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Based upon reviews of medical records, Medical Staff Bylaws/Rules, 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 medical staff member not pronouncing dead a deceased patient, and not requesting an autopsy for an unusual death in accordance with Medical Staff Bylaws/Rules for 1 of 1 (#2) death records reviewed out of a total sample of 12 (#1-12).
Findings:

Review of the Medical Staff Bylaws/Rules revealed in the event of a hospital patient death, the deceased would be pronounced dead by the attending physician and request for autopsy would be made for all unusual deaths. The Medical Staff Bylaws/Rules also revealed the body was not to be released until an entry was made and signed by the physician appointee of the medical staff.

Review of the hospital's Death Log for 2013 to present revealed only 1 patient (Patient #2) listed as a death during a hospital stay.

Patient #2
Review of the medical record for Patient #2 revealed the patient was a 55 year old male admitted to the hospital on 11/14/13 at 2:40 p.m. under a PEC (Physician Emergency Certificate). Review of the PEC revealed the patient presented to the emergency room of another hospital via EMS (Emergency Medical Services) after he was walking naked at a gas station. The PEC revealed the patient had no known psychiatric history and was PEC'd due to being gravely disabled and unwilling to seek voluntary admission.

Review of the nurse's notes dated 11/16/14 at 12:40 a.m. and documented by S16RN (Former DON), revealed the patient's condition changed and the nurse was unable to obtain vital signs due to the patient's restlessness. The nurse's notes revealed the nurse notified the S6MD (Medical Director and Psychiatrist) at 12:43 a.m., and S6MD ordered the patient transferred to an acute care hospital. The nurse's notes revealed Cardio-Pulmonary Resuscitation (CPR) was initiated at 12:55 a.m., when the patient stopped breathing. The ambulance service arrived at 1:07 a.m. and continued the resuscitation efforts until 1:45 a.m., when the patient was pronounced dead by the ambulance personnel, after consulting their affiliated physician. Further review of the nurse's notes revealed the body was released to the coroner's office at 4:00 a.m. and the family was notified at 4:10 a.m.

There was no documented evidence in the patient's record that the patient was pronounced dead by the attending physician as required in the medical staff rules and regulations. There was no documented evidence of an entry in the medical record by the physician before the body was released. There was no documented evidence of a request for autopsy, and there was no documented evidence of an autopsy report.

In an interview on 03/25/14 at 2:10 p.m., S1Adm verified no physician on staff at the hospital came in to evaluate and pronounce Patient #2 dead. S1Adm verified there was no entry by the physician in the medical record as required in the medical staff rules and regulations. S1Adm verified the hospital had not received an autopsy report and one was not requested by the medical staff.

In an interview on 03/27/14 at 3:54 p.m., S6MD stated he recalled Patient #2 and stated when he left the hospital on 11/15/13, the patient was having medical complications. S6MD stated the DON (Director of Nursing-S16RN) was at the hospital and called him and informed him the patient was having breathing problems. S6MD stated he instructed S16RN to send the patient to the emergency room and stated he offered to come in to the hospital. S6MD stated S16RN told him the patient was deceased and everything was taken care of. S6MD verified he did not come into the hospital and did not pronounce the patients.

Based on observations, reviews of information given to patients upon admission, the hospital's Grievance Policy, and interviews, the hospital failed to ensure each patient received complete information on how/who to submit a grievance/complaint and that the patient may choose to notify the State Agency in lieu of utilizing the hospital's complaint/grievance system. Findings:

Observations, 03/25/14 at 10:30am through 11:30am, revealed patient rights and telephone numbers for the Louisiana Mental Health Advocacy Service were posted in a room (numbered S53), across from the Nursing Station. Interview, 03/25/14 at 10:50am, with S8 Registered Nurse (RN) revealed this room was utilized as a "group" meeting room for the patients on the "A-Hall". Observations conducted throughout the remainder of the survey (03/25/14 10:40am through 03/27/14 6:30pm) revealed there were no group meetings conducted in room number S53 during the survey hours.

Observations, 03/25/14 at 1:10pm, revealed patient rights were posted in the dayroom/dining room/TV room. The two locations in the Hospital, room number S53 and dayroom, were the only two places where patient rights were posted.

Review of information on Patient Rights contained in the "PATIENT HANDBOOK" revealed the following: (page 8 of 24) "...V. PATIENT RIGHTS...the right to be informed in writing about the hospital's policies and procedures for initiation, review and resolution of patient complaints, including the address and phone number of where complaints may be filed with the department..." (page 10 of 24) "VII. GRIEVANCE / COMPLAINT PROCEDURE If you or a family member should have a suggestion or a problem during your time...speak with a staff member or put your comments in writing for submission to our Suggestion Box...This information will be held in confidence and only shared with those staff members necessary...informed decision regarding your comments...staff is available to speak to you about your concerns. This facility has a formal Complaint / Grievance procedure in place if you feel that your suggestion or problem is not being resolved. A complaint or formal grievance can be submitted in writing to a staff member who will document your information on a Complaint/Grievance Report form...Administration will be notified. Once submitted in writing, the situation will be discussed and evaluated and a written response will be provided to you within 7 days. All decisions of the hospital's Administrator will be considered final actions of...If you feel your complaint has not been resolved after working with...personnel, you are encouraged to notify the Louisiana Mental Health Advocacy Service at 1 (800) 428-5432..."

Continued review of the Patient Handbook revealed there failed to be an address for Louisiana Department of Health and Hospitals--Health Standards Section. Further review of the information relative to patient complaint/grievance process that was given to the patient upon admission failed to indicate that the patient may notify the State Licensing agency to file a complaint/grievance.

Interview, 03/26/14 at 3:30pm, with S18 Director of Quality Improvement (QI) revealed she was the "patient advocate".

Interview, 03/27/14 at 4:15pm, with Patient #4 revealed he was unaware who the patient advocate was, nor did he know that he could contact the State Agency or the Joint Commission if he had a complaint/grievance against the hospital.

Based on interview and record review, the hospital:
1) failed to ensure the Consent for Treatment was signed prior to the start of treatment for 1 (#1) of 10 (#1-#10) patients reviewed.
2) failed to ensure the consent for psychotropic medications was signed before the medications were administered for 2 (#8,#9) of 10 (#1- #10) patients reviewed.
Findings:
1) Failing to ensure the Consent for Treatment was signed prior to the start of treatment.
Review of the policy titled Subject: Informed Consent, Effective Date: September 1, 2011, read in part:
Written verification of the informed consent must be on the patient's medical record prior to initiation of care, treatment or services.
Patient #1
Patient #1 was a 57 year old male admitted to the hospital on a PEC (Physician Emergency Certificate) on 3/21/14 with an admitting diagnosis of Chronic Paranoid Schizophrenia.
Review of the Nursing Behavioral Assessment on admission (3/21/14 at 4:40 p.m.) revealed Patient #1 was orientated to person, time, place and situation.
Review of the Consent to Treat/Condition of Admission on the medical record on 3/25/14 by the surveyor and confirmed by S1Administrator revealed the Consent to Treat was blank and not filled out or signed by the patient.
Review of the medical record on 3/26/14 by the surveyor revealed a Consent to Treat/Conditions of Admissions on Patient #1's medical record filled out and signed by Patient #1 and dated 3/21/14 and witnessed by S15RN.
An interview was conducted with S1Administrator on 9:15 a.m. She reported she had told the day nurse to get the night nurse to obtain a consent for treatment from Patient #1 on the night shift of 3/25/14, not to back date the consent to 3/21/14, the date of admission. She went on to report S15RN had resigned that morning (3/26/14).

2) Failing to ensure the consent for psychotropic medications was signed before the medications were administered.
Review of the policy titled Subject: Consent to Psychotropic Medications, Effective Date: August 15, 2011, read in part:
Antipsychotic Medication: If a medication is used to treat either a psychosis or a severe mental or emotional disorder, it shall be considered a psychotropic medication for purpose of these regulations.
Policy:
The Department of Health and Hospitals has adopted regulations which set forth the right of Voluntary and Involuntary Psychiatric patients to refuse treatment with Psychotropic Medications (except in emergency situations). To comply with the Department of Health and Hospitals regulations; To ensure that the patient's right to refuse medications (except in emergency) have been explained to the patient; To ensure that the patient has received specific information regarding the nature and effect of psychotropic medications, to enable him/her to make an informed decision.
Written documentation of the patient's decision to consent must be maintained and the patient may withdraw consent at any time.
Prior to the administration of the medication, the Consent to Receive Psychopharmacological Medications Form must be signed by the patient. No nurse may administer the prescribed medication(s) until this form is completed.

Patient #8
Review of the medical record for Patient #8 revealed he was a 33 year old male admitted to the hospital on 3/11/14 for PTSD (Post Traumatic Stress Disorder) with Psychotic Features.

Review of the Physician's Orders revealed an order dated 3/13/14 at 3 p.m. for Resperdol 1 mg (milligram) po (by mouth) Bid (twice a day).

Review of the MAR (Medication Administration Record) revealed he had been administered Resperdol 1 mg po Bid on the following dates:
3/13/14 at 2100
3/14/14 at 0900 and 2100
3/15/14 at 0900

Review of the Physician's Orders revealed an order dated 3/15/14 at 11:45 a.m. to, "Increase Reperdol to 2 mg po bid."

Review of the MAR revealed the patient had been administered Resperdol 2 mg po BID on the following dates:
3/15/14 at 9:00 p.m.
3/16/14 at 9:00 a.m. and 9:00 p.m.
3/17/14 at 9:00 a.m.

Review of the Physician's Orders revealed on order dated 3/17/14 at 6:30 p.m. to Increase Risperdol to 3 mg at hs (bedtime) and to decrease to 1 mg in the a.m.

Review of the MAR revealed the patient was administered Resperdol 3 mg at hs and 1 mg in the a.m. of the following dates;
3/18/14 at 9:00 a.m. and 9:00 p.m.
3/19/14 at 9:00 a.m. and 9:00 p.m.
3/20/14 at 9:00 a.m. and 9:00 p.m.

Review of the Informed Consent for Psychotropic Medications revealed Patient #8 signed his consent on 3/25/14 for psychotropic medications to be administered to him.

An interview was conducted on 3/27/14 at 9:45 a.m. with S2DON. She reported the Resperdol was a new medication for Patient #8 and the consent should have been obtained on 3/13/14 prior to the medication being administered to the patient.

Patient #9
Review of the medical record for Patient #9 revealed he was a 46 year old male admitted
on 3/20/14 at 7:35 p.m. with diagnosis which included Schizophrenia.

Review of the Physician's Orders for Patient #9 revealed the following orders:
3/20/14 at 8:25 p.m.- Ativan 1 mg(milligram) IM (intramuscular) x 1 dose now then Ativan 1mg po (by mouth) q (every) 6 prn (as needed) agitation or Ativan 1mg IM q 6 prn severe agitation. Seroquel 50mg po q hs (hour of sleep).
3/21/14- Geodon 40 mg po bid (twice per day).

Review of the Medication Administration Record for Patient #9 revealed he had received the following medications:
Ativan 1 mg on 3/20/14 at 9:30 p.m.
Seroquel 100mg on 3/21/14 at 9:00 p.m.
Geodon 40 mg on 3/21/14 at 9:00 a.m. and 9:00 p.m.
Ativan 0.5 mg on 3/21/14 at 9:00 a.m. and 3:00 p.m.

Review of the document for Patient #9 titled "Informed Consent for Psychotropic Medications " revealed Ativan, Seroquel and Geodon were selected. In the space for the patient signature was written, " refused to sign at this time 3/22/14." Further review revealed the document had not been signed by the physician until 3/24/14.

In an interview on 3/27/14 at 1:00 p.m. with S1Adm, she said they do not consent the patients for psychotropic medications on admission because they assume whoever started the medications on the patients consented them. S1Adm verified they do not require documentation of the consents from a transferring facility. S1Adm also verified the consents at the hospital were not obtained on a regular basis before the psychotropic medications were administered.

In an interview on 3/27/14 at 3:55 p.m. with S6MD, he verified the consents were not being signed for psychotropic medications before the medications were given. S6MD said he would usually write the orders for the medications and then obtain the consents the next day.



30364

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

1. the hospital's 24 beds had 2 upper and 2 lower siderails, metal bases with 62 removable springs and small interlocking metal pieces and 2 cranks located at the foot of the beds, which elevate and lower the foot and head of the beds.

2. the hospital failed to ensure the staff monitored a patient (#4) on close observation every 15 minutes as ordered by the physician after having a seizure.

Findings:

1. An observation was made on 3/25/14 at 10 a.m. of the hospital's 24 patient's beds having 2 lower and upper oblong siderails, the base of the beds having 62 removable springs and small interlocking metal pieces and 2 cranks located at the foot of the beds, which elevate and lower the head and foot of the beds.

An interview was conducted with S1Administrator on 3/26/14 at 10:30 a.m. S1Administrator reported all the hospital's beds have siderails, metal bases and cranks at the foot of the beds. She went on to state the hospital did not have a policy on how they would keep suicidal patients safe in the hospital's beds. She also confirmed the hospital did have patients in the hospital with suicidal ideations.

2. Failing to ensure the staff monitored a patient (#4) on close observation every 15 minutes as ordered by the physician after having a seizure.

Review of Patient #4's medical record revealed he had a history of seizures and upon admission Patient #4 was ordered to be on Seizure Precautions (per physician's order).

Review of the hospital's policy/procedure for Seizure Precautions revealed the following: "SUBJECT: SEIZURES--NURSING MANAGEMENT POLICY All patients with a history of seizure disorder will be assessed...to ensure the safety of all seizure-prone patients. PROCEDURE 1. The following seizure precautions are taken by the hospital: Increased Observation for Seizures - Warning Signs...2. Nursing Assessment and Implementation of Precautions: ...When documenting the seizure, state whether or not the beginning of the seizure was observed...3. Nursing Interventions During Seizure: Stay with patient during and after the seizure Ensuring an adequate airway: ...Protecting the patient from injury: ...4. Nursing Interventions After Seizure: ...Administer medication as ordered by physician..."

Review of a form titled, "Nursing Flowsheet", dated 03/25/14 at 8:30am, revealed S8 Registered Nurse (RN) documented the following: "pt (patient) in room crying very upset think about brother during consoling pt, pt began to go into seizure. Seizure last approx (approximately) 3-5 min (minutes) then pt laid in bed. Ridget (rigid?) & (and) blank affect. MD (physician) notified (signature of S8 RN) @ (at) 0900 pt in bed still displaying Rigidity. am (morning) meds (medications) administered pt tolerated well. will continue to monitor (signature S8 RN) @ 1100 pt still in bed stated 'I feel weak'. pt allowed to stay in bed (signature S8 RN) @ 1300 (1:00pm) fall precautions initiated (signed S8 RN) 3/25/14 2100 (9:00pm) Pt up in w/c (wheelchair) moderate generalized tremors noted. Med nurse gave Pt Klonopin as ordered by doctor (signed by S15 RN)".

Review of a form titled "CLOSE OBSERVATION FORM", revealed the following under a section (titled "CODE KEYS"): LOCATION (L), ACTIVITY (A), and BEHAVIOR (B). Under the "location" section there were numbers ranging from 1-26 that identified the location of the patient; under "activity" the letters ranged from A-V to show the activity the patient was engaged in; and under "behavior" the numbers ranged from 50-73 to indicate the patients' behaviors that were exhibited during the monitoring.

Continued review of the Close Observation Form revealed S9 Mental Health Technician (MHT) documented the following:
Time Code Initial
L A B
0730 3 P 69 initials of S9 MHT
0745 3 P 69 same as above
0800 3 G 69 as above
0815 3 G 69 as above
0830 3 B 73 as above
0845 3 B 73 as above
0900 5 E 69 as above
0915 5 E 69 as above
0930 5 E 69 as above
0945 1 B 69 as above
1000 1 A 72 as above
(L-3--indicated the lounge; 5--indicated in group; 1--indicated in patient's room)
(A-P--indicated watching TV; G-indicated eating meal/snack; B-indicated laying in bed; E-indicated talking with staff; A-indicated patient sleeping)
(B-69--indicated cooperative; 73-indicated shaking trembling; 72-indicated quiet).

Continued review of the Close Observation Form, dated 3/25/14, revealed S9 MHT documented Patient #4 remained in his "room, sleeping, quiet" from 10:00am through 12:30pm; then from 12:45pm to 1:00pm "toilet and grooming". S9 MHT documented from 1:15pm to 2:45pm, Patient #4 remained in his room sleeping; and from 3:00pm to 4:30pm he was laying in bed. S9 MHT documented Patient #4's behavior, from 10:00am until 4:30pm, was "quiet".

S8 RN had documented Patient #4 was having a seizure (3/25/14 at 8:30am) then resting in his bed at 9:00am; however, S9 MHT documented he was "in group and was cooperative" from 9:00am through 9:45am.

The surveyor observed, on 03/25/14 at 2:40pm, Patient #4 attempt to walk from his room to the dayroom. Patient #4 was unsteady on his feet and was observed holding onto the wall in the hallway while attempting to walk to the dayroom. Continued observations revealed S8 RN and S18 Director Quality Improvement assisted Patient #4 back to his room.

Review of the Close Observation Form revealed S9 MHT failed to show documentation of this activity by Patient #4; S9 MHT had documented at 2:30pm and 2:45pm on 03/25/14, Patient #4 was in his room sleeping, quiet.

Patient #4 had received a physician's order for seizure precautions upon his admission. Review of the Close Observation Form revealed hospital staff failed to ensure seizure precautions, per physician order, was noted on the form.

Hospital staff failed to ensure all patients received care in a safe setting as evidenced by failing to provide increased monitoring on Patient #4 when seizure activity was noted by S8 RN on 03/25/14.

Based on medical record review and staff interview, the hospital failed to ensure restraint/seclusion was used only when less restrictive interventions were determined to be ineffective as evidenced by failing to document the patient's specific behavior that warranted seclusion for 1 of 1 (#12) sampled patients reviewed for the use of restraints out of a total sample of 12 (#1-12). Findings:

Review of the hospital policy titled Restraint or Seclusion Use Violent and Non-Violent Behaviors revised date of 12/17/12, and presented as current by S1Adm (Administrator) revealed in part the following: Policy: The use of restraint shall be based on a comprehensive assessment....Restraint orders must specify for violent or non-violent/self-destructive or non-self-destructive behaviors....Orders for Restraint or Seclusion must specify the reason (medical necessity: rationale for the use of restraint or seclusion) for the restraint or seclusion....Documentation: Documentation in the medical record should include: Restraint orders, including the rationale for the restraint, violent/nonviolent behavior, the type of restraint, the extremity or body part (s) to be restrained and the duration (timeframe) for restraint application, LIP (Licensed Independent Practitioner) authentication....The patient's condition or symptom(s) that warranted the use of restraint or seclusion...

Patient #12
Review of the medical record for Patient #12 revealed the patient was a 54 year old male admitted to the hospital on 03/12/14 under a PEC (Physician Emergency Certificate). The PEC revealed the patient was brought to the emergency room by policy due to confusion and being naked in the street. Review of the psychiatric evaluation dated 03/12/14 revealed the patient's diagnosis was Acute Exacerbation of Schizo Affective Disorder. Further review of the record revealed the patient was discharged from the hospital on 3/21/14.

Review of the physician orders dated 03/13/14 at 5:50 a.m. a verbal order, "To Seclusion Room." Further review of the, "Violent and Non-Violent Restraint/Seclusion Orders" dated 03/13/14 5:50 a.m. revealed the orders were telephone orders and documented the rationale for the seclusion as, "Patient combative towards staff members and verbally aggressive." The order revealed the seclusion was ordered for 4 hours. There was no documented evidence in the physician's orders of the specific patient behavior that warranted seclusion.
Review of the nursing documentation and restraint flow sheets revealed no documented evidence of the specific behavior demonstrated by Patient #12 that warranted seclusion.
Review of the record revealed the seclusion was discontinued at 6:10 a.m. on 03/13/14.

Review of the physician orders dated 03/14/14 at 3:30 a.m. revealed a verbal order, "To Seclusion Room." Further review of the, "Violent and Non-Violent Restraint/Seclusion Orders" dated 03/14/14 at 3:30 a.m. revealed the orders were telephone orders and documented the rationale for the seclusion as, "Patient combative towards staff members and verbally aggressive." The order revealed the seclusion was ordered for 4 hours. There was no documented evidence in the physician's orders of the specific patient behavior that warranted seclusion.
Review of the nursing documentation and restraint flow sheets revealed no documented evidence of the specific behavior demonstrated by Patient #12 that warranted seclusion.
Review of the record revealed the seclusion was discontinued at 5:00 a.m. on 03/14/14.

Review of the physician orders dated 03/14/14 at 7:55 p.m. revealed a verbal order, "To Seclusion Room." Further review of the, "Violent and Non-Violent Restraint/Seclusion Orders" dated 03/14/14 at 7:55 p.m. revealed the orders were telephone orders and documented the rationale for the seclusion as, "Patient combative towards staff members and other patients. Patient physically and verbally aggressive." The order revealed the seclusion was ordered for 4 hours. There was no documented evidence in the physician's orders of the specific patient behavior that warranted seclusion.
Review of the nursing documentation and restraint flow sheets revealed no documented evidence of the specific behavior demonstrated by Patient #12 that warranted seclusion.
Review of the record revealed the 4 point restraints were added at 12:00 a.m. on 3/15/14 due to the patient punching seclusion room walls and door.

In an interview on 03/27/14 at 2:35 p.m., S1Adm and S2 DON verified the patient's specific behavior should have been documented in the physician orders and the nurse's documentation. S1Adm verified the above documentation did not include the patient's specific behavior that warranted the use of seclusion.

Based on record review and staff interview, the hospital failed to ensure the patient's plan of care was updated with the use of restraint/seclusion for 1 of 1 (#12) sampled patient reviewed for use of restraint/seclusion out of a total sample of 12 (#1-12). Findings:

Review of the hospital policy titled Restraint or Seclusion Use Violent and Non-Violent Behaviors revised date of 12/17/12, and presented as current by S1Adm (Administrator) revealed in part the following: Policy: The use of restraint shall be based on a comprehensive assessment. The use of restraint or seclusion shall be documented in the patient's plan of care. This plan of care shall be reviewed and revised as needed....Restraint or seclusion must be used in accordance with a written modification to the patient's plan of care....Documentation in the medical record should include: ....Revisions to the plan of care....

Patient #12
Review of the medical record for Patient #12 revealed the patient was a 54 year old male admitted to the hospital on 03/12/14 under a PEC (Physician Emergency Certificate). The PEC revealed the patient was brought to the emergency room by policy due to confusion and being naked in the street. Review of the psychiatric evaluation dated 03/12/14 revealed the patient's diagnosis was Acute Exacerbation of Schizo Affective Disorder. Further review of the record revealed the patient was discharged from the hospital on 3/21/14.

Review of the record revealed the patient was placed in seclusion on 03/13/14 5:50 a.m. due to being combative towards staff members and verbally aggressive. The seclusion was discontinued at 6:10 a.m. on 03/13/14.

The record revealed the patient was again placed in seclusion on 03/14/14 at 3:30 a.m. due to being combative towards staff members and verbally aggressive. The seclusion was discontinued at 5:00 a.m. on 03/14/14.

The record revealed the patient was again placed in seclusion on 03/14/14 at 7:55 p.m. due to being combative towards staff members and other patients and physically and verbally aggressive. Review of the record revealed the 4 point restraints were added at 12:00 a.m. on 3/15/14 due to the patient punching the seclusion room walls and door. The patient remained in restraints until 03/15/14 at 7:00 p.m.

Review of the Multidisciplinary Plan of Care revealed the plan of care was updated on 03/13/14 with a "Restraint/Seclusion pre-printed form. Review of the Restraint/Seclusion plan of care revealed, "Potential for the need of restraints/seclusion due to violent/self destructive behaviors" was checked and "Seclusion (violent behavior only)" was checked. The "Open Date" was filled in for Short Term Goals and Interventions as 03/13/14. Target dates of 03/18/14 were documented by the 2 short term goals on the form. There was no documented evidence of the patient's specific behavior that warranted the seclusion.

There was no documented evidence that the plan of care of was updated on 03/14/14 when the patient was placed in seclusion two separate times and there was no evidence the plan of care was updated when the patient was placed in 4 point restraints on 03/15/14.

In an interview on 03/27/14 at 2:35 p.m., S1Adm and S2 DON verified the patient's plan of care was not updated after each episode of seclusion and the plan of care was not updated with the use of 4 point restraints.

Based on record review and staff interview, the hospital failed to ensure performance improvement activities were developed and implemented to analyze, track and implement preventative actions for adverse patient events. This was evidenced by the hospital failing to identify a patient death as an adverse event and failing to analyze and implement preventative actions related to patient deaths, after Patient #2 expired at the hospital and was not pronounced dead by the attending physician. Findings:

Review of the Medical Staff Bylaws/Rules revealed in the event of a hospital patient death, the deceased would be pronounced dead by the attending physician and request for autopsy would be made for all unusual deaths. The Medical Staff Bylaws/Rules also revealed the body was not to be released until an entry was made and signed by the physician appointee of the medical staff.

Patient #2
Review of the medical record for Patient #2 revealed the patient was a 55 year old male admitted to the hospital on 11/14/13 at 2:40 p.m. under a PEC (Physician Emergency Certificate). Review of the PEC revealed the patient presented to the emergency room of another hospital via EMS (Emergency Medical Services) after he was walking naked at a gas station. The PEC revealed the patient had no know psychiatric history and was PEC'd due to gravely disabled and unwilling to seek voluntary admission.

Review of the nurse's notes dated 11/16/14 at 12:40 a.m. and documented by S16RN (Former DON), revealed the patient's condition changed and the nurse was unable to obtain vital signs due to the patient's restlessness. The nurse's notes revealed the nurse notified the S6MD (Medical Director and Psychiatrist) at 12:43 a.m., and S6MD ordered the patient to be transferred to an acute care hospital. The nurse's notes revealed Cardio-Pulmonary Resuscitation (CPR) was initiated at 12:55 a.m., when the patient stopped breathing. The ambulance service arrived at 1:07 a.m. and continued the resuscitation efforts until 1:45 a.m., when the patient was pronounced dead by the ambulance personnel, after consulting their affiliated physician.
Further review of the nurse's notes revealed the body was released to the coroner's office at 4:00 a.m. and the family was notified at 4:10 a.m.

There was no documented evidence in the patient's record that the patient was pronounced dead by the attending physician as required in the medical staff rules and regulations. There was no documented evidence of an entry in the medical record by the physician before the body was released. There was no documented evidence of a request for autopsy, and there was no documented evidence of an autopsy report.

In an interview on 03/25/14 at 2:10 p.m., S1Adm verified no physician on staff at the hospital came in to evaluate and pronounce Patient #2 dead. S1Adm verified there was no entry by the physician in the medical record as required in the medical staff rules and regulations. S1Adm verified the hospital had not received an autopsy report and one was not requested by the medical staff.

In an interview on 03/27/14 at 3:54 p.m., S6MD stated he recalled Patient #2 and stated when he left the hospital on 11/15/13, the patient was having medical complications. S6MD stated the DON (Director of Nursing-S16RN) was at the hospital and called him and informed him the patient was having breathing problems. S6MD stated he instructed S16RN to send the patient to the emergency room and stated he offered to come in to the hospital. S6MD stated S16RN told him the patient was deceased and everything was taken care of. S6MD verified he did not come into the hospital and did not pronounce the patient dead.

In an interview on 03/27/14 at 5:00 p.m., S1Adm and S2DON stated the nurse should have called the physician on call for medical issues. S1Adm stated they have a physician on call for medical problems 24/7 and provided an on-call schedule indicating S17MD was on call on 11/16/13. When asked if any corrective action had been taken since the death of Patient #2, both stated no.

In an interview on 03/27/14 at 5:50 p.m., S18Director of Quality Improvement was asked if a root cause analysis had been done regarding the death of Patient #2. S18 Director of Quality Improvement stated they had not done any analysis of the patient's death.

Based on record review and interview the hospital failed to ensure the medical staff enforced the by-laws and the rules and regulations adopted by the medical staff as evidenced by a medical staff member not pronouncing dead a deceased patient, and not requesting an autopsy for an unusual death for 1 of 1 (#2) death records reviewed out of a total sample of 12 (#1-12).
Findings:

Review of the Medical Staff By-Laws, Rules and Regulations, presented as current and approved by S1Adm (Administrator) revealed in part the following: Article XVII General Provisions....Admission and Discharge....13. In the event of a Hospital patient death, the deceased will be pronounced dead by the attending physician or his physician designee within a reasonable time. The attending physician will complete and sign the death certificate. A request for Autopsy will be made for all unusual deaths. The coroner will be notified of all deaths to assist with autopsy determination. No autopsy will be performed without consent unless required by state law. The body will not be released until an entry has been made and signed in the medical record of the deceased by a physician appointee of the staff....

Review of the hospital's Death Log for 2013 to present revealed only 1 patient (Patient #2) listed as a death during their hospital stay.

Patient #2
Review of the medical record for Patient #2 revealed the patient was a 55 year old male admitted to the hospital on 11/14/13 at 2:40 p.m. under a PEC (Physician Emergency Certificate). Review of the PEC revealed the patient presented to the emergency room of another hospital via EMS (Emergency Medical Services) after he was walking naked at a gas station. The PEC revealed the patient had no know psychiatric history and was PEC'd due to gravely disabled and unwilling to seek voluntary admission.

Review of the nurse's notes dated 11/16/14 at 12:40 a.m. and documented by S16RN (Former DON), revealed the patient's condition changed and the nurse was unable to obtain vital signs due to the patient's restlessness. The nurse's notes revealed the nurse notified the S6MD (Medical Director and Psychiatrist) at 12:43 a.m., and S6MD ordered the patient to be transferred to an acute care hospital. The nurse's notes revealed Cardio-Pulmonary Resuscitation (CPR) was initiated at 12:55 a.m., when the patient stopped breathing. The ambulance service arrived at 1:07 a.m. and continued the resuscitation efforts until 1:45 a.m., when the patient was pronounced dead by the ambulance personnel, after consulting their affiliated physician.
Further review of the nurse's notes revealed the body was released to the coroner's office at 4:00 a.m. and the family was notified at 4:10 a.m.

There was no documented evidence in the patient's record that the patient was pronounced dead by the attending physician as required in the medical staff rules and regulations. There was no documented evidence of an entry in the medical record by the physician before the body was released. There was no documented evidence of a request for autopsy, and there was no documented evidence of an autopsy report.

In an interview on 03/25/14 at 2:10 p.m., S1Adm verified no physician on staff at the hospital came in to evaluate and pronounce Patient #2 dead. S1Adm verified there was no entry by the physician in the medical record as required in the medical staff rules and regulations. S1Adm verified the hospital had not received an autopsy report and one was not requested by the medical staff.

In an interview on 03/27/14 at 3:54 p.m., S6MD stated he recalled Patient #2 and stated when he left the hospital on 11/15/13, the patient was having medical complications. S6MD stated the DON (Director of Nursing-S16RN) was at the hospital and called him and informed him the patient was having breathing problems. S6MD stated he instructed S16RN to send the patient to the emergency room and stated he offered to come in to the hospital. S6MD stated S16RN told him the patient was deceased and everything was taken care of. S6MD verified he did not come into the hospital and did not pronounce the patient dead.

Based on record review and interview the hospital failed to ensure the medical staff attempted to secure an autopsy in all cases of unusual deaths as evidenced by a medical staff member not requesting an autopsy for an unusual death for 1 of 1 (#2) death records reviewed out of a total sample of 12 (#1-12).
Findings:

Review of the Medical Staff By-Laws, Rules and Regulations, presented as current and approved by S1Adm (Administrator) revealed in part the following: Article XVII General Provisions....Admission and Discharge....13. In the event of a Hospital patient death, the deceased will be pronounced dead by the attending physician or his physician designee within a reasonable time. The attending physician will complete and sign the death certificate. A request for Autopsy will be made for all unusual deaths. The coroner will be notified of all deaths to assist with autopsy determination. No autopsy will be performed without consent unless required by state law. The body will not be released until an entry has been made and signed in the medical record of the deceased by a physician appointee of the staff....

Review of the hospital's Death Log for 2013 to present revealed only 1 patient (Patient #2) listed as a death during their hospital stay.

Patient #2
Review of the medical record for Patient #2 revealed the patient was a 55 year old male admitted to the hospital on 11/14/13 at 2:40 p.m. under a PEC (Physician Emergency Certificate). Review of the PEC revealed the patient presented to the emergency room of another hospital via EMS (Emergency Medical Services) after he was walking naked at a gas station. The PEC revealed the patient had no know psychiatric history and was PEC'd due to gravely disabled and unwilling to seek voluntary admission.

Review of the nurse's notes dated 11/16/14 at 12:40 a.m. and documented by S16RN (Former DON), revealed the patient's condition changed and the nurse was unable to obtain vital signs due to the patient's restlessness. The nurse's notes revealed the nurse notified the S6MD (Medical Director and Psychiatrist) at 12:43 a.m., and S6MD ordered the patient transferred to an acute care hospital. The nurse's notes revealed Cardio-Pulmonary Resuscitation (CPR) was initiated at 12:55 a.m., when the patient stopped breathing. The ambulance service arrived at 1:07 a.m. and continued the resuscitation efforts until 1:45 a.m., when the patient was pronounced dead by the ambulance personnel, after consulting their affiliated physician.
Further review of the nurse's notes revealed the body was released to the coroner's office at 4:00 a.m. and the family was notified at 4:10 a.m.

There was no documented evidence in the patient's record of a request for an autopsy, and there was no documented evidence of an autopsy report.

In an interview on 03/25/14 at 2:10 p.m., S1Adm verified there was no entry by the physician in the medical record and verified the hospital had not received an autopsy report and one was not requested by the medical staff.

Based on interview and record review the Registered Nurse (RN) failed to ensure that each patients' care was supervised and evaluated as evidenced by: I) failing to ensure patient observation documentation included the Precaution Type and Observation Level for 5 (#4, #7, #8, #11, #12) of 12 (#1-#12) patients reviewed; and II) patients (#4) who experienced seizure activity received increased monitoring and received supervised nursing care (i.e. vital signs assessed per hospital policy) during and after the seizure along with the administration of physician ordered anticonvulsant medications. Findings:
I.
Patient #4
Review of Patient #4's Psychiatric Evaluation, dated 03/13/14, revealed a history for seizures. Patient #4 was admitted under a PEC (Physician's Emergency Certificate) and a CEC (Coroner's Emergency Certificate) for a Suicidal attempt by overdosing on Klonopin (a Benzodiazepine--like valium). Patient #4 was taking the Klonopin for his seizure activity along with 2 anticonvulsant's (Lamictal 200 milligrams--mg every 12 hours and Topamax 200 mg twice daily).
Review of physician's orders, dated 03/13/14, revealed Seizure Precautions were ordered; however, reviews of Close Observation Forms, dated 03/15/14 through 03/25/14, revealed nursing staff failed to ensure the physician order was carried out as evidenced by a lack of documentation for seizure precautions. Continued review of the physician' s orders, dated 03/13/14, revealed the Observation Status was not ordered; however according to the hospital's policy/procedures for Seizures the patient "required an increased observation level".
Review of the hospital's policy/procedure for Seizure Precautions revealed the following: "SUBJECT: SEIZURES--NURSING MANAGEMENT POLICY All patients with a history of seizure disorder will be assessed...to ensure the safety of all seizure-prone patients. PROCEDURE 1. The following seizure precautions are taken by the hospital: Increased Observation for Seizures - Warning Signs...2. Nursing Assessment and Implementation of Precautions: ...When documenting the seizure, state whether or not the beginning of the seizure was observed...3. Nursing Interventions During Seizure: Stay with patient during and after the seizure Ensuring an adequate airway: ...Protecting the patient from injury: ...4. Nursing Interventions After Seizure: ...Perform Neurological and vital sign checks after seizure: level of consciousness, ...blood pressure (BP), pulse, and respiratory rate..Document in the multidisciplinary progress note the following: pre-seizure activity, presence of aura or unusual behavior...Administer medication as ordered by physician..."
Patient #4's observation level was documented every 15 minutes; however, S9 MHT documented patient #4 was "in group", on 03/25/14 at 9:00am, and S8 RN (Registered Nurse) documented that Patient #4 was in his room and had just experienced a seizure.
Interviews, 03/26/14 at 2:30pm, with S1 Administrator and S2 Director of Nursing confirmed the documentation made by S9 MHT was not accurate as it lacked factual information relative to the patient's activity during the seizure.

Patient#7

Review of Patient #7's Master Treatment Plan revealed she was a 58 year old female admitted on 3/10/14 with diagnoses including the following: Schizophrenia, Auditory Hallucinations, Delusions, and Paranoia. Further review revealed the patient's legal status was documented as follows: 3/8/14 PEC (Physician's Emergency Certificate); 3/11/14 CEC (Coroner's Emergency Certificate); 3/23/14 Formal Voluntary Admission.
Review of Patient #7's Psychiatric Evaluation revealed the following, in part : Admit Diagnosis: long history of Schizophrenia with multiple hospitalizations, tangential, delusional, paranoid, flight of ideas, hallucinations: auditory, delusions: persecutory, being controlled. Judgment poor.
Review of Patient#7's Close Observation Forms revealed the following possible options for
Precaution Type: Assaultive, Suicide, Withdrawal,Fall, Elopement, Seizure, Other and
Observation Level: Level I-1:1, Level II- Constant Observation, Level III- Close Observation.

Review of Patient#7's Close observation Forms revealed on 3/13/14, 3/15/14, 3/20/14, 3/21/14, and 3/24/14 the Precaution Type section of the form was left with no precaution level chosen.

Additional review of Patient#7's Close Observation Forms revealed on 3/25/14 the Observation Level section of the form was left with no level of observation chosen.

In an interview on 3/27/14 at 3:03 p.m. with S1Adm she confirmed the Close Observation Forms were incomplete. She further acknowledged lack of completing of forms was a problem at the hospital.


Patient #8
Review of the medical record for Patient #8 revealed he was a 33 year old male admitted to the hospital on 3/11/14 for PTSD (Post Traumatic Stress Disorder) with Psychotic Features, Major Depression, and Suicidal Ideation's.

Review of the Psychiatric Evaluation dated 3/12/14 at 3 p.m. revealed Patient #8 had a long history of depression with psychotic features and PTSD, admits to increase in auditory hallucinations and having suicidal thoughts.

Review of Patient #8's Suicide Risk Assessment dated 3/11/14 revealed his total score was 13. Continued review of the Suicide Risk Assessment revealed if the patient's score was a 12 or above the patient should be considered for increased acuity level or additional precautions.

Review of the Close Observation form for 3/11/14, 3/12/14, 3/13/14, 3/15/14, 3/19/14, 3/21/14, 3/24/14 and 3/25/14 revealed no precaution type (Assaultive, Suicide, Withdrawal, Fall, Elopement, Seizure, and other) marked. Review of the Close Observation form for 3/14/14, 3/16/14, 3/17/14, and 3/18/14, 3/22/14, 3/23/14 revealed under precaution type "routine" was written in by the word "other". With further review of the Close Observation Forms revealed the level of observation (Level I, II, or III) was not indicated on the following dates: 3/15/14 and 3/24/14.
An interview was conducted with S1Administrator on 3/26/14 at 2:30 p.m. and the information not included on the Close Observation forms was confirmed.
Patient #11
Review of the medical record for Patient #11 revealed the patient was a 57 year old female admitted to the hospital under a PEC on 03/17/14 for suicidal texts. The psychiatric evaluation dated 03/17/14 revealed the patient's diagnoses included Bipolar Disorder-most recent episode depression, Alcohol Abuse, and Chronic Back Pain. The CEC (Coroner's Emergency Certificate) dated 03/20/14 revealed the patient had suicidal ideations and was Dangerous to self, gravely disabled, and unwilling to seek voluntary admission.
Review of the Close Observation form for 3/17/14 and 3/24/14 revealed no precaution type (Assaultive, Suicide, Withdrawal, Fall, Elopement, Seizure, and other) and no Observation Level (Level I, II, or III) marked. Review of the Close Observation form for 3/19/14, 3/20/14, and 3/21/14 revealed no precaution type was marked.
In an interview on 3/27/14 at 3:03 p.m. with S1Adm she confirmed the Close Observation Forms were incomplete. She further acknowledged lack of completing of forms was a problem at the hospital.

Patient #12
Review of the medical record for Patient #12 revealed the patient was a 54 year old male admitted to the hospital on 03/12/14 under a PEC (Physician Emergency Certificate). The PEC revealed the patient was brought to the emergency room by policy due to confusion and being naked in the street. Review of the psychiatric evaluation dated 03/12/14 revealed the patient's diagnosis was Acute Exacerbation of Schizo Affective Disorder. Further review of the record revealed the patient was discharged from the hospital on 3/21/14.

Review of the physician orders dated/timed 03/12/14 at 7:00 p.m. revealed the patient was placed on 1:1 observation level (Level I).
Review of the Close Observation form for 3/12/14 and 3/14/14 revealed no precaution type (Assaultive, Suicide, Withdrawal, Fall, Elopement, Seizure, and other) and no Observation Level (Level I, II, or III) marked. Review of the Close Observation form for 3/16/14 revealed no precaution type was marked.
In an interview on 3/27/14 at 3:03 p.m. with S1Adm she confirmed the Close Observation Forms were incomplete. She further acknowledged lack of completing of forms was a problem at the hospital.

II.
Abbreviations used: RN-Registered Nurse; mg-milligrams; PEC-Physician's Emergency Certificate; CEC-Coroner's Emergency Certificate

Patient #4:
The RN failed: to ensure physician ordered anticonvulsant medications were administered; and to assess and evaluate the nursing care provided by other staff (Licensed Practical Nurse and MHTs) when there failed to be documentation relative to Patient #4's vital signs following his seizure per policy/procedures.

Patient #4 was admitted on 03/13/14 under a PEC and CEC for a suicide attempt by taking an overdose of Klonopin. Continued review of Patient #4's medical record revealed a form titled, "ADMISSION MEDICATION RECONCILIATION AND ORDER FORM". Review of this form revealed S19 RN and S6 Physician had both signed the form. Further review of the form revealed "yes" was circled next to Lamictal 200 mg by mouth every 12 hours and Topamax 200 mg which indicated the physician wanted to continue these medications upon admission. As noted above, these two medications were classified as anticonvulsants and Patient #4 had been taking them for his seizure activity/disorder.

Review of the Medication Administration Record (MAR) revealed even though S6 Physician had ordered Patient #4's anticonvulsant medications, Lamictal and Topamax, there failed to be documentation the patient received them.
Interview, 03/27/14 at 4:30pm, with Patient #4 confirmed he had not received his anticonvulsant medications.
Continued review of the Close Observation Form revealed S9 MHT documented Patient #4 remained in his "room, sleeping, quiet" from 10:00am through 12:30pm; then from 12:45pm to 1:00pm "toilet and grooming". S9 MHT documented from 1:15pm to 2:45pm, Patient #4 remained in his room sleeping; and from 3:00pm to 4:30pm he was laying in bed. S9 MHT documented Patient #4's behavior, from 10:00am until 4:30pm, was "quiet".

S8 RN had documented Patient #4 was having a seizure (3/25/14 at 8:30am) then resting in his bed at 9:00am; however, S9 MHT documented he was "in group and was cooperative" from 9:00am through 9:45am.

The surveyor observed, on 03/25/14 at 2:40pm, Patient #4 attempt to walk from his room to the dayroom. Patient #4 was unsteady on his feet and was observed holding onto the wall in the hallway while attempting to walk to the dayroom. Continued observations revealed S8 RN and S18 Director Quality Improvement had to assist Patient #4 back to his room.

Review of the Close Observation Form revealed S9 MHT failed to show documentation of this activity by Patient #4; S9 MHT had documented at 2:30pm and 2:45pm on 03/25/14, Patient #4 was in his room sleeping, quiet.


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30984

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30364


Based on interview and record review, the hospital failed to ensure: I) all entries in the medical record were authenticated, dated and/or timed for 4 (#2, #6, #9, #12) of 12 patients reviewed; and II) all entries required by hospital policy/procedures and Medical Staff Rules/Regulations were documented in the medical records as evidenced by a lack of an admission diagnosis on 1 of 12 patients reviewed (#4).
Findings:
I)
Review of Medical Staff Rules/Regulations revealed: page 5, "...8. All clinical entries and summaries in the patient's medical record shall be accurately signed, dated, timed..."

Review of the policy titled Telephone Orders and Written Orders- General, Effective Date: September 1, 2011, revealed in part:
Procedure:
3. The prescribing practitioner dates, times and authenticates the telephone order within 10 days per Louisiana State Law.
5. Preprinted Order: When a practitioner has written a set of orders, or is using a preprinted order set contained on one page or on several pages, the following guidelines are followed: Last Page: Sign, date and time the last page of the orders ...
Review of the hospital Medical and Professional Staff Rules and Regulations revealed in part:
8. All clinical entries and summaries in the patient's medical record shall be accurately signed, dated, timed.

Patient #2
Review of the medical record for Patient #2 revealed the verbal admission orders dated 11/14/13 at 2:40 p.m. Review of the admission orders revealed the order had been cosigned by the physician on 11/14/13, but the authentication had not been timed. Further review of the physician orders revealed the following verbal orders:
11/15/13 at 10:00 a.m. Wrap left second toe with Betadine soaked gauze three times a day. The order was cosigned by the physician, but the authentication had not been dated or timed.
11/15/13 at 6:20 p.m. Cogentin 1 mg. by mouth, twice a day. The order was not cosigned by the physician.
11/15/13 at 7:50 p.m. Geodon 10 mg. IM (Intramuscular injection) now and every 8 hours for psychosis. Ativan 1 mg. IM every 8 hours for psychosis. The order was not cosigned by the physician.
11/15/13 at 9:00 p.m. OK to hold HS (Bedtime) meds for tonight. The orders was cosigned by the physician, but the authentication had not been dated or timed.
11/16/13 at 12:45 a.m. Transfer to ___ (Local hospital) for evaluation of restlessness/diaphoretic. The order was not cosigned by the physician.

Patient #6
Review of the medical record for Patient #6 revealed a verbal order dated 3/12/14 at 10:30 a.m. Further review revealed the order read: D/C (Discontinue) Hydrocodone. Norco 10/325 po (by mouth) q (every) 6 hours prn (as needed). Further review revealed the entry had been cosigned by the physician, but the authentication had not been dated or timed.

Review of a telephone order for Patient #6 dated 3/12/14 at 2:15 a.m. for the Admission Medication Reconciliation and Order Form revealed it had been cosigned by the physician on 3/12/14, but the authentication had not been timed.

Review of the Informed Consent for Psychotropic Medications for Patient #6 revealed it had been signed by the physician on 3/21/14, but his signature was not timed.

Review of the Psychiatric Evaluation for Patient #6 revealed it had been dated by the physician, but his signature was not timed.

Patient # 7
Review of the medical record for Patient #7 revealed a telephone order dated 3/10/14 at 2:30 p.m. for the Physician's Admit Orders and Admit Note. Further review revealed the physician had cosigned the order, but did not time or date his authentication.
Review of the document titled Informed consent for Psychotropic Medications for Patient #7 revealed the physician had signed the order on 3/20/14, but had not timed his signature.

Patient #9
Review of the medical record for Patient #9 revealed a telephone order on 3/20/14 at 8:25 p.m. for Ativan 1 mg (milligram) IM (intramuscular) x 1 dose now then Ativan 1mg po q 6 prn agitation or Ativan 1mg IM q 6 prn severe agitation. Further review revealed the order had been cosigned by the physician, but his authentication had not been dated or timed.
Review of a telephone order for Patient #9 on 3/20/14 at 8:25 p.m. revealed a telephone order for Seroquel 50 mg po q hs. Further review revealed the order had been cosigned by the physician, but his authentication had not been dated or timed.
Review of the Psychiatric Evaluation for Patient #9 dated 3/21/14 revealed the physician had authenticated and dated the document, but had not timed his signature.

Patient #12
Review of the physician orders revealed a telephone order dated 03/12/14 at 6:00 p.m. for Ativan 2 mg. by mouth now. The order revealed the physician had cosigned the order, but the authentication had not been dated or timed.
Review of the physician orders dated 03/12/14 at 7:00 p.m. revealed a verbal order for 1:1 observation. Review of the order revealed the physician had cosigned the order, but the authentication had not been dated or timed.
Review of the physician orders dated 03/13/14 at 5:45 p.m. revealed a verbal order for Ativan 1 mg. by mouth, one dose now, then Ativan 1 mg. IM every 4 hours as needed for psychosis. The order was cosigned by the physician, but the authentication had not been dated or timed.
Review of the physician orders dated 03/13/14 at 5:50 a.m. revealed a verbal order, "To Seclusion Room." Review of the order revealed the physician had cosigned the order, but the authentication had not been dated or timed.
Review of the, "Violent and Non-Violent Restraint/Seclusion Orders" dated 03/13/14 5:50 a.m. revealed the orders were telephone orders and the physician had cosigned the orders, but the authentication had not been dated or timed.
Review of the physician orders dated 03/14/14 at 3:30 a.m. revealed a verbal order, "To Seclusion Room." Review of the order revealed the physician had cosigned the order, but the authentication had not been dated or timed.
Further review of the, "Violent and Non-Violent Restraint/Seclusion Orders" dated 03/14/14 at 3:30 a.m. revealed the orders were telephone orders and the physician had cosigned the orders, but the authentication had not been dated or timed.
Review of the physician orders dated 03/14/14 at 12:25 p.m. revealed a verbal order to discontinue Zyprexa. Geodon 40 mg. by mouth twice a day and Geodon 10 mg. IM as needed every 8 hours for agitation. Review of the order revealed the physician had cosigned the order, but the authentication had not been dated or timed.
Review of the physician orders dated 03/14/14 at 7:55 p.m. revealed a verbal order, "To Seclusion Room." Review of the order revealed the physician had cosigned the order, but the authentication had not been dated or timed.
Further review of the, "Violent and Non-Violent Restraint/Seclusion Orders" dated 03/14/14 at 7:55 p.m. revealed the orders were telephone orders and the physician had cosigned the orders, but the authentication had not been dated or timed.
Review of the physician orders revealed a verbal order dated 03/15/14 at 12:00 a.m. to place the patient in 4 point restraints. The order was cosigned by the physician, but the authentication had not been dated or timed.
Review of the physician orders revealed a verbal order dated 03/15/14 at 4:00 a.m. to place the patient in 4 point restraints. The order was cosigned by the physician, but the authentication had not been dated or timed.
Review of the physician orders revealed a verbal order dated 03/15/14 at 8:11 a.m. to keep the patient in 4 point leg and wrist restraints. The order was cosigned by the physician, but the authentication had not been dated or timed.
Further review of the, "Violent and Non-Violent Restraint/Seclusion Orders" dated 03/15/14 at 12:00 a.m. and 4:00 a.m. revealed the orders were telephone orders for leather 4 point restraints and the physician had cosigned the orders, but the authentication had not been dated or timed.
Review of the physician verbal orders dated 03/15/14 and timed at 12:00 p.m., 4:00 p.m., and 4:30 p.m. for renewal of 4 point restraints revealed the physician had cosigned the verbal orders, but the authentication had not been dated or timed.
Review of the physician orders revealed a verbal order dated 03/18/14 at 8:05 p.m. to discontinue 1:1 observation. The order was cosigned by the physician, but the authentication had not been dated or timed.

In an interview on 03/27/14 at 2:35 p.m., S1Adm (Administrator) and S2DON (Director of Nursing) confirmed the above physician orders had not been authenticated/dated/timed and further acknowledged lack of dating and timing physician signatures was a problem at the hospital.

In an interview on 03/27/14 at 3:54 p.m. S6MD (Medical Director) confirmed he was aware his co-signature on verbal orders was to be dated and timed and confirmed he had not always dated and timed his signature.

II.
Review of Patient #4's preprinted Physicians' Admit Orders, dated 03/13/14, revealed S6 MD failed to ensure an admission diagnosis was documented on the admit orders. Continued review of the preprinted physician admit orders revealed there also lacked an ordered "Observation Status".

Review of Medical Staff Rules/Regulations revealed: "...ADMISSION AND DISCHARGE
1. All attending medical staff members with authority to admit patients will be governed by the official admitting policy of the Hospital...5. Except in the case of emergency admissions, no patients will be admitted to the Hospital until a provisional diagnosis or valid reason for admission has been stated..."

Interviews, 03/27/14 at 4:00pm, with S1 Administrator and S6 MD, confirmed a diagnosis should have been documented on the Physicians' Admit Orders. S6 MD stated he should have ensured a diagnosis was documented.


30984

Based on record review and staff interview, the hospital failed to ensure the OPO (Organ Procurement Organization) was notified of the patient's death for 1 of 1 (#2) sampled records reviewed for OPO notification out of a total sampled of 12 (#1-12). Findings:

Patient #2
Review of the medical record for Patient #2 revealed the patient was a 55 year old male admitted to the hospital on 11/14/13 at 2:40 p.m. under a PEC (Physician Emergency Certificate). Further review of the record revealed the patient went into cardio-pulmonary arrest on 11/16/13 at 12:55 a.m., and was pronounced dead by the physician affiliated with the ambulance service. There was no documented evidence the OPO was notified of the patient's death.

In an interview on 03/27/14 at 10:55 a.m., S1Adm verified the OPO was not notified of the death of Patient #2.

Based on reviews of 1 of 12 medical records (#4), Medical Staff Bylaws/Rules/Regulations, and interview, the hospital failed to ensure the psychiatrist followed the Medical Staff Bylaws/Rules/Regulations and this federal requirement and documented a diagnosis(es) or provisional diagnosis(es) upon the patients' admission. Findings:

Review of Patient #4's medical record revealed a physician's order, dated 03/13/14 at 10:30am, without the admitting diagnosis/es documented. The section of the physician's order titled "Admitting Axis I Diagnosis", was left blank. Continued review of the physician's order revealed S19 Registered Nurse documented the physician's orders.

Review of the Medical Staff Rules and Regulations, under a section titled "ADMISSION AND DISCHARGE", revealed the following: "...5. Except in the case of emergency admissions, no patients will be admitted to the Hospital until a provisional diagnosis or valid reason for admission has been stated..."

Interview, 03/27/14 at 4:30pm, with S6Psychiatrist confirmed the physician must state an admission diagnosis or provisional diagnosis at the time of admit. S6Psychiatrist agreed Patient #4 did not have an admission diagnosis documented.

Based upon observations, record reviews and interviews, the hospital failed to ensure each patient received an individualized treatment care plan as evidenced by the use of generic treatment care plans for 10 of 10 patients (#s 3-12) reviewed out of a total sample of 12 patients. Findings:

Observations, conducted 03/25/14 1:30pm through 3:00pm, revealed 10 patients engaged in different activities while they were in the dayroom/TV/dining room (large area with sofas, chairs, and TV on one side of the room; on the other side were rectangular shaped tables for meals and other activities). Patient #3 was sitting at the table putting a jigsaw puzzle together; Patient #10 was noted to be sitting in a chair (which was up against a wall), with her feet elevated on a foot stool, with her eyes closed, head back, and mouth open. Patient #s 5, 6, 8, and 11 were observed sitting together in chairs along the wall by the TV talking among themselves. Patient #1 was walking around the room singing a song; and Random patients (#13, #14, and #18) were sitting at the table with Patient #3, no specific activity noted, they were looking around the room. One Mental Health Technician (MHT) was in the room to monitor the patients (identified as S9 MHT).

Review of the "DAILY PROGRAM SCHEDULE" revealed the time frame (1:15pm-2:15pm), was "Relaxation" and "Break" time for the inpatients. Then from 2:15pm-3:00pm was scheduled as "NSG (Nursing) Group"; however, on 03/25/14 the Nursing Group was not conducted as the surveyor observed the inpatients as above, while other inpatients were in their rooms.

Observations, conducted 03/26/14 at 9:50am through 11:50am, revealed S21 Counselor Intern rounded up inpatients who were to attend her group therapy at 10:00am, and had them go to the "Activity Room". The surveyor attended the group session along with Patient #s 3, 5,10, and Random Patient #s13, 15, 16, 19. S21 Counselor Intern introduced herself to the patients and instructed them to think about what things they could and could not control and gave them each a marking felt pen and piece of paper for them to use. As soon as the marking pens and paper had been passed out to the patients, Random Patient #15 got up and left the group (10:05am). Patient #5 got up and left the group at 10:25am; as Patient #5 was going out the door, S21 Counselor Intern asked her if she was going to return, at this time the patient told S21 Counselor Intern that she was not sure. Patient #5 returned to the group with a glass of juice at 10:50am, just as the group was ending. The surveyor observed there was very little interaction with the patients and S21 Counselor Intern. S21 would ask the patients if they could name something they could or could not control and the patients could/would not respond.

Review of medical records revealed the following:

1. Patient #3. The master treatment plan (3/20/14; last update 3/25/14), Problem #1 identified as "Potential to harm self". "Measurable Desired Behavior Change 1. Pt (patient) will deny the presence of any suicidal thoughts prior to d/c (discharge) 2. Pt will complete a crisis/safety plan prior to d/c 3. Pt will display a brighter mood and affect within next 7 days...Interventions...Staff will reinforce reality as needed Nursing or Psycho-Education Group daily for 45 minutes Social Services group daily for at least 45 minutes MD to prescribe medication and monitor efficacy and side effects every 60 hours Therapeutic recreational group daily for at least 20 minutes..."

2. Patient #4. The master treatment plan (3/17/14; last update 3/25/14), Problem #1 identified as "Potential to harm self". "Measurable Desired Behavior Change 1. Pt will deny the presence of suicidal thoughts prior to d/c 2. Pt will complete a crisis/safety plan prior to d/c 3. Pt will display a brighter mood and affect within next 7 days 4. Crisis plan prior to d/c 5. Family session prior to d/c Interventions..Staff will reinforce reality as needed...MD to prescribe medications and monitor efficacy and side effects every 60 hours...

3. Patient #5. The master treatment plan (last update 3/25/14) included interventions for the identified problems, "audio/visual hallucinations" and "depressed mood." (Same as for Patient #6)

4. Patient #6. The treatment plan (3/17/14, updated 3/25/14), Problem #1 identified as "Altered Thoughts--Delusions and paranoia". "Measurable Desired Behavior Change 1. Pt will display clearer thought process by answering questions and responding when prompted within 5 days...3. Pt will display a more appropriate mood and affect within 7 days...5. Pt will be medication compliant within 3 days Interventions...Nursing or Psycho-Education At lease one group per day, 45-60 min. (minutes) Social Services Group At least one group per day, 45-60 min. Psychiatrist Rounds / Med (medication) Management-at least every 60 hours...".

5. Patient #7. The master treatment plan (3/14/14; last update 3/25/14) Same as above for Patient #6.

6. Patient #8. Master treatment plan (3/14/14; last updated 3/25/14). Same as noted for Patient #s 3 and 4.

7. Patient #9. Same information as contained in treatment plans for Patients #6, #7.

8. Patient #10. Master treatment plan (3/18/14; updated 3/25/14). Problem #1 identified as "Behavioral disturbances". "Measurable Desired Behavior Change 1. Pt will comply with treatment recommendations 5x (5 times) within the next 7 days 2. Pt will accept redirection as needed 5x within next 7 days 3. Pt will exhibit a calmer mood and more pleasant affect within 7 days...Interventions Staff will reinforce reality as needed Nursing Education...MD to prescribe medications and monitor efficacy and side effects every 60 hours..."

9. Patient #11. Master treatment plan (3/21/14; updated 3/25/14). Problem #1 identified "Potential Harm Self". Same Measurable Desired Behavior Change and Interventions as identified with Patients #s 3, 4, 6, and 8.

10. Patient #12. Review of the Multidisciplinary Plan of Care identified Problem #1 as "Altered Thoughts"; however on the Treatment Sheet Problem #1 was identified as "Agitation". "Measurable Desired Behavior Change 1. Pt. will complete a Crisis/Safety Plan prior to d/c 2. Patient will respond appropriately to staff's therapeutic re-direction of inappropriate comments and/or behavior within next 7 days...Pt. will be more medication and treatment compliant within next 7 days...Interventions...Staff will reinforce reality as needed Nursing Education Group...MD to prescribe medication and monitor efficacy and side effects every 60 hours...".

The only Activity Therapy interventions on the treatment plans for 10 of 10 of the sampled patients was "Music Therapy". All patients received the same Activity Therapy which was Music therapy; there failed to be Activity/Recreational Therapy assessments of the sampled patients to see if the Music Therapy would be beneficial for the individual patients (#s 3-12).

On 3/27/14 at 2:30 p.m. when discussing the generic interventions with the surveyor, S10 LCSW (Licensed Clinical Social Worker) and S11 SW (Social Worker) agreed that the interventions "Staff to reinforce reality; Social Services group daily for at least 45 minutes and MD to prescribe medication and monitor efficacy and side effects every 60 hours", were not specific and did not describe the action/s that needed to be taken.

Failure to develop and document individualized, comprehensive interventions for patients hinders the staff's ability to provide purposeful and goal directed treatment and coordinate team treatment efforts. This can impede patients' progress in treatment.

Based on record reviews and interviews, the hospital failed to ensure the Multidisciplinary Team:
I. Developed treatment plans that included individualized and focused interventions for 10 of 10 active sample patients (Patient #s 3-12) out of a total of 12 patients reviewed. The plans listed interventions that were generic, expected role functions for staff rather than treatments based on individual patients' assessed needs.
Findings:

I. The facility failed to develop treatment plans that included individualized, focused interventions for 10 of 10 active sample patients (#s 3-12).

A. Record review: (dates of initial and updated master treatment plans in parentheses)

1. Patient #3. The master treatment plan (3/20/14; last update 3/25/14), Problem #1 identified as "Potential to harm self". "Measurable Desired Behavior Change 1. Pt (patient) will deny the presence of any suicidal thoughts prior to d/c (discharge) 2. Pt will complete a crisis/safety plan prior to d/c 3. Pt will display a brighter mood and affect within next 7 days...Interventions...Staff will reinforce reality as needed Nursing or Psycho-Education Group daily for 45 minutes Social Services group daily for at least 45 minutes MD to prescribe medication and monitor efficacy and side effects every 60 hours Therapeutic recreational group daily for at least 20 minutes..."

2. Patient #4. The master treatment plan (3/17/14; last update 3/25/14), Problem #1 identified as "Potential to harm self". "Measurable Desired Behavior Change 1. Pt will deny the presence of suicidal thoughts prior to d/c 2. Pt will complete a crisis/safety plan prior to d/c 3. Pt will display a brighter mood and affect within next 7 days 4. Crisis plan prior to d/c 5. Family session prior to d/c Interventions..Staff will reinforce reality as needed...MD to prescribe medications and monitor efficacy and side effects every 60 hours...

3. Patient #5. The master treatment plan (last update 3/25/14) included interventions for the identified problems, "audio/visual hallucinations" and "depressed mood." (Same as for Patient #6)

4. Patient #6. The treatment plan (3/17/14, updated 3/25/14), Problem #1 identified as "Altered Thoughts--Delusions and paranoia". "Measurable Desired Behavior Change 1. Pt will display clearer thought process by answering questions and responding when prompted within 5 days...3. Pt will display a more appropriate mood and affect within 7 days...5. Pt will be medication compliant within 3 days Interventions...Nursing or Psycho-Education At lease one group per day, 45-60 min. (minutes) Social Services Group At least one group per day, 45-60 min. Psychiatrist Rounds / Med (medication) Management-at least every 60 hours...".

5. Patient #7. The master treatment plan (3/14/14; last update 3/25/14) Same as above for Patient #6.

6. Patient #8. Master treatment plan (3/14/14; last updated 3/25/14). Same as noted for Patient #s 3 and 4.

7. Patient #9. Same information as contained in treatment plans for Patients #6, #7.

8. Patient #10. Master treatment plan (3/18/14; updated 3/25/14). Problem #1 identified as "Behavioral disturbances". "Measurable Desired Behavior Change 1. Pt will comply with treatment recommendations 5x (5 times) within the next 7 days 2. Pt will accept redirection as needed 5x within next 7 days 3. Pt will exhibit a calmer mood and more pleasant affect within 7 days...Interventions Staff will reinforce reality as needed Nursing Education...MD to prescribe medications and monitor efficacy and side effects every 60 hours..."

9. Patient #11. Master treatment plan (3/21/14; updated 3/25/14). Problem #1 identified "Potential Harm Self". Same Measurable Desired Behavior Change and Interventions as identified with Patients #s 3, 4, 6, and 8.

10. Patient #12. Review of the Multidisciplinary Plan of Care identified Problem #1 as "Altered Thoughts"; however on the Treatment Sheet Problem #1 was identified as "Agitation". "Measurable Desired Behavior Change 1. Pt. will complete a Crisis/Safety Plan prior to d/c 2. Patient will respond appropriately to staff's therapeutic re-direction of inappropriate comments and/or behavior within next 7 days...Pt. will be more medication and treatment compliant within next 7 days...Interventions...Staff will reinforce reality as needed Nursing Education Group...MD to prescribe medication and monitor efficacy and side effects every 60 hours...".

The only Activity Therapy interventions on the treatment plans for 10 of 10 of the sampled patients was "Music Therapy". There failed to be Activity/Recreational Therapy assessments of the sampled patients to see if the Music Therapy would be beneficial for the individual patients (#s 3-12).

B. Interviews
On 3/27/14 at 2:30 p.m. when discussing the generic interventions with the surveyor, S10 LCSW (Licensed Clinical Social Worker) and S11 SW (Social Worker) agreed that the interventions "Staff to reinforce reality; Social Services group daily for at least 45 minutes and MD to prescribe medication and monitor efficacy and side effects every 60 hours", were not specific and did not describe the action that needed to be taken.

Failure to develop and document individualized, comprehensive interventions for patients hinders the staff's ability to provide purposeful and goal directed treatment and coordinate team treatment efforts. This can impede patients' progress in treatment.

Based on observation, interview and record review, the hospital failed to ensure patient treatment plans were revised based upon patient response to treatment for 1 (#7) of 10 (#1-#10) patient reviewed for treatment plans.
Findings:
Review of Patient #7's Master Treatment Plan revealed she was a 58 year old female admitted on 3/10/14 with diagnoses including the following: Schizophrenia, Auditory Hallucinations, Delusions, and Paranoia. Further review revealed the patient's legal status was documented as follows: 3/8/14 PEC (Physician's Emergency Certificate; 3/11/14 CEC (Coroner's Emergency Certificate); 3/23/14 Formal Voluntary Admission.
Review of Patient #7's Psychiatric Evaluation revealed the following, in part : Admit Diagnosis: long history of Schizophrenia with multiple hospitalizations, tangential, delusional, paranoid, flight of ideas, hallucinations: auditory, delusions: persecutory, being controlled. Judgment poor.
Review of Patient#7's daily group progress notes dated 3/13/14, 3/19/14 and 3/24/14 revealed the following:
Group Psychotherapy: Patient not in attendance of scheduled treatment service.
Therapist intervention toward above goal: blank;
Patient response to intervention: blank;
Continue to implement current Master Treatment Plan: blank;
Revision to Master Treatment Plan: blank
No revisions to the treatment plan were documented in the medical record.

Review of the Group Nursing daily progress notes dated 3/14/14, 3/15/14, 3/18/14, 3/19/14, 3/24/14 and 3/25/14 revealed Patient #7 was documented as having refused treatment. Further review revealed the response " Continue to implement current Master Treatment Plan " had been selected. No revisions to the treatment plan were documented in the medical record.

Review of the Therapeutic Activity daily progress notes dated 3/12/14, 3/18/14, 3/19/14 and 3/20/14 revealed Patient #7 was documented as not being in attendance of the scheduled treatment service. Further review revealed the response " Continue to implement current Master Treatment Plan " had been selected. No revisions to the treatment plan were documented in the medical record.

On 3/26/14 at 11:00 a.m., Patient #7 was observed in her room lying in bed with the door closed. In an interview during the observation, Patient #7 said she was not attending group therapy because she had trouble being in a room with a group of people. She explained she was agoraphobic (anxiety disorder- sufferer perceives certain environments as dangerous or uncomfortable) and preferred being alone. Patient #7 further explained she had trouble opening up to others in a group setting.

On 3/27/14 at 1:30 p.m., an observation was made of Patient#7 in her room lying in bed with the door closed. In an interview conducted during the observation, Patient#7 said she was not planning on attending group therapy because groups of people made her anxious and uncomfortable. She also said she felt her treatment should not just consist of medicating her.

In an interview on 3/27/14 at 3:27 p.m. with S10LCSW, she said she had not realized Patient #7 had decompensated and had not been attending group therapy until 3/26/14. S10LCSW was asked about why individual therapy was not instituted for Patient#7 and she replied the hospitals admit orders had specified group therapy.

In an interview on 3/27/14 at 4:01 p.m. with S6MD he said he would have written an order for individual therapy if he was notified one of the patients would benefit from it. S6MD said the notification would have been by one of the social workers.

Based on reviews of records and interviews, the hospital failed to ensure there was a Certified Therapeutic Activities/Recreational Therapist available to provide patient assessments within 72 hours to aid in the formulation and implementation of individualized treatment plans for each patient as evidenced by a lack of Therapeutic Activity assessments for 19 of 19 current inpatients (#s 1-19). Findings:

Review of 19 of 19 (#s 1-19) current inpatient records revealed there failed to be Therapeutic Activity assessments documented by a Certified/Licensed Therapeutic Activities/Recreational Therapist documented in the patients' medical records.

Review of a hospital policy, titled "Chapter: PC 73- PROVISION OF CARE, TREATMENT, AND SERVICES SUBJECT: THERAPEUTIC RECREATIONAL ACTIVITIES POLICY The hospital...provides individualized therapeutic activities. Therapeutic activities focus upon the development and maintenance of adaptive skills that will improve the patient's functioning. Leisure activities provide the patient with individualized opportunities to acquire knowledge, skills and attitudes about meaningful leisure involvement and experiences. PROCEDURE ...Qualified staff completes their respective discipline assessments for use in the patient's multidisciplinary plan of care...Therapeutic activities are monitored and evaluated by the Social Service Director to ensure quality and appropriateness of therapeutic services delivered to patients..."

Review of the job description for the Corporate Activity Therapist revealed: "...QUALIFICATIONS 1. Bachelor of Science degree in Recreation Therapy or Music Therapy, Masters preferred. Must be licensed or certified by the State to perform Activity Therapy...SPECIFIC RESPONSIBILITIES AND DUTIES ...4. Responsible for direct and indirect patient care and the facilitation of Activity Group Therapy as ordered by physician. 5. Works collaboratively with the social worker to complete the psychosocial assessment, including but not limited to leisure and recreation assessment within 72 hours..."

Interviews, 03/26/14 at 2:30pm, with S1 Administrator and S2 Director of Nursing (DON), revealed when questioned who conducted the Therapeutic Activities assessments, S1 Administrator stated the social worker completed the psychosocial assessment and she thought that included the some of the therapeutic activity assessment.

Review of the Psychosocial Assessment form revealed: "...17. LEISURE AND RECREATION". There were 7 question/statements under the section on leisure and recreation and they follow: "Majority of leisure time is spent Alone With others" (the person completing the assessment would indicate the patient's response by placing a mark next to either Alone or With others); "Favorite Activities, Hobbies & Interests:", area for patient's responses; "Organized Groups/Clubs:", area for patient's responses; "What activities have you stopped in the last few months?" space supplied for patient's response; List healthy and unhealthy ways you relax or manage stress, space available for patient's response; "How much free time do you have weekly?" area to place a mark by "Too little", "Enough", or "Too much".

Follow-up interview, 03/26/14 at 2:40pm, with S1 Administrator agreed the patients did not receive an assessment by a Recreation/Activities Therapist even though the hospital had a Corporate Activity Therapist.

Based on observations and record review the hospital failed to ensure nursing services had adequate staffing to provide adequate supervision to the patients according to hospital policy as evidenced by three (3) Mental Health Techs (MHT) monitoring 17 patients on every 15 minute monitoring while the fourth MHT monitored 2 patients under constant observation. Findings:

Review of the hospital's Staff Matrix, Staffing Needs for Varying Census, Effective April 7, 2013 revealed the following:
Nursing
Shift Census RN LPN MHT
7a-7p 16-19 1 1 4
13-15 1 1 3
9-12 1 1 2
5-8 1 1 1
0-4 1 0 1


An observation was made on 3/26/14 at 11 a.m. of S14MHT sitting in front of a patient's room in hallway B. S14MHT reported she was monitoring 2 patients on Level II observation (constant observation) and the other 3 MHTs were monitoring the other patients (17 patients, the census was 19 at the time of the observation).

An interview was conducted with S1Administrator on 3/27/14 at 2:30 p.m. She reported she usually will call in more staff if the hospital has admissions and/or observations levels are increased on patients. She reported due to being busy with the survey process, she did not identify the staff storage on 3/26/14.

Based on reviews of records and interviews, the hospital failed to ensure there was a Certified Therapeutic Activities/Recreational Therapist available to provide patient assessments within 72 hours to aid in the formulation and implementation of treatment plans to ensure they were individualized for each patient as evidenced by a lack of Therapeutic Activity assessments for 19 of 19 current inpatients (#s 1-19). Findings:

Review of 19 of 19 current inpatients' records revealed there failed to be Therapeutic Activity assessments documented in the patients' medical records.

Review of a hospital policy, titled "Chapter: PC 73- PROVISION OF CARE, TREATMENT, AND SERVICES SUBJECT: THERAPEUTIC RECREATIONAL ACTIVITIES POLICY The hospital...provides individualized therapeutic activities. Therapeutic activities focus upon the development and maintenance of adaptive skills that will improve the patient's functioning. Leisure activities provide the patient with individualized opportunities to acquire knowledge, skills and attitudes about meaningful leisure involvement and experiences. PROCEDURE ...Qualified staff completes their respective discipline assessments for use in the patient's multidisciplinary plan of care...Therapeutic activities are monitored and evaluated by the Social Service Director to ensure quality and appropriateness of therapeutic services delivered to patients..."

Review of the job description for the Corporate Activity Therapist revealed: "...QUALIFICATIONS 1. Bachelor of Science degree in Recreation Therapy or Music Therapy, Masters preferred. Must be licensed or certified by the State to perform Activity Therapy...SPECIFIC RESPONSIBILITIES AND DUTIES ...4. Responsible for direct and indirect patient care and the facilitation of Activity Group Therapy as ordered by physician. 5. Works collaboratively with the social worker to complete the psychosocial assessment, including but not limited to leisure and recreation assessment within 72 hours..."

Interviews, 03/26/14 at 2:30pm, with S1 Administrator and S2 Director of Nursing (DON), revealed when questioned who conducted the Therapeutic Activities assessments, S1 Administrator stated the social worker completed the psychosocial assessment and she thought that included the some of the therapeutic activity assessment.

Review of the Psychosocial Assessment form revealed: "...17. LEISURE AND RECREATION". There were 7 question/statements under the section on leisure and recreation and they follow: "Majority of leisure time is spent Alone With others" (the person completing the assessment would indicate the patient's response by placing a mark next to either Alone or With others); "Favorite Activities, Hobbies & Interests:", area for patient's responses; "Organized Groups/Clubs:", area for patient's responses; "What activities have you stopped in the last few months?" space supplied for patient's response; List healthy and unhealthy ways you relax or manage stress, space available for patient's response; "How much free time do you have weekly?" area to place a mark by "Too little", "Enough", or "Too much".

Follow-up interview, 03/26/14 at 2:40pm, with S1 Administrator agreed the patients did not receive an assessment by a Recreation/Activities Therapist even though the hospital had a Corporate Activity Therapist.