcome." No "Organization Plan of Action Risk Reduction Strategies" or other action items were identified in this Root Cause Analysis.

3. Interview

During an interview with the Medical Director on 7/8/15 at 9:45 a.m., he acknowledged that he participated in the Root Cause Analysis of the death of Patient E1 dated 9/24/14. The Medical Director acknowledged that there were no findings or action resulting from this Root Cause Analysis and the review of Patient E1's death.

F. Ensure that patients received sufficient hours of active treatment, including groups, individual sessions, and therapeutic activities especially on evening hours and weekends for all patients in the facility with a census of 38 patients. For the Geriatric Unit patients, there was only one (1) hour of Psychotherapy Group and one hour of Recreational Therapy scheduled for each weekday, and one hour of Psychotherapy Group for each weekend day. For the Adult Unit patients, there was only one hour of Psychotherapy or Relapse Prevention Group, one hour of Life Skills or Psychotherapy Group, and one (1) hour of Recreational Therapy scheduled for each weekday, and one hour of Psychotherapy Group for each weekend day. No active treatment groups or therapeutic activities were scheduled for evenings. Failure to provide sufficient active treatment potentially results in patients being hospitalized without the level and intensity of treatment needed to achieve their optimum level of functioning prior to discharge. (Refer to B125 III)

II. Ensure that the Director of Nursing provided adequate oversight to ensure quality nursing services. (Refer to B148)

III. Provide an adequate number of licensed nursing staff to provide nursing care, supervise, and monitor patients on the high acuity Adult Psychiatric and Geriatric Units especially on the night shift. This practice results in the potential for insufficient number of licensed nursing staff to response to psychiatric and medical emergencies leading to the potential for an unsafe environment. (Refer to B150)

Based on observation, interview, and medical record and document review, the Medical Director failed to provide adequate medical oversight to ensure quality medical services. Specifically, the Medical Director failed to:

I. Ensure the provision of comprehensive Master Treatment Plans that reflected appropriate active treatment to be given to patients and provided by the facility staff. Specifically, the facility failed to:

A. Provide comprehensive Master Treatment Plans (MTPs) that were individualized with all necessary components to provide active treatment. The MTPs were missing the following components:

1. Behaviorally descriptive psychiatric problem statements to be used as the basis for developing MTPs for eight (8) of eight (8) active sample patients (A5, A6, A10, A13, B4, B6, B7 and B15) identified in clinical assessments. (Refer to B119)

2. Individualized and specific active treatment interventions for eight (8) of eight (8) active sample patients (A5, A6, A10, A13, B4, B6, B7 and B15). (Refer B122)

Failure to develop master treatment plans with all the necessary components hampers the staff's ability to provide coordinated interdisciplinary care; potentially resulting in patients ' active treatment needs not being met.

B. Ensure that appropriate treatment plan revision occurred for the care and treatment of two (2) of eight (8) active sample patients (A6 and B7). Specifically, the treatment plans for these patients were not updated to reflect appropriate interventions based on their presenting needs and current level of functioning. This failure results in patients being without a plan with appropriate interventions to provide guidance for staff to assist them, potentially resulting in patients' active treatment needs not being met. (Refer to B118)

II. Based on record review and interview, the facility failed to ensure that each patient had individualized psychiatric problem statements written in behavioral and descriptive terms on the Master Treatment Plans (MTPs). Instead, the stated problems on the treatment plans included diagnostic and/or generalized psychiatric terms rather than behaviorally descriptive psychiatric problems based on clinical assessment data and/or how presenting symptoms were specifically manifested by each of eight (8) of eight (8) active sample patients (A5, A6, A10, A13, B4, B6, B7 and B15). This failure results in fragmented treatment plans that are not comprehensive or individualized to patients' presenting psychiatric problems. (Refer to B119)

III. Based on record review and interview, the facility failed to consistently develop Master Treatment Plans (MTPs) that evidenced sufficient individualized planning of interventions with specific focus based on individual needs and abilities of eight (8) of eight (8) active sample patients (A5, A6, A10, A13, B4, B6, B7 and B15). Specifically, interventions were stated as generic discipline functions written as active treatment interventions. Some MTPs also failed to consistently state the specific focus for interventions, and whether interventions would be delivered in group or individual sessions. These deficiencies result in treatment plans that fail to reflect an individualized approach to interdisciplinary treatment and failed to provide guidance to staff regarding the specific interventions and purpose for each. These failures also potentially result in inconsistent and/or ineffective treatment.

Findings include:

A. Record Review

The MTPs for the following patients were reviewed (dates of plans in parentheses): A5 (6/19/15), A6 (6/19/15), A10 (6/26/15), A13 (6/29/15), B4 (6/23/15), B6 6/27/15), B7 (6/26/15) and B15 (7/3/15). This review revealed that the MTPs contained a preprinted form for each category of problem. These forms included preprinted problem, long and short-term goals, and identical clinical interventions. These forms contained routine and generic discipline functions such as monitoring, assessing, prescribing, evaluating, encouraging, etc. written as active treatment interventions. Interventions for one of the psychiatric problems listed included the following findings: Psychiatrist Interventions: For the problem "Alt [Alteration] of Mood R/T [related to]: Depression," for seven (7) active sample patients (A5, A6, A10, A13, B4, B6 and B7) and Related to: "Elevated Manic Mood" for one (1) patient (B15), all had the following identical non-individualized and generic interventions despite different presenting symptoms selected from a preprinted list of interventions: "Complete Psychiatric Evaluation within 24 hours of admit." "Direct treatment plan & team x 1 per week." "Meet with the patient at least (handwritten entry) x per wk to assess status, evaluate effectiveness of medication & prescribe medication as needed throughout the duration of tx [treatment]." "Monitor risk level and direct team as needed to keep patient safe." "Complete H & P exam/medical consult within 24 hours of admit per [MD's name]." These interventions were generic physician tasks instead of specific treatment intervention statements that included a modality (group or individual sessions), a frequency of contact, and a focus of treatment that would assist each patient to accomplish his/her treatment goals and improve specific presenting problems.

B. Staff Interview

During an interview with the Medical Director on 7/8/15 at 9:45 a.m., he acknowledged that the physician interventions on the MTPs for these patients were generic and not specific to the individual patients.

IV. Ensure that active treatment measures, such as individual treatment and other therapeutic activities, were available for two (2) of eight (8) active sample patients (A6 and B7) who were unwilling or unable to attend group therapies or benefit from the groups provided. Specifically, these patients spent many hours on the unit without appropriate alternative structured therapy or activities. Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered to them in a timely fashion, potentially delaying their improvement. (Refer to B125 I)

V. Assess and treat the medical problems of one (1) of one (1) patient (Patient E1) reviewed due to the death of Patient E1 in the facility as well as failure to identify factors that may have contributed to the death. Failure to address and respond to medical issues and failure to identify factors that may have contributed to the death of a patient result in a potential risk to the health and lives of patients.

A. Refer to B125II.

B. Document review

A review of the Root Cause Analysis dated 9/24/14 stated that the only "Root cause" identified was that the "Patient's medical history of Huntington's disease directly affected the patient's outcome." No "Organization Plan of Action Risk Reduction Strategies" or other action items were identified in this Root Cause Analysis.

C. Interview

During an interview with the Medical Director on 7/8/15 at 9:45 a.m., he acknowledged that he participated in the Root Cause Analysis of the death of Patient E1 dated 9/24/14. The Medical Director acknowledged that there were no findings or action resulting from this Root Cause Analysis and the review of Patient E1's death.

VI. Ensure that patients received sufficient hours of active treatment, including groups, individual sessions, and therapeutic activities especially on evening hours and weekends for all patients in the facility with a census of 38 patients. For the Geriatric Unit patients, there was only one hour of Psychotherapy Group and one hour of Recreational Therapy scheduled for each weekday, and one hour of Psychotherapy Group for each weekend day. For the Adult Unit patients, there was only one hour of Psychotherapy or Relapse Prevention Group, one hour of Life Skills or Psychotherapy Group, and one hour of Recreational Therapy scheduled for each weekday, and one hour of Psychotherapy Group for each weekend day. No active treatment groups or therapeutic activities were scheduled for evenings. Failure to provide sufficient active treatment potentially results in patients being hospitalized without the level and intensity of treatment needed to achieve their optimum level of functioning prior to discharge. (Refer to B125 III)

Based on record review and interview, it was determined that the Director of Nursing failed to monitor and take corrective action to:

I. Develop Master Treatment Plans (MTPs) that evidenced sufficient individualized planning of nursing interventions with specific focus based on individual needs and abilities of eight (8) of eight (8) active sample patients (A5, A6, A10, A13, B4, B6, B7 and B15). Specifically, interventions were stated as generic nursing functions written as treatment interventions. MTPs also failed to consistently include the specific focus for interventions, and whether interventions would be delivered in group or individual sessions. These deficiencies result in treatment plans that fail to reflect an individualized approach to interdisciplinary treatment and also fail to provide guidance to staff regarding the specific nursing interventions and purpose for each. These failures also potentially result in inconsistent and/or ineffective treatment.

Findings include:

A. Record Review:

The MTPs for the following patients were reviewed (dates of plans in parentheses): A5 (6/19/15), A6 (6/19/15), A10 (6/26/15), A13 (6/29/15), B4 (6/23/15), B6 6/27/15), B7 (6/26/15) and B15 (7/3/15). This review revealed that the MTPs contained a preprinted form for each category of problem. These forms included preprinted problem, long and short-term goals, and identical nursing interventions. These forms contained routine and generic nursing functions such as monitoring, assessing, evaluating, encouraging, etc. written as active treatment interventions. Nursing interventions for one of the psychiatric problems listed included the following findings.

Registered Nurse Interventions: For the problem "Alt [Alteration] of Mood R/T [related to]: Depression," for seven (7) active sample patients (A5, A6, A10, A13, B4, B6 and B7) and Related to: "Elevated Manic Mood" for one patient (B15), all had the following identical non-individualized and generic interventions despite different presenting symptoms for each patient.

"Complete Nursing Assessment & formulate plan on admit." "Provide safe, structure environment daily for the duration of tx [treatment]." "Communicate to TX [Treatment] team the patient's status." "Assess mood, behavior & effectiveness of intervention(s) daily for duration of treatment." "Implement close q 15 observation for duration of Tx [Treatment]." "Assess physical status, vital signs, appetite & sleep daily for duration of TX [treatment]." "Administer medications as prescribed for duration of treatment."

These interventions were actually generic nursing tasks instead of specific treatment intervention statements that included a modality (group or individual sessions), a frequency of contact, and a focus of treatment that would assist each patient to accomplish his/her treatment goals and make improvements in presenting problems.

The following nursing interventions were the only treatment interventions included on the preprinted list:

"Provide education on disease process and alternative to self-harm via nursing group x45-60 min daily x (left blank) weeks." [This intervention statement was very broad in that it did not a specific focus of treatment related to "disease process" that would direct targeted information based on each patient's needs and/or presenting symptoms.

"Educate on medication prescribed x 1 per wk [week]." "Provide nursing groups x45-60 min [minutes] (Number of weeks) per week for duration of TX [treatment]." These intervention statements failed to include a focus of treatment based each patient's need and/or presenting symptoms. In addition, the intervention statement regarding medication education did not include whether the intervention would be conducted in group or individual sessions.

B. Staff Interview

During interview on 7/7/15 at 3:45 p.m. with the Director of Nursing, the MTPs for A6, A13, B4 and B15 were reviewed. She acknowledged that interventions were routine nursing functions instead of specific and individualized treatment interventions to assist patients to improve their presenting problems.

II. Ensure that the nursing interventions listed on the Master Treatment Plans (MTPs) were documented by registered nurses for eight (8) of eight (8) active sample patients (A5, A6, A10, A13, B4, B6, B7 and B15). Specifically, there was no documentation showing the topic(s) discussed and/or information provided during nursing treatment interventions. In addition, there was limited documentation regarding the response to the treatment interventions provided. This failure potentially hampers the treatment team's ability to determine patients' response to treatment interventions, evaluate whether there are measurable changes in patients' condition, and revise the treatment plan if/when needed. (Refer to B124)

III. Deploy adequate numbers of Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) to provide nursing care, supervise, and monitor patients on the high acuity Adult Psychiatric and Geriatric Units especially on the night shift. This practice results in the potential for insufficient number of licensed nursing staff to response to psychiatric and medical emergencies leading to the potential for an unsafe environment. (Refer to B150)

Based on record review and interviews, the facility failed to deploy adequate numbers of Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) to provide nursing care, supervise, and monitor patients on the high acuity Adult Psychiatric and Geriatric Units especially on the night shift. This practice results in the potential for insufficient number of licensed nursing staff to response to psychiatric and medical emergencies leading to the potential for an unsafe environment.

Findings include:

A. Document Review

1. The staffing documents produced by the Director of Nursing were: The "Geriatric Staffing Matrix 2013" which reflected an assignment of one (1) RN 1 LPN, and four (4) Mental Health Technicians (MHT) from 7 a.m. to 11 p.m. and one (1) RN and four (4) MHTs from 11 p.m. to 7 a.m. with a census ranging from 16 - 18 patients. The "Adult Staffing Matrix" which reflected an assignment of one (1) RN, one (1) LPN, and two (2) MHTs from 7 a.m. to 11 p.m. and one (1) RN and two (2) MHTs from 11 p.m. to 7 a.m. with a census range from 13 - 20 patients. These documents revealed that the facility only provide one (1) RN to cover each unit from 11 p.m. to 7 a.m. resulting in no additional licensed staff to provide assistance in cases of medical and psychiatric emergences and for meals and breaks.

2. The "NSG-05: Staff Plan" reflected that the Director of Nursing also acted as the Nurse Manager for both units. The one (1) RN covering from 11 p.m. to 7 a.m. was responsible for staffing the unit in addition to other clinical duties. The Policy stated, "Charge Nurse after hours and weekends: Evaluates the staffing needs based on patient acuity established criteria on a shift-by-shift basis and adjusts staff levels accordingly."

3. An analysis of the staffing data collected during the survey revealed that the census on the Geriatric Unit ranged from 16-18 patients and was consistently staffed with one (1) RN and four (4) MHTs. An LPN was also assigned to pass medications on the Adult Unit from 7 a.m. to 3 p.m. and 3 p.m. To 11 p.m. After 11 p.m., there was only one (1) RN available to provide nursing care for 16 to 18 patients and supervise the two (2) MHTs.

4. A review of the needs assessment document for the Geriatric Unit revealed a high patient acuity that would potentially require another license nursing staff to be available for the two units on the night shift to assist with clinical and supervisory needs. The Needs Assessment Document completed on the first day of the survey revealed a census of 18 patients with the following needs:

a. Physical care needs: 10 patients requiring partial assistance from staff for ADLs, four (4) patients requiring total assistance from staff; three (3) bedfast patients, seven (7) patients in wheelchairs requiring partial assistance from staff; two (2) patients requiring decubitus care, four (4) patients on diabetic checks; and five (5) seizure precautions.

b. Psychiatric nursing care needs: Six (6) patients potentially assaultive, three (3) patients actively assaultive, five (5) patients on assault precaution, and 14 patients on fall precautions. In addition, the Geriatric Unit reported that the average number of admission per week was five (5) five admissions on the day and three (3) on the evening shift. The average number of discharges per week was seven on the day shift and one (1) on the evening shift.

5. An analysis of the staffing data collected during the survey indicated that staffing for the Adult Unit with a census ranging from 19-20 patients was consistently one (1) RN and two (2) MHTs. An LPN was also assigned to pass medications on the Adult Unit from 7 a.m. to 3 p.m. and 3 p.m. To 11 p.m. After 11 p.m., there was only one RN available to provide nursing care for 19 to 20 patients and supervise the two (2) MHTs.

6. A review of the needs assessment document for the Adult Unit revealed a high patient acuity of that would potentially require the availability of another license nursing staff between the two units on the night shift to assist with nursing care needs. The Needs Assessment Document completed on the first day of the survey revealed a census of 20 patients with the following needs:

Physical care needs: Two (2) patients requiring partial assistance from staff for ADLs, one (1) patient requiring dressing changes, two (2) patients on diabetic checks, one (1) patient on seizure precautions and one (1) patient requiring catheter care.

Psychiatric care needs: Two (2) patients potentially assaultive, one patient actively assaultive, four (4) patients potentially suicidal, and 1 patient at acute risk of suicide, two (2) diabetic patients needing monitoring, one (1) patients on seizure precautions and one (1) patients who was utilizing a detox protocol. In addition, the Adult Unit reported that the average number of admission per week was five (5) five admissions on the day and on the evening shift, and one (1) on the night shift. The average number of discharges per week was nine (9) on the day shift and two (2) on the evening shift.

7. A review of the facility's Policy titled, "TX-MED: 17 Sliding Scale Insulin" revealed that the facility failed to always require the standard of good nursing practice for patients requiring insulin. The policy stipulated, "Insulin requires a double check method verifying correct medication and dose by two (2) RN's or RN and LPN prior to administration." The policy also stipulated, "In the case where there is only one licensed nurse available, the nurse performs the double check method by initialing the MAR a second time next to his/her previous initials."

8. A standard formula to assess for RN coverage to factor in time off (days off, vacation, sick leave, etc.) indicated that a least nine RNs were needed for minimum coverage. The total number of RN full time equivalent (FTE) positions for the two (2) acute units was eight (8) FTEs.

C. Staff Interviews

1. During interview on 7/7/15 at approximately 3:45 p.m., with the Director of Nursing, the staffing pattern for the Geriatric and Adult Psychiatric Units were discussed. The Director of Nursing confirmed the patient acuity on these units and stated that MHTs were added to account for the acuity. However, the Director of Nursing acknowledged the RN staff was not increased to adjust for acuity but a LPN was added to cover both units from 11 a.m. to 7 p.m. This coverage not available on the 7 p.m. to 7 a.m. resulting in only one (1) licensed staff on this shift. The Director of Nursing acknowledged there was no other licensed staff to provide coverage in case of medical or psychiatric emergencies and licensed staff available to allow the RN to take the standard meal break and two 15 min breaks during the night shift.

2. During interview on 7/8/15 with RN 3 at 9:30 a.m., stated that some patients may need to have their insulin on the night shift when there is only one licensed staff. RN 3 noted, "The RN would have to go to the other unit to have the other RN verify the dosage." RN 3 admitted that this would leave the unit no licensed coverage.

Based on record review and interview, the Social Work Director failed to consistently develop Master Treatment Plans (MTPs) that evidenced sufficient individualized planning of interventions with specific focus based on individual needs and abilities of eight (8) of eight (8) active sample patients (A5, A6, A10, A13, B4, B6, B7 and B15). Specifically, interventions were stated as generic social work functions written as active treatment interventions. Some MTPs also failed to consistently state the specific focus for interventions, and whether interventions would be delivered in group or individual sessions. These deficiencies result in treatment plans that fail to reflect an individualized approach to interdisciplinary treatment and failed to provide guidance to social work staff regarding the specific interventions and purpose for each. These failures also potentially result in inconsistent and/or ineffective treatment.

Findings include:

A. Record Review

The MTPs for the following patients were reviewed (dates of plans in parentheses): A5 (6/19/15), A6 (6/19/15), A10 (6/26/15), A13 (6/29/15), B4 (6/23/15), B6 6/27/15), B7 (6/26/15) and B15 (7/3/15). This review revealed that the MTPs contained a preprinted form for each category of problem. These forms included preprinted problem, long and short-term goals, and identical clinical interventions. These forms contained routine and generic discipline functions such as assessing, evaluating, encouraging, etc. written as active treatment interventions. Social work interventions for one of the psychiatric problems listed included the following findings: for the problem "Alt [Alteration] of Mood R/T [related to]: Depression," for seven (7) active sample patients (A5, A6, A10, A13, B4, B6 and B7) and Related to: "Elevated Manic Mood" for one (1) patient (B15), all had the following identical non-individualized and generic interventions despite different presenting symptoms. "Meet with patient 1:1 to complete Psychosocial/ Multidisciplinary Treatment Integration within 72 hours." "Develop and establish rapport with patient daily and ongoing within 5 days." "Engage patient's family/significant others in continued support within 48 hours of admit & via wkly [weekly] collatera1 contracts throughout the duration tx [treatment]." These interventions were actually generic social work and not specific treatment intervention statements reflecting what would be done by the social worker to assist the patient to make improvement in the specific and descriptive presenting symptom(s).

The following social work interventions were the only treatment intervention included on the preprinted list: "Provide Group Psychotherapy to process issues & address tx [treatment] goals x 45-60 min [minutes] x 1 sessions per day for 1-2 weeks." This intervention statement was very broad in that it failed to include specific information regarding issues to be addressed based on each patient's presenting symptoms. "Provide individual/Family Therapy sessions as ordered by MD." This intervention statement did not include a focus of treatment or a frequency of contact.

B. Staff Interviews

In an interview on 7/7/15 at 2:25 p.m. with the Chief Executive Officer (CEO) and Director of Social Work, the Master Treatment Plan process was discussed. The CEO stated, "I understand the need to individualize the treatment plan."