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

1. Ensure that at Outpatient Location A, the hospital's Governing Body reviewed all department-specific outpatient administrative policies and procedures for approval before they were considered effective (Refer to A-0048).

2. Ensure that all policies and procedures for the hospital's pharmaceutical services were reviewed and approved by the Governing Body before they were considered effective throughout the entire hospital (Refer to A-0491).

3. Ensure that the hospital established an organ, tissue and eye procurement process (Refer to A-0886 and A-0887).

The cumulative effects of these systemic practices resulted in the hospital's inability to provide quality healthcare in a safe setting for a universe of 71 patients.

Based on staff interview and facility record review, the hospital failed to ensure that at Outpatient Location A, the hospital's medical staff had submitted all department-specific outpatient administrative policies and procedures to the Governing Body for review, revision and approval before they were considered effective. This deficient practice resulted in the hospital's Medical Staff not apprising the Governing Body of all outpatient policies and procedures for review and approval ensuring that the highest quality of care was being provided for all outpatients treated at Outpatient Location A.

Findings:

On 6/25/12, a review of all administrative policies and procedures at Outpatient Location A was conducted. There was no documented evidence in the Administrative Policy and Procedure Manual that all department-specific policies and procedures were reviewed, revised or approved by the hospital's Governing Body as per the hospital's Medical Staff's bylaws.

On 6/25/12, a review of the Hospital's bylaws dated 2/28/12 was conducted. In section 1.2, it stipulated, "...The Operating Board shall require the Medical Staff and service to cause written policies and procedures to be developed, maintained, reviewed and appropriately revised and that such polices be approved by the Operating Board. The Operating Board shall further require the medical Staff to conduct specific review and evaluation of activities to assess, preserve and improve the overall quality and effectiveness of patient care in the hospital ..."

In addition, the hospital's bylaws stipulated in section 2.1, "...The Medical Staff shall conduct and be accountable to the Governing Body in maintaining an ongoing monitoring of patient care practices, including consideration of risk management and safety issues through hospital administration and other professional services ..."

On 6/25/12, a review of the hospital's bylaws, dated 2/28/12, stipulated in Section 4.3 and 4.5, "...The Governing Board shall organize and supervise the medical staff which shall approve bylaws, rules and regulations assuring the medical staff establishes mechanisms to achieve and maintain high quality medical practice and patient care and assures a safe environment to patients ..."

On 6/29/12, at approximately 3:30 PM, the Director of Quality Resource Management confirmed the finding that not all of the policies and procedures were reviewed and approved by the hospital's Governing Body at Outpatient Location A, as per hospital policy.

Based on interview and record review, the hospital failed to implement their grievance process for 1 of 30 sampled patients (Patient 6), when Patient 6 reported to the hospital that her personal belongings were taken and that the staff had failed to administer a medication after she (Patient 6) requested to be medicated. Patient 6 also reported to the hospital that a psychiatrist, who had previously treated the patient, did not treat her appropriately. This failure contributed in Patient 6's complaints to go uninvestigated and also had the potential to affect the quality of care for a universe of 71 patients.

Findings:

A record review, on 6/25/12 at 1:30 PM, of the hospital's grievance log, "Log - 2012 Patient Complaint," indicated that Patient 6 filed a complaint on 3/19/12. The hospital log documented the following: "Patient (referring to Patient 6), claims right violated by not getting meds, staff stealing her possessions, wasn't treated appropriately by former psychiatrist."

An interview and a concurrent record review of Patient 6's medical record, on 6/25/12 at 1:55 PM, with the hospital's Director of Quality were conducted. She stated that the complaint was forwarded to the department's Manager for Adult Services but that she did not believe that the complaint was formally investigated or that this investigation was completed.

An interview and a concurrent record review of Patient 6's medical record, on 6/25/12 at 2:10 PM, with the Manager for Adult Services were conducted. He stated that he remembered that Patient 6 was very delusional but he did not formally investigate the complaints.

A record review, on 6/25/12 at 2:10 PM, of the facility policy titled, "Patient Complaints and Grievances, effective June 2012," documented the following: "...Each complaint shall be addressed by the unit/department for review and appropriate follow-up action. The department staff or manager shall also consult or communicate with the attending physician involved with the patient's care, as appropriate ..." The policy also documented the following: "...Quality of Care - complaints/grievances regarding quality of care issues shall be referred to the Quality Risk Management Department ...Patient Property - If patient property is lost or misplaced and cannot be found by staff in the patient care area, the patient ...shall be referred to the unit/department manager for assistance in accessing the Lost and Found property ...Medical Staff Conduct - Complaints relating to competence or professional conduct of the Medical Staff shall be referred directly to the Medical Director for appropriate referral and follow-up in accordance with the (facility name) Medical Staff Bylaws ..."

Based on interview and record review the hospital failed to ensure that 1 of 30 sampled patients (Patient 18) received care in a safe setting. This failure contributed to the patient reporting to feel uncomfortable in group therapy with Counselor 1.

Findings:

A review of Patient 18's clinical record was conducted on 6/27/12. Patient 18 was admitted to the hospital on 6/26/12 with a diagnosis that included alcohol dependency.

Patient 18 asked to speak with the survey team.

In an interview with Patient 18 on 6/27/12 at 4:30 PM, he stated that he felt very uncomfortable in group therapy with Counselor 1. He stated that the counselor disrespected him and used foul language. He stated that when he opened up to say he had been abused in the past, the counselor disregarded what he had said.

In a review of a written complaint Patient 18 submitted to the hospital, Patient 18 wrote that "I feel very uncomfortable being in group and almost do not want to go unless things change."

In an interview with unsampled Patient A on 6/28/12 at 2:45 PM, the patient stated that Patient 18 is sensitive. Also, Counselor 1 can be frank and he does use foul language. Patient A stated that, "It works for some (patients) but offends some people."

In an interview with Counselor 1 on 6/28/12 at 3:15 PM, he stated that Patient 18 got up to leave the group and as he was leaving he stated "I was molested." To which the counselor replied, "What does that have to do with me?"

A review of Counselor 1's employee file on 6/28/12 showed a form titled "Radical Loving Care." On the form the following was documented: "I saw you bring the value of Integrity when you have been working on your 'Potty Mouth' in and out of the program."

A review of a hospital operating policy titled "Code of Conduct-Employee/Staff" and dated with an effective date of 1/12 showed the following: "Appropriate language shall be used at all times in all hospital areas for patients, professionals and the public. Swearing, degrading and profane language shall be prohibited."

Based on interview and record review, the quality assurance program failed to ensure the implementation of an effective, facility-wide quality assurance and performance improvement (PI) program when:

1. At Outpatient Location A, the hospital's Governing Body failed to review all department-specific outpatient administrative policies and procedures for approval before they were considered effective (Refer to A-0048).

2. All policies and procedures for the hospital's pharmaceutical services were not reviewed and approved by the Governing Body before they were considered effective (Refer to A-0491).

3. The hospital failed to established an organ, tissue and eye procurement process (Refer to A-0886 and A-887).

The cumulative effect of these systemic problems resulted in the hospital's inability to develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program in order to achieve high standards of healthcare in a safe environment for a universe of 71 patients.

Based on interview and record review, the facility failed to ensure that a Registered Nurse (RN) supervised and evaluated the nursing care for 1 of 30 sampled patients (Patient 14) by not ensuring that all physician orders were followed. This is evidenced by Patient 14 not being taken to a group meeting. This failure had the potential to contribute to substandard patient care.

Findings:

A review on 6/27/12 of Patient 14's clinical record showed that the patient was admitted to the facility on 6/25/12 with a diagnosis of major depressive disorder (depression).

A review of the physician orders dated 6/25/12 showed an order for the patient to attend AA (alcoholics anonymous) group.

A review of the 24-Hour Nursing Flow Sheet dated 6/26/12 showed a note by a behavioral health specialist (BHS) that read "PT (patient) in bed appears to be sleeping. Will not awake for AA do (due) to lack of staff to take to AA meeting."

In a telephone interview with the night shift BHS (responsible for the 6/25/12 24-Hour Nursing Flow Sheet notation) on 6/28/12 at 3:00 PM, he stated that there were, "eight (8) kids going to AA that morning. I couldn't send all of them with one person due to safety. The charge nurse instructed me to send 2 patients from each side of the unit. We didn't have an extra person. I'm not sure where the resource person was."

In an interview on 6/28/12 at approximately 4:30 PM with the Manager of Youth Services, she acknowledged that the physician order for Patient 14 to attend AA was not followed.

A review of a hospital policy titled "Physicians Orders" with an effective date of 8/11 showed the following: "Orders shall be completed as prioritized by the following definitions:

a. Routine

1) signs and symptoms that are not life threatening
2) completed within 24 hours of being ordered..."

Based on staff interview and facility record review, the hospital failed to ensure that outpatient medical records contained complete and comprehensive information to describe the patients' progress, support the diagnosis and any response to outpatient services that were provided for 3 of 6 sampled outpatients (Patient 7, 9 and 13) when the hospital failed to document in the medical record the patients' temperature, blood pressure, pulse, respiratory rate and numerous components in the Multidisciplinary Patient Assessment form required for each outpatient treated in the hospital. This deficient practice contributed in the incomplete assessments of the patients' condition and the prevention of other physicians and care providers in making accurate assessments and decisions for providing effective care for these patients.

Findings:

1a. On 6/25/12, a review of Patient 7's outpatient medical record was conducted. Patient 7 was admitted as an outpatient on 5/9/12 for chemical dependency and alcohol abuse.

On 6/25/12, a review of Patient 7's Multidisciplinary Patient Assessment sheet, dated 4/30/12, revealed the following sections that were found incomplete and left blank:
a. E-1: BEHAVIOR RISK SCREEN
b. E-2: FUNCTIONAL SCREEN
c. E-3: NUTRITIONAL RISK SCREEN
d. E-4 A: SKIN INTEGRITY RISK SCREEN
e. E-6 : PAIN SCREEN
f. E-7 : LEARNING BARRIERS SCREEN

There was no documented evidence in the medical record or from other facility sources that a blood pressure, pulse, respiratory rate or temperature was performed and documented on the Multidisciplinary Patient Assessment sheet dated 4/30/12.

On 6/25/12, a review of the hospital's policy titled, "MEDICAL RECORDS, COMPOSITION, MANAGEMENT AND ACCESS" dated 11/09, stipulated, "...complete medical records of an outpatient record shall include all components in the Multidisciplinary progress notes/documentation ..."

On 6/25/12, a review of the hospitals' policy titled, "DOCUMENTATION AND AUTHENTICATION OF MEDICAL RECORDS" dated 8/11, stipulated, "...The patient care process shall be documented by staff according to the established system. Documentation of care shall reflect the whole person in order to meet the patient's physical, psychosocial, educational, spiritual, self-care needs. Documentation shall include initial assessments, reassessments, patient care needs, plan, intervention, evaluation, and patient advocacy as appropriate to type of patient visit ..."

On 6/25/12, at approximately 2:00 PM, the Director of Outpatient Services at Location A confirmed the finding that Patient 7's Multidisciplinary Assessment Sheet dated 4/30/12 was incomplete with numerous sections not filled out completely.

1b. On 6/25/12, a review of Patient 9's medical record was conducted. Patient 9 was admitted to the hospital as an outpatient on 4/24/12 for the treatment of depression.

On 6/25/12, a review of Patient 9's Mental Status Examination sheet dated 5/31/12 was conducted. The Mental Status Examination sheet revealed the following sections that were found to be incomplete and left blank:
a. ASSOCIATION EVALUATION
b. THOUGHT PROCESS
c. ORIENTATION
d. WEIGHT

On 6/25/12, a review of Patient 9's Mental Status Examination sheet dated 6/15/12 was conducted. The Mental Status Examination sheet revealed the section for documenting the patient's weight, blood pressure, temperature, pulse and respiratory rate was incomplete and left blank.

On 6/25/12, a review of Patient 9's Mental Status Examination sheet dated 6/25/12 was conducted. The Mental Status Examination sheet revealed the section for recording the patients' weight, blood pressure, temperature, pulse and respiratory rate was incomplete and left blank.

The section titled: "INTELLECTUAL FUNCTION was incomplete, not filled out and left blank on 6/25/12.

On 6/25/12, a review of the hospitals' policy titled, "MEDICAL RECORDS, COMPOSITION, MANAGEMENT AND ACCESS" dated 11/09, stipulated, "...complete medical records of an outpatient record shall include all components in the Multidisciplinary progress notes/documentation ..."

On 6/25/12, a review of the hospitals' policy titled, "DOCUMENTATION AND AUTHENTICATION OF MEDICAL RECORDS" dated 8/11, stipulated, "...The patient care process shall be documented by staff according to the established system. Documentation of care shall reflect the whole person in order to meet the patient's physical, psychosocial, educational, spiritual, self-care needs. Documentation shall include initial assessments, reassessments, patient care needs, plan, intervention, evaluation, and patient advocacy as appropriate to type of patient visit ..."

On 6/25/12, at approximately 2:00 PM, the Director of Outpatient Services at Location A confirmed the finding that Patient 9's Multidisciplinary Assessment Sheet dated 5/31/12, 6/15/12 and 6/25/12 were incomplete with numerous sections that were not filled out completely.

1c. On 6/25/12, a review of Patient 13's outpatient medical record was conducted. Patient 13 was admitted as an outpatient on 6/20/12 for paranoia and alcohol abuse.

On 6/25/12, a review of Patient 13's Mental Status Examination sheet dated 6/13/12 and 6/20/12 was conducted. The Mental Status Examination sheet revealed the section for recording the patients' weight, blood pressure, temperature, pulse and respiratory rate was incomplete and left blank on 6/13/12 and 6/20/12.

On 6/25/12, a review of the hospital's policy titled, "DOCUMENTATION AND AUTHENTICATION OF MEDICAL RECORDS" dated 8/11, stipulated, "...The patient care process shall be documented by staff according to the established system. Documentation of care shall reflect the whole person in order to meet the patient's physical, psychosocial, educational, spiritual, self-care needs. Documentation shall include initial assessments, reassessments, patient care needs, plan, intervention, evaluation, and patient advocacy as appropriate to type of patient visit ..."

On 6/25/12, a review of the hospitals' policy titled, "MEDICAL RECORDS, COMPOSITION, MANAGEMENT AND ACCESS" dated 11/09, stipulated, "...complete medical records of an outpatient record shall include all components in the Multidisciplinary progress notes/documentation ..."

On 6/25/12, at approximately 2:00 PM, the Director of Outpatient Services at Location A confirmed the finding that Patient 13's Multidisciplinary Assessment Sheet dated 6/13/12 and 6/20/12 were incomplete.

Based on interview and record review, the facility failed to ensure that all telephone orders were authenticated within 48 hours. This failure resulted in 2 of 30 sampled patients (Patients 10 and 11) physician orders to not be authenticated within 48 hours and had the potential to contribute to medication errors and affect patient quality of care.

Findings:

1. A record review, on 6/25/12 at 11 AM, of Patient 10, indicated that the patient was admitted on 2/9/12 with a diagnosis which included Intermittent Explosive Disorder (repeated episodes of aggressive violent behaviors). Patient 10 was discharged from the facility on 3/1/12.

An interview and a concurrent record review, on 6/26/12 at 11 AM, with a facility Charge Nurse were conducted. Patient 10's physician orders dated 2/13/12 at 3:25 PM revealed a telephone order was obtained for Zyprexa (used to treat psychotic disorders) 5 milligrams intramuscular and Benadryl 50 milligrams intramuscular to be administered as a one-time order for agitation. The Charge Nurse reviewed the order and stated that the telephone order was signed by the ordering physician on 2/16/12 at 9 AM and not authenticated within 48 hours.

2. A record review, on 6/26/12 at 11:30 AM, of Patient 11, indicated that the patient was admitted on 1/19/12 with a diagnosis which included Major Depressive Disorder (recurrent depression). Patient 11 was discharged from the facility on 1/27/12.

An interview and a concurrent record review, on 6/26/12 at 11:30 AM, with a facility Charge Nurse were conducted. Patient 11's physician orders revealed the following: On 1/25/12 at 4:15 PM, Patient 11's physician's telephone order revealed that the physician ordered emergency medications to be administered for severe agitation. The physician authenticated the orders on 3/18/12 at 10:21 PM. On 1/26/12 at 5:50 PM, the physician's telephone order revealed that the physician canceled Patient 11's discharge and ordered to administer Patient 11's evening medications. The physician authenticated the orders on 2/21/12 at 7:28 PM. On 1/27/12 at 3:30 PM Patient 11's physician telephone order indicated that the physician ordered for the patient to be discharged from the facility. The physician authenticated the orders on 2/21/12 at 7:28 PM. The Charge Nurse stated that the physician orders were not signed within 48 hours and also stated, "That was a long time after."

A record review, on 6/26/12 at 12:10 PM, of the facility policy titled "Physicians Orders, effective August 2011," documented the following: "...Shall be authenticated within 48 hours by the physician giving the telephone order or, in his or her absence, by a physician who is involved in the patient's care. Authentication includes a signature, date and time ..."

Based on staff interview and facility record review, the hospital failed to ensure that all policies and procedures for the hospital's pharmaceutical services department were submitted to the Governing Body for review, revision and approval before they were considered effective. This deficient practice resulted in one pharmaceutical policy not reviewed and approved by the Governing Body in order for that policy to be considered effective.

Findings:

On 6/26/12, a review of all administrative pharmaceutical policies and procedures for the hospital was conducted.

On 6/26/12, a pharmaceutical policy titled, "HEPARIN LOCK MANAGEMENT", dated 1/2012, was reviewed and it revealed no documented evidence that the hospital's Governing Body reviewed or approved the policy as articulated.

On 6/26/12, a review of the Hospital's bylaws, dated 2/28/12 was conducted. In section 1.2, it stipulated, "...The Operating Board shall require the Medical Staff and service to cause written policies and procedures to be developed, maintained, reviewed and appropriately revised, and that such polices be approved by the Operating Board. The Operating Board shall further require the medical Staff to conduct specific review and evaluation of activities to assess, preserve and improve the overall quality and effectiveness of patient care in the hospital ..."

On 6/29/12, at approximately 3:30 PM, the Director of Quality Resource Management confirmed the finding that not all policies and procedures were reviewed and approved by the hospital's Governing Body for the Department of Pharmacy.

Based on observation and interview, the hospital failed to have a food service director who ensured the daily management of the dietary services provided to patients, staff and visitors with a safe and high quality food service due to a lack of the staff monitoring by labeling and dating of the food with an expiration date when it was removed from its original container so that staff would know when to discard 2 different products. This failure had the potential to contribute to expired food being served to patients with the potential for food borne illness for a universe of 71 patients.

Findings:

During the initial observation tour of the kitchen on 6/25/12, it was observed that in the walk-in freezer there were two brown bags that had been removed from their original packaging with no label to identify the food item or an expiration date placed on the bags. There was also an undated plastic bag with meatballs that had been removed from the original packaging and had no expiration date placed on it.

In an interview on 6/25/12 at 9:45 AM with the Dietary Department Manager (DDM), she agreed that the bags that were stored in the freezer should have been labeled and dated.

Based on observation and interview, the hospital failed to ensure that the dietary staff were fully trained in sanitizing food contact surfaces. This failure had the potential to contribute to unsanitary conditions in the kitchen that could contribute to food borne illness in patients, for a universe of 71 patients.

Findings:

In an observation of Cook 1 on 6/25/12 at 9:55 AM, the cook was using a red bucket and a towel to wipe down a food preparation counter.

In a concurrent interview with Cook 1, he stated that the red bucket contained sanitizer solution and that the solution was changed every two hours to ensure that the sanitizer was working.

Cook 1 then obtained a test strip to check for the proper concentration of sanitizer. The test strip read zero, indicating that there was no sanitizer within the bucket.

Cook 1 then stated that he had just changed the sanitizer at 9:00 AM.

In an interview with the Dietary Department Manager, she acknowledged that the sanitizer level should not be at zero to properly sanitize the counters.

Based on staff interview and facility record review, the hospital failed to ensure that a sanitary environment was maintained to avoid sources and transmission of infections and communicable diseases when it failed to recognize medications considered to be for single patient use only, were used on multiple patients in a universe of 71 patients. This deficient finding had the potential to create a risk of spreading infectious diseases due to the lack of antimicrobial preservatives in the single-dose medication vial.

Findings:

On 6/26/12, during the medication storage inspection process, it was observed in the 200 Unit medication room's refrigerator, that an open and used vial of Humalog Insulin U-100 bottle was found not dated and not labeled with the patients name on the medication bottle.

On 6/26/12, at approximately 10:45 AM, during an interview with the Medication Nurse assigned to the 200 Unit, when asked if the Humalog Insulin Medication bottle was used on multiple patients, she responded, "Yes."

According to the United States Pharmacopeia (USP) established standards in 2008 and recognized by the Federal Drug Administration (FDA), issued quality standards under the heading : "Pharmaceutical Compounding-Sterile Preparations Chapter 797" it stated, "...Medications labeled as single-use or single dose by manufacturers typically lack antimicrobial preservatives, and once a Single-Dose Vial (SDV) is entered, the contents can support the growth of microorganisms ..."

According to the Centers for Disease Control (CDC), dated 2008, "ongoing outbreaks provide evidence that medications from SDVs can become contaminated and serve as a source of infection when they are used inappropriately."

On 6/26/12, at the time of the finding, the Director of Patient Care Services confirmed the finding that Humalog U-100 multidose Insulin bottle was used on multiple patients and was not dated or used for single patient use only.

Based on interview and record review, the hospital failed to ensure that they had established an organ, tissue and eye procurement process. This failure had the potential for a universe of 71 patients and their family, who may want to donate vital organs for transplant to not have a process to assist them in accomplishing this patient desired task.

Findings:

An interview and a concurrent record review was conducted on 6/27/12 at 9:55 AM, with the facility Director of Quality. The Director of Quality revealed that the hospital had no protocols in place to address the matter of organ, tissue and eye procurement. The Director of Quality stated, "The hospital has no contract or policies and procedures. We didn't think we had to, for our hospital. We had no idea and we have had no deaths here."

The cumulative effect of this deficient practice caused the hospital to not be able to provide this service to its patients in the event that the patients desire to have this accomplished.

Based on interview and record review, the hospital failed to ensure that they had established an organ, tissue and eye procurement process. This failure had the potential for a universe of 71 patients and their family, who may want to donate vital organs for transplant to not have a process to assist them in accomplishing this patient desired task.

Findings:

An interview and a concurrent record review was conducted on 6/27/12 at 9:55 AM, with the facility Director of Quality. The Director of Quality revealed that the hospital had no protocols in place to address the matter of organ, tissue and eye procurement. The Director of Quality stated, "The hospital has no contract or policies and procedures. We didn't think we had to, for our hospital. We had no idea and we have had no deaths here."

The cumulative effect of this deficient practice caused the hospital to not be able to provide this service to its patients in the event that the patients desire to have this accomplished.