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Based on contract review, medical record review, and staff interview, the facility failed to assure contracted laboratory services reported a STAT laboratory result in the required time frame for two (N13 and N15) of eleven patient medical records reviewed.

Findings include:

1. On 1-21-14 between 4:30 PM and 4:45 PM, review of laboratory contract signed on "1-27-12" read: "Stat orders for routine testing will be completed within 3 hours of receipt in the laboratory. All Stat and critical values will be phoned to the Hospital."

2. On 1-22-14 between 10:10 AM and 3:00 PM, review of patient medical records indicated the following:
a. Patient N13 (admitted "12/26/13") had a STAT potassium ordered on 1-10-14 at 1710. The sample was received in the laboratory on "01/10/2014" at "19:30" and reported on "01/11/2014" at "03:11" as 4.1 within normal range 7 hours and 41 minutes after the laboratory received the sample. The STAT result was not phoned to the hospital as required per contract.
b. Patient N15 (admission date "12/26/2013") had a STAT potassium ordered on 1-10-14 at 1700. The sample was received in the laboratory on "01/10/2014" at "19:30" and reported on "01/11/2014" at "02:52" as 4.6 within normal limits 7 hours and 22 minutes after the laboratory received the sample. The STAT result was not phoned to the hospital as required per contract.

3. In interview on 1-23-14 between 3:05 PM and 3:38 PM, Staff Member P11 acknowledged Patients N13 and N15 had STAT potassium orders that were not reported by the laboratory within three hours, as required by the hospital's contract with the laboratory.







26641

Based on contract review, policy and procedure review, medical record review and personnel interview, the facility failed to assure contracted dietary services assessed patient according to facility protocol for 1 of 5 (N1) closed patient medical records reviewed.

Findings:

1. At approximately 12:55 PM on 1/23/14, review of the Dietitian Services Contract, signed January 26, 2012, for contracted dietary services, indicated "the Registered Dietitian that is designated will fulfill the State and Federal requirements."

2. Policy No.: III.E.5.3, titled "Consulting Dietitian", revised/reapproved 1/2014, was reviewed on 1/23/14 at approximately 12:14 PM, and indicated on pg. 1 under:
A. Specific Responsibilities section, "1. Screen, assess, plan treatment, evaluate care, educate and follow-up on patients according to state/federal/accreditation rules and regulations. Ensure continuous improvement in performance outcomes...3. Collect nutrition risk data on patients to determine priorities for care...4. Conduct comprehensive nutrition assessments in a timely manner according to facility policy/rules/accreditation requirements."

3. Policy No.: II - A.11, titled "Nutritional Screening", revised/reapproved 12/11, was reviewed on 1/22/14 at approximately 9:10 AM, and indicated under Procedure section, point 3., "When the need to consult the contracted Registered Dietitian arises, she will be contacted by phone and/or written communication is placed in the Dietary mailbox. The contracted dietitian will perform an assessment within 72 hours or as the patient's need warrants."

4. Review of closed patient medical records on 1/21/14 at approximately 3:01 PM and 1/22/14 at approximately 10:00 AM, indicated Patient:

A. N1 was a 75-year-old admitted to the facility on 1/3/14 for bipolar schizophrenia. Documentation in the medical record included:
a. per Nursing Admission Assessment dated 1/3/14, weight was 80.7 kg or 178 pounds and nutritional services was contacted at 1835 for a dietary order. A 2gm Na+ diet was ordered. According to nursing documentation on Patient Care Flow Sheets weight was 151 pounds the next day on 1/4/13 and 144 pounds on transfer on 1/8/14. There is no documentation that nursing contacted the consulting dietitian for an assessment.

5. Personnel P13 was interviewed on 1/22/14 at approximately 4:18 PM and confirmed:
A. patient N1 had a diet order for a 2gm Na+ (sodium) diet, which means it is 2000mg low sodium diet. It may be used for renal insufficiency or in this patient's case "elevated sodium" or serum sodium level. There is documentation that this type of diet was ordered and communicated to dietary services via Dietary Orders communication sheet 1/3/14. On the Neuropsych side of the facility we see patient when we are consulted and we do an assessment within 72 hours and make recommendations if appropriate.
B. when this patient was on the Neuromedical side I did a nutrition assessment on 12/29/13 and the patient's weight was 178 pounds. I met with the patient and the family that day at mealtime. Patient was very threatening and difficult to assist to feed. Patient had difficulty getting food to mouth due to physical limitations, cognitive deficits, and aggressive behaviors.
C. was not notified by nursing to reassess patient even after a Nurse Practitioner documented on 1/5/14 that patient had "poor appetite" and was "drinking poorly". Nursing does a nutrition screening on admission, NPs or MDs order consultations with the Dietitian to assess the patient ' s nutritional status, then nursing communicates that to Dietary Services on the Dietary Orders communication sheet, they contact the Dietitian and we assess the patient. This protocol was not followed for this patient to the best of my knowledge.

Based on policy review, medical record review and staff interview, the medical staff failed to document in the progress notes that critical values were reviewed and actions were taken in a timely manner by the attending physician of Patient N5 for a decreasing hemoglobin from 1-6-14 to 1-17-14.

Findings include:

1. On 1-23-14 between 3:45 PM and 4:15 PM, review of policies and procedures indicated a procedure titled: "Critical Test Results," policy number "II.C.4," last revised on "1/2014," which read: "The attending physician will document in a progress note that the critical value(s) were reviewed and actions taken within twenty-four (24) hours..."

2. On 1-22-14 between 10:10 AM and 10:42 AM, review of medical record for Patient N5 (admitted on "12/23/13") indicated the following:
a. The patient had decreasing, critical, hemoglobin results from 1-6-14 to 1-17-14, as indicated below:
Date Time Result (g/dL)
--------------------------------------------------
1-6-14 1502 8.0
1-9-14 0048 7.5
1-13-14 1643 7.3
1-17-14 1936 7.2

Date - Date test result was reported to hospital; Time - time test result was reported to hospital; Result - hemoglobin test result; g/dL - grams per deciliter
b. The physician orders on "1-18-14" at "1115" read: "Pt also needs referral to GI for positive occult blood upon discharge as well..." The patient was not discharged until 1-22-14, when a decline in the patient's condition was noted by a physician (Staff Member D1).

3. In interview on 1-23-14 at 3:11 PM, Staff Member P11 acknowledged Patient N5 had decreasing hemoglobin test results without documentation in the patient's medical record that critical values were reviewed and actions were taken in a timely manner by the attending physician.

4. In interview on 1-22-14 between 5:15 PM and 5:45 PM, Staff Member D1 was informed that Patient N5 had multiple critical hemoglobin results and that the patient's hemoglobin had been decreasing over an 11 day period, without documentation in the patient's progress notes that the attending physician reviewed the critical results or took action in a timely manner. Staff Member D1 acknowledged Patient N5's decreasing, critical, hemoglobin results.

5. On 1-23-14 between 11:04 AM and 11:55 AM, Staff Member D1 (a physician) indicated that after the surveyors exited the facility on 1-22-14 at 5:45 PM, Staff Member D1 assessed Patient N5 and determined the patient was beginning to decline and Staff Member D1 ordered the patient to be transferred through an emergency ambulance service (911). Staff Member D1 indicated nursing staff had not noticed the patient's decline and had not notified a physician.


26641


Based on policy and procedure review, medical record review, and personnel interview, the medical staff failed to identify in the medical record any follow-up of critical lab values provided to patients for 3 of 4 (N1, N3, and N4) closed patient medical records reviewed.

Findings:

1. Rules and Regulations of the Medical Staff, revised/reapproved 12/13, was reviewed on 1/23/14 at approximately 12:55 PM, and indicated on pg. 7, under section I. Medical Records, "1. The attending physician shall be held responsible for the preparation of a complete and legible medical record for each individual evaluated or treated as an inpatient, patient which accurately reflects the patient's condition and care.

2. Policy No.: II.C.4, titled "Critical Test Results", revised/reapproved 1/2014, was reviewed on 1/22/14 at approximately 9:10 AM, and indicated on pg. 1 under:
A. Policy section, "to provide a mechanism for expedient reporting of critical values to designated care providers in order to ensure timely and appropriate patient treatment interventions."
B. Definitions section, under Critical Values, "Critical Values are laboratory results with the following attributes...they have the potential for serious adverse consequences if not dealt with promptly; they require an appropriate action..."
C. Procedures section, points D and E, "The Attending Physician will document in a progress note that the critical value(s) were reviewed and actions taken within twenty-four (24) hours...The following laboratory values are defined as critical in this facility...Sodium < or = 120 mEq/L to > or = 160 mEq/L."

3. Review of closed patient medical records on 1/21/14 at approximately 3:01 PM and 1/22/14 at approximately 10:00 AM, indicated Patient:

A. N1 was a 75-year-old admitted to the facility on 1/3/14 for bipolar schizophrenia. Documentation in the medical record included:
a. per Laboratory Report a critical sodium level of 164 mEq/L was reported to nursing staff at 1838 on 1/8/14, results were called to the Nurse Practitioner (NP) at 2000 and "no new orders" given.
b. last Physician Progress Note was documented on 1/8/14 at 1000 and stated "Medical problems: dehydrated...possible cascading stroke, new dysphagia, get repeat CT (computed tomography) scan" and by an NP on 1/8/14 at 1025 "per nursing - having trouble swallowing, alert but lethargic, respiratory effort diminished throughout, needs new head CT...new dysphagia, ? acute CVA (cerebrovascular accident), hypernatremia, dehydration, start IV (intravenous)..." These Progress Notes are approximately 10 hours and 50 minutes prior to patient's transfer.
c. lacked documentation in progress note of follow up of critical sodium value by Physician or NP prior to transfer at 2050 on 1/8/14.

B. N3 was a 76-year-old admitted to the facility on 12/18/13 for vascular dementia, altered mental status. Documentation in the medical record included:
a. a. per Laboratory Report a critical sodium level of 161 mEq/L was reported to nursing staff at 0230 on 12/24/13, results were called to the NP at 0305 and "no new orders" given.
b. last Physician Progress Note was documented on 12/23/13 at 1230 and stated "patient sleeping" (the rest is illegible) and by an NP on 12/24/13 at 1130 "sedated, River Crest ?, yes per Dr. Posar, order written...multi lobar pneumonia, elevated WBC's (white blood cell), chronic respiratory failure, oxygen dependent COPD (chronic obstructive pulmonary disorder), type II diabetes with renal manifestations, chronic kidney disease stage II..."
c. lacked documentation in progress notes of follow up of critical sodium value by Physician or NP prior to transfer on 12/24/13 at 2300.

C. N4 was a 79-year-old admitted to the facility on 12/11/13 for acute psychosis, altered mental status with dementia. Documentation in the medical record included:
a. per Laboratory Report a critical glucose level of:
i. 51 mg/dL was reported to nursing staff at 1829 on 12/13/13, results were called to the NP at 1030 on 12/16/13 and no new orders given.
ii. 486 mg/dL was reported to nursing staff at 0324 on 12/17/13, results were called to the NP on 12/17/13, no time documented, and no new orders given.
b. last Physician Progress Note was documented on 12/17/13 at 1800 and stated "chronic kidney disease...12/16/13, need to resolve issues with fluids versus transfer to another facility (doubtful), very violent last night, 1mg Ativan given to sleep, pleasant through am...12/17/13, discharged to [F3] after I spoke with [physician]."
c. lacked documentation in progress notes of follow up of critical glucose values by Physician or NP prior to transfer on 12/17/13 at 1505.

4. Personnel P10 was interviewed on 1/22/14 at approximately 11:00 AM and confirmed facility policy and procedure was not followed related to documenting follow up in progress notes and monitoring/evaluating critical lab values by physicians or other health care providers.

Based on document review, policy and procedure review, patient medical record review and personnel interview, it was determined that the hospital failed to ensure nursing staff reported critical lab values as required for 5 of 15 (N1, N3, N4, N5 and N18) closed patient medical records reviewed (Refer to A 395), followed physician orders related to medication administration, completed transfer records according to policy and procedure for 3 of 4 (N1, N3 and N4) closed patient medical records reviewed (Refer to A 395), followed physician orders related to intake and output for 4 of 4 (N1-N4) closed patient medical records reviewed and 1 of 4 (N6) open patient medical records reviewed (Refer to A 395) and notified the Dietitian of need for reassessment for 1 of 4 (N1) closed patient medical records reviewed (Refer to A 395). As a result, it was determined that the Conditions of Nursing services was not in compliance.

At the time of the survey, the facility census ranged from 19-17 inpatients. Critical lab values reporting had not yet been fully addressed, placing these patients at serious risk for lack of timely follow-up to critical lab results.

An Immediate Jeopardy (IJ) and serious threat to patients' safety and wellbeing was created from the cumulative effects of these systematic problems that resulted in the hospital's inability to ensure nursing services were furnished and supervised by a registered nurse.

Based on review of policies and procedures, patient records, and staff interview, the nursing staff failed to A) follow physician's orders for laboratory testing for 3 (N12, N14 and N17) of 11 patient records reviewed; and B) notify the responsible physician of critical laboratory test results in a timely manner for 2 (N5 and N18) of 11 patient records reviewed.

Findings include:

A:
1. On 1-23-14 between 3:45 PM and 4:14 PM, review of policies and procedures indicated the following:
a. A procedure titled: "Noting Physician Orders," policy number "II-C.52," last revised on "1/2014," which read: "All routine orders will be addressed and signed off the RN/LPN (sic) with (sic) 90 minutes."
b. A procedure titled: "Venipuncture," policy number "II-C.19," last revised on "12/2013," which read: "Routine orders will be drawn so that results may be obtained, if available by lab, by the next day. Stat orders will be drawn within one hour of the order."

2. On 1-22-14 between 10:10 AM and 3:00 PM, and on 1:23-14 between 1:18 PM and 3:45 PM, review of patient records indicated the following:
a. Patient N12 was admitted on "01/19/14." "Physician Admission Order" indicated a verbal order for "Urinalysis...Urine Culture and Sensitivity" on "1-20-14" at "0400." Urinalysis results and urine culture and sensitivity results were not available for review in the patient's medical record.
b. Patient N14 was admitted on "12/18/13" and discharged on "1/21/14." "Physician Admission Order" indicated a verbal order for ""Chem 12 (CMP)...CBC with Differential...BNP...ESR...T4 Total...Urinalysis...Urine Culture and Sensitivity...Magnesium / Zinc..." on "12-18-13" at "1845." Samples for laboratory tests ordered upon admission were not collected until 12-23-13 at 1930 (urine) and 12-24-13 at 0630 (blood), 5 to 6 days after the orders were given by the physician. Physician orders on "1/13/14" at "1100" indicated the physician requested "VPA, ammonia, CBC, Chem 12 Tuesday". Laboratory records indicate the samples for the ordered laboratory tests were obtained on Wednesday, "01/15/2014" at "1907" instead of Tuesday, 1-14-14, as ordered.
c. Patient N17 was admitted on "01/17/14." "Physician Admission Order" indicated a verbal order for "Chem 7 (BMP)" on "1-18-14" at "1020." The laboratory results from South Bend Medical Foundation, the hospital's contracted laboratory service, indicated a comprehensive metabolic panel (CMP) was drawn on "01/19/2014" at "10:15" and reported on "01/19/2014" at "20:01," instead of the basic metabolic panel (BMP) that was ordered by the physician.

3. In interview on 1-23-14 between 2:38 PM and 3:27 PM, Staff Member P11 indicated Patient N12 was exhibiting "behaviors" on 1-20-14 and 1-21-14 and nursing staff had been unable to collect urine sample for the time it was ordered until date of survey. Staff Member P11 indicated Patient N14 refused treatment from 12-19-13 to 12-23-13 and allowed laboratory samples from the admission orders to be obtained on 12-24-13. Staff Member P11 acknowledged admission orders for Patient N17 were for a basic metabolic panel (BMP), not a comprehensive metabolic panel (CMP), and physician orders for a BMP were not followed. Staff Member P11 acknowledged the procedure titled: "Noting Physician Orders" read: "All routine orders will be addressed and signed off the RN/LPN (sic) with (sic) 90 minutes..." but indicated the word "addressed" meant the orders were received and documented, not necessarily carried out, by nursing staff. Staff Member P11 acknowledged there should not be a delay in obtaining laboratory testing samples and laboratory samples should be obtained when ordered.

B:
1. On 1-23-14 between 3:45 PM and 4:15 PM, review of policies and procedures indicated the following:
a. A procedure titled: "Critical Test Results," policy number "II.C.4," last revised on "1/2014," which read: "The Nurse (sic) will complete the Critical Values Report form and document on the log sheet designated for tracking of "Critical Value" data..." The "Critical Values Report" attached to the procedure read: "Any Critical (sic) value must be reported to the physician within 30 minutes of receipt from the lab..."
b. A procedure titled: "Critical Lab Values and Diagnostic Test Results, Notification Of," policy number "II.C.4," revised "6/2013," which read: "The responsible physician will be notified within 15 minutes of receipt of critical laboratory and diagnostic radiologic test results..."

2. On 1-22-14 between 10:10 AM and 3:00 PM, and on 1:23-14 between 1:18 PM and 3:45 PM, review of patient records indicated the following:
a. Patient N5, admitted on "12/23/13," had a critical hemoglobin result (8.0 g/dL) reported to the hospital by the laboratory on "01/06/2014" at "15:02." There was no documentation to indicate the critical result was reported to the physician. On "01/08/2014" at "00:48," the laboratory reported a critical hemoglobin result (7.5 g/dL) to the hospital. Nursing notes and documentation on the laboratory report indicated the nurse phoned a nurse practitioner with the critical result on "1/9/14" at "0258," 2 hours and 10 minutes after the hospital received the result from the laboratory.
b. The laboratory reported critical hemoglobin results for Patient N18 (admitted on "12/04/13") on the following dates. There was no documentation to indicate the critical results were reported to the physician:
Date Time Result (g/dL)
__________________________________
12-7-13 1826 6.5
12-8-13 1849 6.5
12-9-13 1434 6.6

Date - Date laboratory reported result to hospital; Time - time laboratory reported result to hospital; Result - test result; g/dL - grams per deciliter

3. In interview on 1-22-14 between 10:42 AM and 11:00 AM, Staff Member P10 indicated the procedure titled: "Critical Lab Values and Diagnostic Test Results, Notification Of," policy number "II.C.4," revised on "6/2013," which required physicians to be notified of critical values within 15 minutes of receiving a critical test result, was in effect prior to January of 2014. The procedure titled: "Critical Test Results," policy number "II.C.4," last revised on "1/2014," which required physicians to be notified within 30 minutes of receiving a critical test result, became effective January 1, 2014.

4. In interview on 1-22-14 between 5:15 PM and 5:45 PM, staff members P6 and D1 acknowledged Patient N5's decreasing hemoglobin results.

5. In interview on 1-23-14 between 11:04 AM and 11:55 AM, Staff Member D1 (physician) indicated that on 1-22-14 he/she assessed Patient N5 and determined the patient was beginning to decline and Staff Member D1 ordered the patient to be transferred through an emergency ambulance service. Staff member D1 indicated nursing staff did not notice the patient's decline and had not alerted a physician of the patient's decline.

6. In interview on 1-23-14 between 2:45 PM and 3:11 PM, Staff Member P11 acknowledged Patient N5 had a critical hemoglobin reported to the hospital on 1-6-14 at 1502 that was not reported to the physician and the patient had another critical hemoglobin reported to the hospital on 1-8-14 at 0048 that was reported to the physician 2 hours and 10 minutes after the hospital received the report from the laboratory. Staff Member P11 acknowledged patient N18 had critical hemoglobin results reported to the hospital from the laboratory on 12-7-13, 12-8-13, and 12-9-13 that were not reported to the physician.



26641


Based on document review, policy and procedure review, medical record review and personnel interview, nursing staff failed to supervise and evaluate the nursing care for each patient related to reporting of critical lab values, following physician orders related to an order for IV (intravenous) administration, completion of transfer records according to policy and procedure for 3 of 4 (N1, N3, and N4) closed patient medical records reviewed, following physician orders related to intake and output for 4 of 4 (N1-N4) closed patient medical records reviewed and 1 of 4 (N6) open patient medical records reviewed and notification of Dietitian of need for reassessment for 1 of 4 (N1) closed patient medical records reviewed.

Findings:

1. Review of closed patient medical records on 1/21/14 at approximately 3:01 PM and 1/22/14 at approximately 10:00 AM, indicated Patient:

A. N1 was a 75-year-old admitted to the facility on 1/3/14 for bipolar schizophrenia. Documentation in the medical record included:
a. per Laboratory Report a critical sodium level of 164 mEq/L was reported to nursing staff at 1838 on 1/8/14, results were called to the Nurse Practitioner (NP) at 2000 and "no new orders" given. This is approximately 1 hour and 22 minutes after nursing staff received the result.
b. lacked documentation of this result on the Critical Values Report form.
c. per Physician Orders dated:
i. 1/3/14 at 1000, 2gm Na+ (sodium) diet.
ii. 1/5/14 at 1239, "Strict I & O (intake and output)."
iii. 1/8/14 at 1040, "Head CT without contrast, IV D5 1/2 NS (Normal Saline) - give 500ml bolus now and then 100ml/hour." 500ml bolus was not given until 1600.
d. per Nursing Admission Assessment dated 1/3/14, weight was 80.7 kg or 178 pounds and nutritional services was contacted at 1835 for a dietary order. A 2gm Na+ diet was ordered. According to nursing documentation on Patient Care Flow Sheets weight was 151 pounds the next day on 1/4/13 and 144 pounds on transfer on 1/8/14. There is no documentation that nursing contacted the consulting dietitian for an assessment.
e. unable to determine exact time IV was inserted because there is no time documented on 1/8/14 in the MAR (Medication Administration Record), only the nurse's initials that it was done.
f. lack of I & O totals on Patient Care Flow Sheets from 1/3/14 through 1/8/14.
g. per Nurses Notes on 1/8/14 at:
i. 1600 "has IV bolus given per NP order, 500cc left wrist, CT, CXR (chest x-ray), ST (speech therapy) canceled." Order for bolus was for now (at 1040). First documentation of IV bolus as given is 1600.
ii. 1705, "IV now at 100cc/hour."
iii. 2000, "in bed sleeping, lungs wet with audible gurgles, nonverbal, to be transferred to [other acute care facility]. Critical results called to NP of sodium 164, no new orders."
iv. 2050, "picked up by [ambulance] to be transported to [F2]. Discontinued IV, kept reseal in per hospital request. Called [F2] and informed nurse of critical sodium level of 164."
v. 2110, "faxed critical lab results to [F2]."
vi. 2200, "EMS (emergency medical services) that was transporting this patient called and informed this nurse that on way to [F2] patient went into respiratory distress and they took patient to [F3] ER (Emergency Room), to work on him/her. Stated wasn't looking good and requested this nurse to call [F3] where family was waiting and inform them..."
h. Patient Transfer Form lacked documentation of transferring physician, receiving physician, who report was called to and when, what records were sent with the patient, date and time of current vital signs, and what the patient is at risk for.
i. Discharge Disposition Form lacked nurse's signature and date/time discharged.
j. Patient Transfer Assessment lacked nurse's signature and date/time.
k. Patient Transfer Orders were signed by a NP, but dated 1/10/14 at 1225 which was 2 days after the transfer occurred.

B. N2 was a 72-year-old admitted to the facility on 12/30/13 for agitation. Documentation in the medical record included:
a. per Physician's Orders dated 1/5/14 at 1239, "Strict I & O (intake and output)."
b. lack of I & O totals on Patient Care Flow Sheets from 12/30/13 through 1/13/14.

C. N3 was a 76-year-old admitted to the facility on 12/18/13 for vascular dementia, altered mental status. Documentation in the medical record included:
a. per Laboratory Report a critical sodium level of 161 mEq/L was reported to nursing staff at 0230 on 12/24/13, results were called to the NP at 0305 and "no new orders" given. This is approximately 35 minutes after nursing staff received the result.
b. per Nurses Notes on 12/24/13 at:
i. 1103, "WBC's greater than 22, NP notified, new orders to start IV D51/2 NS at 75ml/hr...IV 24 gauge started in right hand...shallow respirations noted, NC (nasal cannula) at 2 liters in mouth due to patient breathing more through mouth..."
ii. 1740, "up in geri chair with IV infusing, no adverse reactions noted, appetite poor, restless at times but redirectable. No distress noted."
c. lacked documentation of nurse's notes from 1740 on 12/24/13 until transfer same date at 2300 (according to Patient Transfer Assessment). Unsure of exact transfer time due to lack of documentation of transfer time.
d. lack of I & O totals on Patient Care Flow Sheets from 12/18/13 through 12/24/13. Has chronic kidney disease, stage III.
e. Patient Transfer Form lacked documentation of transferring physician, and who report was called to and when. Current vital signs dated 12/24/13 at 1800, which is approximately 5 hours prior to transfer.
f. lacked Discharge Disposition Form.
g. Patient Transfer Orders (Medications pages) were signed by a NP, but dated 12/26/13 at 1000 which was 2 days after the transfer occurred.

D. N4 was a 79-year-old admitted to the facility on 12/11/13 for acute psychosis, altered mental status with dementia. Documentation in the medical record included:
a. per Laboratory Report a critical glucose level of:
i. 51 mg/dL was reported to nursing staff at 1829 on 12/13/13, results were called to the NP at 1030 on 12/16/13 and no new orders given. This is approximately 3 days after nursing staff received the result.
ii. 486 mg/dL was reported to nursing staff at 0324 on 12/17/13, results were called to the NP on 12/17/13, no time documented, and no new orders given. Unsure of exactly time between lab report and physician notification after nursing staff received the result.
b. per Nurses Notes on 12/17/13 at:
i. 1505, "discharged to [F4] per family request, transferred via [ambulance]."
ii. 1520, "report called to RN at [F4], face sheet and allergies faxed over, personal belongings list reconciled."
c. lack of I & O totals on Patient Care Flow Sheets from 12/11/13 through 12/17/13. Has chronic kidney disease.
d. Patient Transfer Form lacked documentation of receiving physician and who report was called to and when. Current vital signs dated 12/17/13 at 0700, which is approximately 8 hours prior to transfer.
e. Discharge Disposition Form lacked time of discharge.

E. N6 was a 76-year-old admitted to the facility on 1/16/14 for dementia with behaviors. Documentation in the medical record included:
a. per Physician's Orders dated 1/20/14 at 1230, "Strict I & O."
b. lack of I & O totals on Patient Care Flow Sheets from 1/16/14 through 1/23/14. Has chronic kidney disease.

2. Personnel P10 was interviewed on 1/22/14 at approximately 11:00 AM and confirmed the protocol for critical lab results is for nursing staff to notify physician or on-call provider of the results within 30 minutes. This was changed recently in a policy revision from within 15 minutes. Facility policy and procedure was not followed related to reporting of critical lab values by nursing staff and monitoring/evaluating critical lab values by physicians or other health care providers. Also, orders were not followed for patient N1 related to IV start and bolus administration or strict I & O as described above and transfer documentation was not completed according to facility policy and procedure. In addition, patient N1 weight was documented on the Patient Transfer Form as 144 pounds, which is a 34 pound weight loss from admission to transfer in 5 days. At the time this patient was here, staff was using 2 different scales to weigh patients, one was a standing scale and one was a bed scale. This may explain the weight differences.

3. Personnel P13 was interviewed on 1/22/14 at approximately 4:18 PM and confirmed:
A. patient N1 had a diet order for a 2gm Na+ (sodium) diet, which means it is 2000mg low sodium diet. It may be used for renal insufficiency or in this patient's case "elevated sodium" or serum sodium level. There is documentation that this type of diet was ordered and communicated to dietary services via Dietary Orders communication sheet 1/3/14. On the Neuropsych side of the facility we see patient when we are consulted and we do an assessment within 72 hours and make recommendations if appropriate.
B. when this patient was on the Neuromedical side I did a nutrition assessment on 12/29/13 and the patient's weight was 178 pounds. I met with the patient and the family that day at mealtime. Patient was very threatening and difficult to assist to feed. Patient had difficulty getting food to mouth due to physical limitations, cognitive deficits, and aggressive behaviors.
C. was not notified by nursing to reassess patient even after a Nurse Practitioner documented on 1/5/14 that patient had "poor appetite" and was "drinking poorly". Nursing does a nutrition screening on admission, NPs or MDs order consultations with the Dietitian to assess the patient ' s nutritional status, then nursing communicates that to Dietary Services on the Dietary Orders communication sheet, they contact the Dietitian and we assess the patient. This protocol was not followed for this patient to the best of my knowledge.

4. Rules and Regulations of the Medical Staff, revised/reapproved 12/13, was reviewed on 1/23/14 at approximately 12:55 PM, and indicated on pg:
A. 6, under section G. Transfer of Patients, "Prior to transferring a patient to another facility or to a community agency, the attending physician shall ensure: 1. Available medical treatment necessary to minimize the risks to the patient is provided before and during transfer. 2. The receiving facility...has agreed to accept the transfer. 3. Copies of all medical records available at the time of transfer are sent to the receiving facility. 4. With respect to unstable patients, the attending physician shall also ensure that the patient is only transferred after either the patient requests transfer in writing after being informed of the risks and benefits of the transfer or a certification of transfer is completed verifying the medical necessity of the transfer and that the medical benefits of treatment at the facility outweigh the risks of transfer..."
B. 7, under section I. Medical Records, "1. The attending physician shall be held responsible for the preparation of a complete and legible medical record for each individual evaluated or treated as an inpatient, patient which accurately reflects the patient's condition and care.

5. Policy No.: II.C.4, titled "Critical Test Results", revised/reapproved 1/2014, was reviewed on 1/22/14 at approximately 9:10 AM, and indicated on pg. 1 under:
A. Policy section, "to provide a mechanism for expedient reporting of critical values to designated care providers in order to ensure timely and appropriate patient treatment interventions."
B. Definitions section, under Critical Values, "Critical Values are laboratory results with the following attributes...they have the potential for serious adverse consequences if not dealt with promptly; they require an appropriate action..."
C. Procedures section, points B, D, and E, "The Nurse will complete the Critical Values Report form and document on the log sheet designated for tracking of 'Critical Value' data...Notification: Name of Physician and Time Notified...Action ordered and Taken; Check 'Yes' to confirm completion of documentation on the critical values report form; initial log, with identification of initials/signature at bottom of page...The following laboratory values are defined as critical in this facility...Sodium < or = 120 mEq/L to > or = 160 mEq/L." This policy applies to patient N1 because of the date of their critical lab value and the revised date of this policy.

6. Policy No.: II.C.4, titled "Critical Test Results", revised/reapproved 7/2012, was reviewed on 1/22/14 at approximately 9:10 AM, and indicated on pg. 1 under:
A. Policy section, "A. The responsible physician will be notified within 15 minutes of receipt of critical laboratory and diagnostic radiologic test results...F. The following laboratory values are defined as critical in this facility...Glucose < or = 50mg/dL to > or = 600mg/dL...Sodium < or = 120 mEq/L to > or = 160 mEq/L." This policy applies to patients N3 and N4 because of the dates of their critical lab values and the revised date of this policy.

7. Policy No.: C.65, titled "Standardized Medication Administration", revised/reapproved 12/13, was reviewed on 1/22/14 at approximately 9:10 AM, and indicated on pg. 1, under Procedure section, point 2.0 and 2.3, "Definitions: When used within medication orders...'Now' means 'within one (1) hour'." Policy No.: II - A.11, titled "Nutritional Screening", revised/reapproved 12/11, was reviewed on 1/22/14 at approximately 9:10 AM, and indicated under Procedure section, point 3., "When the need to consult the contracted Registered Dietitian arises, she will be contacted by phone and/or written communication is placed in the Dietary mailbox. The contracted dietitian will perform an assessment within 72 hours or as the patient's need warrants."

Based on policy and procedure review, medical record review and personnel interview, the nursing executive failed to ensure the documentation of follow-up of medications given on the MAR (Medication Administration Record) for 1 of 1 (N6) open patient medical records reviewed.

Findings:

1. Policy No.: II - F.20, titled "Medication Administration Record Documentation", revised/reapproved 12/11, was reviewed on 1/22/14 at approximately 9:10 AM, and indicated under Policy section, "to ensure complete and accurate records of medication administration, Nursing Services and Pharmacy Services will maintain a daily medication administration record (MAR) for inpatients."

2. Review of open patient medical records on 1/22/14 at approximately 10:00 AM, indicated Patient:

A. N6 was a 76-year-old admitted to the facility on 1/16/14 for dementia with behaviors. Documentation in the medical record included:
a. per Restraint & Seclusion Packet dated 1/16/14, on pg:
i. 1, Geodon 10mg IM (intramuscularly) and Ativan 1mg IM were given at 2220 and "medication follow-up and patient education must be noted on MAR (Medication Administration Record)"; there was no follow-up documented on the MAR.
ii. 1/20/14, on pg. 1, IM injection to right thigh (no medication name documented) and "medication follow-up and patient education must be noted on MAR (Medication Administration Record)"; there was no follow-up documented on the MAR.
b. still admitted to facility at time of survey.

3. Personnel P10 was interviewed on 1/21/14 at approximately 3:59 PM and on 1/22/14 at approximately 11:00 AM and confirmed, on the Restraint & Seclusion Packet for patient N6 dated 1/16/14 on pg. 1, medication follow-up was not documented on the MAR as required and stated needs to be completed on this form.

Based on document review and staff interview, the facility failed to maintain, or have available, an accurate radiologic services agreement to meet the needs of the patients.

Findings:

1. On January 21, 2014 at 2:45pm, review of the document titled "Radiology Services Agreement" indicated "the Agreement is made this 1st day of February 2012...".

2. On January 21, 2014 at 2:45pm, further review of the document titled "Radiology Services Agreement" also indicated "...the term of this Agreement shall commence on February 1, 2014...".

3. Upon interview on January 21, 2014 at 3pm, Employee #4 indicated "this must be a typo".

4. On January 22, 2014 at 10:30am, review of the document titled "Doctors Neuropsychiatric Hospital Contracts" indicated no contract for Radiology Services.

Based on observation, record review and interview, the facility failed to ensure 1 of 1 fire door sets was arranged to automatically close and latch (see K 044), failed to document testing of emergency lighting for 3 of 3 battery operated emergency lights (see K 046), failed to conduct fire drills at unexpected times under varying conditions in 4 of 4 second shift fire drills (see K 050), failed to ensure 1 of 1 sprinkler systems was continuously maintained in reliable operating condition and inspected and tested periodically (see K 062) and failed to ensure 2 of 2 flexible cords were not used as a substitute for fixed wiring to provide power for equipment with a high current draw (see K 147).

Findings:

1. During a tour of the facility with DPO1 on 01/21/14 at 3:20 p.m., the fire door set near the Psychiatrist office was tested three times. One door in the fire door set failed to latch each time the doors were released to close.

2. In interview at the time of observation, DPO1 acknowledged the doors should latch and needed adjustment.

3. Review of "Emergency Lights - 2013" documentation with DPO1 during record review at 2:55 p.m. on 01/21/14 indicated functional testing of the three battery operated emergency lights in the facility was evidenced by a check mark for each month on 2013.

4. In interview at the time of record review, DPO1 acknowledged the battery operated emergency lights documentation did not specify the duration of the monthly test or document the annual 90 minute test.

5. Observations with DPO1 during a tour of the facility from 3:00 p.m. to 4:00 p.m. on 01/21/14 indicated the three battery operated emergency lights observed in the facility were functional.

6. Review of "Fire Drill Report" documentation with DPO1 on 01/21/14 during paperwork review from 1:15 a.m. to 3:00 p.m. indicated four second shift fire drills were conducted between 4:30 p.m. and 5:30 p.m. and near the same date of the month as follows:
a. 02/22/13; 5:00 p.m.
b. 05/25/13; 5:10 p.m.
c. 08/22/13; 4:30 p.m.
d. 11/20/13; 5:00 p.m.

7. In interview during the time of record review, the days and times the second shift fire drills were conducted were acknowledged by the Director of Plant Operations.

8. It was observed with DPO1 from 3:00 p.m. to 4:00 p.m. on 01/21/14 that the sprinkler system located in the sprinkler riser room had two pressure gauges with 06/08 written on the gauges.

9. In interview at the time of observation, DPO1 acknowledged the date written on the gauges was when the gauges were last checked.

10. Observation with DPO1 on 01/21/14 at 3:15 p.m. indicated the psychiatrist's office had a coffee maker plugged into an extension cord which was plugged into a power strip.

11. In interview at the time of observation, the aforementioned condition was acknowledged by DPO1.

Based on observations, interview and document review, the facility failed to:

I. Ensure that psychiatric evaluations were completed by or reviewed by a physician for 6 of 7 active sample patients (2, 9, 12, 14, 16, and 19). Instead, psychiatric evaluations for these patients were completed by advanced practice nurses without documented physician review. This results in the failure to have patient care provided under the direction of a physician. (Refer to B110)

II. Develop and document comprehensive treatment plans based on the individual needs of 7 of 7 sample patients (2, 6, 9, 12, 14, 16 and 19). This failure resulted in absence of specific plans to direct staff in the implementation, evaluation and revision of care based on individual patient findings. (Refer to B118)

III. Assess and treat the medical problems of 1 discharged patient (D6) reviewed for medical care, in order to identify potentially treatable medical etiologies of mental status changes, and identify potential concurrent medical illnesses. Failure to address medical issues and obtain a correct diagnosis and treatment results in a potential risk to patients' lives/health and prevents patients from achieving an optimal level of functioning. (Refer to B125 Part I)

IV. Ensure that active individualized psychiatric care was provided for 2 of 7 active sample patients (16 and 19) based on their specialized treatment needs. These patients functioned at low cognitive and social levels, yet adequate modalities to address their specific problems/needs were not provided. This results in patients being hospitalized without all interventions for recovery being provided in a timely fashion, delaying improvement. (Refer to B125 Part II)

V. Ensure that patients attended programming or received alternative treatment based on individualized treatment needs for 3 of 7 active patients (6, 9 and 14). These patients spent much of their time in bed or sitting idly in front of the television, oftentimes missing assigned programming. This prevented patients from achieving their optimal level of functioning during hospitalization. (Refer to B125 Part III)

VI. Provide structured and/or group treatment based on the individual needs of all patients on this unit, including 7 of 7 active sample patients (2, 6, 9, 12, 14, 16 and 19). This unit served up to 20 patients (20 on the first day of the survey-1/21/14), most with severe cognitive and social skill needs. This failure hindered patient's participation in active treatment and resulted in patients remaining in bed, roaming the wards, sleeping in chairs and idly sitting around on the units. (Refer to B125 Part IV)


VII. Ensure that discharge summaries included an assessment of the condition of patients on the day of discharge, including psychiatric, physical and functional conditions for 6 out of 6 discharged patients (D1, D2, D3, D4, D5, and D6). This results in critical clinical information documenting the patient's level of psychiatric and medical symptoms and risk at the time of discharge not being available to the aftercare providers. (Refer to B135)

Based on record review and interview, the facility failed to provide social work assessments that included a social evaluation of strength/deficits and high risk psychosocial issues, conclusions and recommendations of the anticipated necessary steps for discharge to occur, specific community resources/support systems for utilization in discharge planning, and the anticipated social work role in discharge planning for 7 of 7 sample patients (2, 6, 9, 12, 14, 16, and 19). As a result, the treatment team did not have necessary social information and evaluation of social functioning level to utilize in developing treatment goals and interventions.

Findings include:

A. Record Review

1. Patient 2

The social work assessment for Patient 2 dated 1/15/14 stated the "Discussion/Case Formulation" was "[age/sex] admitted for inpatient treatment due to exacerbated depression with possible suicidal ideation. No formal psychiatric/psychological treatment. Recently widowed after 44 yrs. (years) of marriage. Clear cognitive deficits noted. Psychology to follow-up with cognitive eval (evaluation), psychological services." This psychosocial assessment did not contain sufficient social information and evaluation of social functioning level to utilize in developing an effective and meaningful treatment plan.

2. Patient 6

The social work assessment for Patient 6 dated 1/15/14 stated the "Discussion/Case Formulation" was "[age] year-old [fe/male] with long history of major depression, previous suicide attempt - 15 years ago. Patient also has significant family (daughter is schizophrenic) and medical stressors. Patient would benefit from on-going psychological services." This psychosocial assessment did not contain sufficient social information and evaluation of social functioning level to utilize in developing an effective and meaningful treatment plan.

3. Patient 9

The social work assessment for Patient 9 dated 1/15/14 stated the "Discussion/Case Formulation" was "Pt has a history of bipolar disorder, most recent depressed. Pt has had increased depression since [his/her] son died and [his/her] skin disease began." This psychosocial assessment did not contain sufficient social information and evaluation of social functioning level to utilize in developing an effective and meaningful treatment plan.

4. Patient 12

The social work assessment for Patient 12 dated 1/21/14 stated the "Discussion/Case Formulation" was "Pt (patient) is a [age] year old Caucasian [fe/male] [with] a history of bipolar disorder. Pt reported a history of feeling depressed and anxiety. Reported periods of time [with] decreased need for sleep & elevated mood. Pt reported cognitive/memory changes and hx (history) of substance abuse." This psychosocial assessment did not contain sufficient social information and evaluation of social functioning level to utilize in developing an effective and meaningful treatment plan.

5. Patient 14

The social work assessment for Patient 14 dated 1/20/14 stated the "Discussion/Case Formulation" was "[age] year-old [fe/male] admitted for inpatient psychiatric treatment [secondary] to dangerous ideation. Patient has no formal psych (psychiatric) treatment history but history of anxiety & depression. Recent decompensation of mood with increased depression, anxiety and agitation. Pt was threatening staff and to harm [him/herself]." This psychosocial assessment did not contain sufficient social information and evaluation of social functioning level to utilize in developing an effective and meaningful treatment plan.

6. Patient 16

The social work assessment for Patient 16 dated 1/20/14 stated the "Discussion/Case Formulation" was "[age] y.o. (year old) [fe/male] who has been residing at SNF (skilled nursing facility) since Sept (September) 2012. Pt. (patient) has at least 3 year history of progressive cognitive decline as well as history of depression. Pt. was on hospice recently, but evidenced an acute mental status change with [increased] agitation, yelling out." This psychosocial assessment did not contain sufficient social information and evaluation of social functioning level to utilize in developing an effective and meaningful treatment plan.

7. Patient 19

The social work assessment for Patient 19 dated 1/14/14 stated the "Discussion/Case Formulation" was "[age] year-old [fe/male] with a 10 year history of dementia by spouse report. No formal psychiatric/psychological treatment history. Patient sustained recent fall and [right] shoulder fx (fracture) at home. Patient would benefit from on-going psychological services/monitoring." This psychosocial assessment did not contain sufficient social information and evaluation of social functioning level to utilize in developing an effective and meaningful treatment plan.

B. Interview

During an interview with the Medical Director on 1/22/14 at 3:40 p.m., he acknowledged that the psychosocial assessments for these patients did not contain an evaluation and impression of the current baseline social functioning (strengths and deficits) of patients from which treatment interventions and discharge plans could be formulated.

Based on record review and interviews, the facility failed to ensure that psychiatric evaluations were completed by or reviewed by a physician for 6 of 7 active sample patients (2, 9, 12, 14, 16, and 19). Instead, psychiatric evaluations for these patients were completed by an advanced practice nurse without documented physician review. This results in the failure to have patient care provided under the direction of a physician.

Findings include:

A. Record Review

The Psychiatric Evaluations (dates in parentheses) for the following patients were completed by advanced practice nurses without documented physician review: Patient 2 (1/16/14), Patient 9 (12/26/13), Patient 12 (1/21/14), Patient 14 (1/18/14), Patient 16 (1/17/14), and Patient 19 (1/14/14).

B. Staff Interview

1. During an interview on 1/23/14 at 12:15 p.m. with MD1, attending psychiatrist for the ward, he stated that he did not directly supervise the advance practice nurses completing the psychiatric evaluations and the collaborative contract with the advance practice nurses was with the Medical Director who was not a psychiatrist. He stated there was no hospital policy for reviewing the psychiatric evaluations and that he countersigned the evaluations "the next time I'm in."

2. During an interview on 1/23/14 at 12:05 p.m., the Quality Management Director stated that the facility did not have a policy on physician review of psychiatric evaluations performed by advanced practice nurses. She stated that the requirement was determined by Indiana regulations which required the supervising physician review 5% of the practitioner's work.

3. During an interview with the Medical Director on 1/22/14 at 3:40 p.m., he acknowledged that the psychiatric evaluations for these patients did not contain documentation that there was physician review of these evaluations.

Based on observation, interview and record review it was determined that the facility failed to develop and document comprehensive treatment plans based on the individual needs of 7 of 7 sample patients (2, 6, 9, 12, 14, 16 and 19). This failure resulted in absence of specific plans to direct staff in the implementation, evaluation and revision of care based on individual patient findings.

Findings include:

A. Review of treatment plans revealed that the master treatment plans were preprinted forms that included 2 sections for problem identification, "Psychology and Social Services" and "Primary Care and Nursing Services." Each list of possible problems was followed by check lists to identify chosen long term goals, short-term goals and interventions. These lists identified several symptoms/ behaviors/diagnoses. Goals and interventions were not correlated with the specific items identified in the problem section of the plan. The majority of the goals were non-measurable and all interventions were modality structures, tests to be performed or staff role functions without individualization based on patient findings. There was no section in the format to identify the staff member responsible for the chosen intervention(s); therefore, the interventions were not assigned to a specific staff member. There were a nominal number of additions or changes to the plans based on individual patient findings. This practice resulted in all plans being almost the same with no individualization.

B. Interviews:

1.During an interview on 1/22/14 at 10:00 a.m. with the ward treatment team including the Medical Director (also the supervising medical provider and treatment team leader), MD1 (attending psychiatrist), NP1, RN3, SW1, Psychologist 1, and Psychologist 2, they described the treatment planning process as follows: Nursing staff develop initial care plans at the time of admission. Within 72 hours, the team social worker and/or psychologist, defines the problem based on referral information in the chart. The goals and interventions are added by the team members individually. Medical problems and interventions were addressed by nursing staff only. Observations made at this treatment team meeting revealed that the treatment plans were not developed during the team meetings.
During this meeting with the ward treatment team, MD1 stated "we haven't figured this [treatment plans] out yet." The Medical Director stated that the treatment plans were "a work in progress." When asked if the treatment plans were useful in the treatment of patients, no one responded that they were useful.

failed to:

I. Assess and treat the medical problems of 1 discharged patient (D6) reviewed for medical care, in order to identify potentially treatable medical etiologies of mental status changes, and identify potential concurrent medical illnesses. Failure to address medical issues and obtain a correct diagnosis and treatment results in a potential risk to patients' lives/health and prevents patients from achieving an optimal level of functioning.

II. Ensure that active individualized psychiatric care was provided for 2 of 7 active sample patients (16 and 19) based on their specialized treatment needs. These patients functioned at low cognitive and social levels, yet adequate modalities to address their specific problems/needs were not provided. This results in patients being hospitalized without all interventions for recovery being provided in a timely fashion, delaying improvement.

III. Ensure that patients attended programming or received alternative treatment based on individualized treatment needs for 3 of 7 active patients (6, 9 and 14). These patients spent much of their time in bed or sitting idly in front of the television, oftentimes missing assigned programming. This prevented patients from achieving their optimal level of functioning during hospitalization.

IV. Provide structured and/or group treatment based on the individual needs of all patients on this unit, including 7 of 7 active sample patients (2, 6, 9, 12, 14, 16 and 19). This unit served up to 20 patients (20 on the first day of the survey-1/21/14), most with severe cognitive and social skill needs. This failure hindered patient ' s participation in active treatment and resulted in patients remaining in bed, roaming the wards, sleeping in chairs and idly sitting around on the units.

Specific Findings are as follows:

I. Medical Care:

A. Record Review

Patient D6 was admitted 1/3/14 at 10:00 a.m.

The "Pre-Admission Assessment" dated 1/3/14 indicated that Patient D6 was referred for admission with confusion and psychosis with an unsteady gait and incontinence. The "Pre-Admission Assessment" stated the following: "Patient is currently w/ (with) altered mental status and active delusions....[S/he] is currently confused and making no sense. [S/h]e is unsteay (sic) on his feet...[S/he] is typically contient (sic) but due to his confusion is incontinent at this time...Interdisciplinary Needs" included "Nutritional Eval (evaluation)." This assessment did not identify any specific medical diagnoses or issues requiring further assessment or treatment.

The "Psychiatric Evaluation" dated 1/3/14 stated that Patient D6 was "currently lying in bed. The patient is somewhat restless. The patient is disorganized and cannot focus well....His language is mostly preserved but at times the patient would have some expressive aphasia and loose associations." The admission diagnoses included "Axis I: 1. Schizophrenia," "2. Bipolar," "3. Manic with psychotic features," "4. Vascular dementia with behaviors," "Axis II. Mental disorder not otherwise specified secondary to a history of brain injury," and "Axis III. Deferred." This evaluation did not include information about a history of hypernatremia or possible contribution of hypernatremia to the patient's mental status findings.

The "History & Physical Examination" dated 1/3/14 stated the diagnoses included "Hypernatremia [elevated serum sodium]." The "Past Medical History" included "Elevated sodium which is also improving." No information was included in the examination that identified the level of the elevated serum sodium prior to admission, the stated improvement referred to in the examination, or the etiology of the elevated serum sodium.

Admission laboratory studies drawn 1/4/14 at 05:50 a.m. included the following abnormal values: Sodium = 154 mEq/L (miliequivalents/liter) (reference range 134-145 mEq/L), BUN (blood urea nitrogen) = 26 mg/dL (milligrams/deciliter) (reference range 8-23 mg/dL), and chloride = 113 mEq/L (reference range 96-108 mEq/L). No progress note in the medical record referenced these abnormal laboratory studies or documented an immediate plan for assessment and treatment.

The progress note by the advanced practice nurse on 1/4/14 at 10:45 a.m. stated "...Wife reported wt (weight) loss over recent weeks - incontinent now. Not eating drinking [with] significant encouragement...Results still pending - Admitting labs...A (assessment): Encephalomalacia," "Hx Brain tumor excision," "HTN - Stable," and "DM - [Stable]." The plan of treatment was "P (plan): Continue current treatment." This progress note failed to document the patient's hypernatremia, possible contribution to the patient's condition, or an assessment and treatment of the hypernatremia.

The progress note by the advanced practice nurse on 1/5/13 at 10:50 a.m. stated "Per nursing: poor appetite - requires continuous cues....Drinking poorly...A: Encephalomalacia. Bipolar D/O. Schizophrenia." The plan of treatment was "P: Continue current plan. Enc. Encourage po (by mouth) fluid intake. Strict I/O. CBC (complete blood count)/BMP (basic metabolic profile) MWF (Monday-Wednesday-Friday). Prealbumin in AM (morning)." This progress note failed to document the patient's hypernatremia, possible contribution to the patient's condition, or an assessment and treatment of the hypernatremia.

Laboratory studies drawn on 1/6/14 at 07:30 a.m. included the following abnormal values: Sodium = 159 mEq/L, BUN = 43 mg/dL, and chloride = 117 mEq/L. No documentation in the medical record referenced these worsening abnormal laboratory studies or documented an immediate plan for assessment and treatment.

The progress note by the psychiatrist on 1/6/14 at 10:55 a.m. stated "Acted as if eating something...poor appetite...Pt lost 20 lbs (pounds) over a month....possibly sedated." This progress note failed to document the patient's hypernatremia, possible contribution to the patient's condition, or an assessment and treatment of the hypernatremia.

Laboratory studies drawn on1/8/14 at 06:16 a.m. included the following abnormal values: Sodium = 164 mEq/L (designated "critical" value by reference lab), BUN = 43 mg/dL, and chloride = 117 mEq/L. No progress notes referenced these worsening abnormal laboratory studies, critically elevated sodium level, or documented an immediate plan for assessment and treatment.

Neither the "Initial Nursing Treatment Plan" dated 1/3/14 nor Master Treatment Plan dated 1/8/14 identified hypernatremia or dehydration as problems and no interventions were included to address these problems.

The "Patent Care Flow Sheet" documented only 840 milliliters in addition to "sips" of fluid and an estimated total of one meal was consumed by Patient D6 from 1/3/14 to 1/8/14. This flow sheet documented that Patient D6 lost 7.2 pounds from151.6 to 144.4 pounds from 1/4/14 to 1/8/14. No progress notes referenced the lack of intake or significant weight loss or documented an immediate plan for assessment and treatment.

The progress note by the psychiatrist on 1/8/14 at 10:00 a.m. stated "possible cascading stroke. New dysphagia....Dehydration...Conference call [with] [spouse]. [S/he] wants [him/her] in nearby Michigan hospitals." The note contained no documentation of the abnormal laboratory studies, assessment of the results, or planned interventions.

The "Physician Orders" by the medical provider on 1/8/14 at 10:40 a.m. stated "IV D5 1/2NS - give 500 ml bolus now and then 100 ml/hour," "CBC, CMP today," and "daily BMP." The "IV Solution Flow Sheet" indicated that the 10:40 a.m. order for the bolus was not given until six hours later at 4:40 p.m. and the intravenous flow was not started until 5:00 p.m.

The progress note by the advanced practice nurse on 1/8/14 at 10:25 a.m. stated "Per nursing - having trouble swallowing - ST (speech therapy) eval pending. This is new - RC for multiple medical & neurocognitive issues....0600 Blood sugar 161. Alert but lethargic... Assessment New - dysphagia - ? acute CVA. Hypernatremia. Acute dehydration [elevated] BUN, [elevated] chloride, Hyperglycemia - need monitoring." The note contained no documentation of the abnormal laboratory studies, assessment of the results, or planned interventions other than "need monitoring."

The nursing progress note on 1/8/14 at 8:00 p.m. stated "lungs wet [with] audible gurgles." The "Patient Transfer Assessment" completed by nursing staff on 1/8/14 (no time) indicated that "breath sounds" were "diminished."

Patient D6 was discharged for transfer to another facility on 1/8/14 at 8:50 p.m. at the request of the family. Although Patient D6 was assessed to require a higher level of medical care for a possible cerebral vascular accident and was noted to have abnormal respiratory findings by nursing staff, there was no documented assessment of Patient D6's condition by a medical provider for over 8 hours prior to transfer.

In the course of the transportation to another facility, Patient D6 reportedly stopped breathing and was taken to the closest hospital emergency department.

Patient D6 remained hospitalized for five days without documented assessment or interventions for increasingly elevated serum sodium, reduced oral intake, weight loss, and possible dehydration. When necessary treatment for dehydration was ordered, execution of the order was delayed for six hours. There was no documented assessment by a medical provider of Patient D6's deteriorating medical condition for over 8 hours prior to transfer despite critical laboratory values and respiratory findings by nursing staff. The transfer was executed in a non-emergency manner requiring the transportation ambulance to divert to the closest hospital with emergency care capacity.

B. Staff Interviews

During an interview with the Medical Director and MD1, the attending psychiatrist for the ward, on 1/22/14 at 1:40 p.m., the hospitalization of Patient D6 was reviewed. The Medical Director described Patient D6 as "behaviorally unstable." He stated that Patient D6 had "chronic hypernatremia" based on the report from the family. He stated that intravenous fluids were considered but acknowledged that consideration of this treatment was not documented in the medical record. He stated that the patient's medical status was managed "behaviorally and psychiatrically" and that intravenous fluids were not given because the patient was agitated and they did not want to "sedate" or "restrain" the patient to provide intravenous fluids. He stated the facility "would not do restraints" to administer intravenous fluids. MD1 stated that dehydration was a condition many of the patients experienced and that "this is something [patients not eating and drinking] we deal with all the time...we are used to handling this [patients not eating and drinking]." He stated that "most of the time" the patients responded to encouragement and medications. MD1 stated that the reason for the transfer of Patient D6 to another facility was "we thought [s/he] was stroking (having a cerebrovascular accident)." The Medical Director stated that Patient D6 was not a candidate for immediate treatment of a cerebrovascular accident. The Medical Director stated that during the last 36 hours of hospitalization " we probably should have intervened [to treat his medical conditions]." The Medical Director acknowledged that no documentation was available in the medical record to indicate that Patient D6 was evaluated by a medical provider during the final 8 hours of hospitalization. He stated "documentation has been a concern." The Medical Director acknowledged that there was no documentation that a medical provider had reviewed and assessed the lack of oral intake or output by Patient D6 during this hospitalization. The Medical Director stated that he was not aware of the six hour delay in beginning intravenous therapy after the order was written on 1/8/14.

The Medical Director stated that the patient was hospitalized at the outside hospital in the intensive care unit and "appeared to have a stroke."

II. Treatment based on cognitive and social levels:

A. Patient 16 was a 94 year old patient admitted on 1/17/14 with a diagnosis of Vascular Dementia with psychotic features.

1. As documented in the psychiatric evaluation (1/17/14) this patient was admitted to the hospital due to "The patient has been screaming for months, but it got worse to the point where it appears that the nursing home insisted the patient receive hospitalization."

2. During an observation of the scheduled "Exercise" time on 1/21/14 from 11:40 a.m. to 12:00 noon and at 2:00 p.m. during the scheduled "Arts and Crafts" activity, Patient 16 was observed sleeping in his/her bedroom, separate from other patients. No staff were observed interacting with Patient 16 during this time period.

3. Observations of the ward day room on 1/21/14 at 2:00 p.m. and on 1/22/14 at 9:50 a.m. revealed Patient 16 to be "screaming out" at intervals. Content of her screaming was not based on events occurring in the day Froom. At intervals s/he hollered, "I want to go home." During each of these intervals s/he was sitting alone; staff intervention nor alternative treatment was observed nor documented.

4. During an interview with Patient 16 on 1/21/14 at 3:15 p.m., s/he appeared disoriented. She was unable to identify the place or the year. She appeared angry and unwilling to engage in an interview, with other patients, or with activities on the ward.

5. During attempted interview on 1/22/14 at 9:50 a.m., Patient 19 was sitting in a chair in the day room, staring without focus and was unable to give any response to questions.

6. During an interview with MD1, attending psychiatrist for the ward, on 1/23/14 at 12:15 p.m., he stated that the hospital was "unique. We consider ourselves a psych-neuro-medical unit. Most don't have pre-existing psychiatric disorders. They have dementia...most times medical problems cause behavior problems."

7. Review of the master treatment plan (1/20/14) revealed a list of general modalities for the treatment of Patient 16. These were stated as "Supportive Therapy," "Group Therapy," "Medication Management," "Structured Activities," and "Coordination of Care." There were no specific interventions for this patient's specialized needs documented in his/her treatment plan.

B. Patient 19 was an 83-year old patient admitted on 1/13/14 with a diagnoses of Dementia and Alzheimer's disease.

1. As documented in the psychiatric evaluation (1/14/14), Patient 19 was admitted due to "becoming more withdrawn and less functional in doing things for (her/his self)." S/he was "screaming out constantly, 'Help! Help!..."

2. During a group (titled exercise) held in the patient day room on 1/21/14 at 11:40 a.m., conducted for all patients, including Patient 19, observation revealed that s/he was sitting in front of the day room television in a reclining chair. During observations at this time, there was no evidence that staff attempted to involve patient in the activity, nor was alternative treatment attempted. During a brief interview of the patient at this time, s/he did attempt to respond to direct questions, but unable to cognitively carrying on a conversation with the interviewer.

3. During an observation of the scheduled "Education/Life Skills" group on 1/21/14 from 3:00 p.m. to 3:30 p.m., 16 patients were observed in the day room sitting at 5 tables, including Patient 19 who was sitting in a reclining chair in front of the television. Two patients were observed folding towels. The other patients were observed not engaged in any activity or watching television. No staff were observed interacting with these patients during this period. During an interview with non-sample Patient 20 at 3:25 p.m., when asked why s/he was folding towels, s/he stated "it's better than just sitting here and doing nothing."

4. Review of Patient 14's "Daily Group Log" for 1/-16/14 through 1/22/14 revealed that s/he has refused to attend 20 of 30 groups/activities offered. During telephone interview on 1/22/14 at 11:30 a.m., when asked what "present and participated" means on the daily group logs, AT8 reported that meant that present meant that "patient was in the day room where the activity/group was being held" and participated meant that patient "made eye contact or smiled."

5. Review of the master treatment plan (1/15/14) revealed a list of general modalities for the treatment of Patient 19. These were stated as "Medication Management," "Coordination of Care," Disease Process Education," "Psychoactive education initiation and/or adjustment," "Mental Status/Neuropsychiatric assessment," "Discharge planning and appropriate care plan initiated on date of admission" and "Monitor vitals q [every] shift it as (sic) needed." There were no specific interventions for this patient's specialized needs documented in his/her treatment plan.

III. Failure to ensure that patients attended scheduled treatment groups/activities or received alternative treatment based on individualized needs:

A. Patient 6 was a 52 year old patient admitted on 1/15/14 with a diagnosis of Major Depressive Disorder, recurrent with suicidal ideation.

1. According to the psychiatric evaluation (1/16/14), Patient 6 was "admitted due to having suicidal ideations of driving (his/her) car into a tree or wall. The patient has intractable migraines with pain."

2. Observations on 1/21/14 at 2:15 p.m. revealed Patient 6 lying in bed in his/her room during the assigned treatment program (Psychosocial/music). The patient stated that s/he has a migraine.

3. Observations on 1/22/14 at 9:50 a.m. revealed Patient 6 asleep in bed.
When asked if s/he had attended the Psychosocial group led by psychology this morning, s/he replied, "No, I have a migraine." S/he stated that no one reminder him/her about the group that morning.

4. Review of Patient 6's "Daily Group Log" for 1/21-22/14 (only sheets provided for staff as proof of treatment since admission on 1/15/14) revealed that s/he has refused to attend 6 of 12 groups/activities offered.

5. Review of the master treatment plan (1/16/14) revealed a list of general modalities for the treatment of Patient 6. These were stated as "Supportive Therapy," "Group Therapy," Medication Management," "Coordination of Care" and "Structured Activities." Even though this patient was admitted with suicide ideation and refused much of his/her assigned treatment activities, there were no specific interventions for this patient's specialized needs documented in the treatment plan.

6. During discussion of this patient's treatment at the treatment team conference on 1/22/14 at 10:00 a.m., the team members stated that this patient's treatment plan should include specific treatment based on his/her treatment needs. The medical director stated, "[His/her] behaviors may be learned behavior (rather than a result of migraines)."

B. Patient 9 was a 62 year old patient admitted on 12/23/13 with a diagnosis of recurrent major depression and Pain syndrome due to general medical condition with psychological factors.

1. According to the psychiatric evaluation (12/16/13), Patient 9 was admitted for "very severe depression."

2. Observations (1/21/14 at 11:30 a.m., 1/21/14 at 3:45 p.m., 1/22/14 at 9:50 a.m.) revealed Patient 9 to be lying in bed, at times asleep. This patient's entire body is covered with open wounds that were seeping fluids due to psoriasis. During interview on 1/21/14 at 11:30 a.m., s/he reported constant discomfort and pain.

3. Review of Patient 9's "Daily Group Log" for 1/-16/14 through 1/22/14 revealed that s/he has refused to attend 25 of 30 groups/activities offered. According to documentation in the medical record and telephone interview (Psychologist 2 on 1/23/14 at 11:55 a.m.) the only alternative treatment provided for Patient 9 is individual therapy 15-30 minutes daily when the agrees to meet.

4. Review of the master treatment plan (12/30/13) revealed a list of general modalities for the treatment of Patient 9. These were stated as "Supportive Therapy," "Group Therapy," "Medication Management," "Coordination of Care" and "Structured Activities." Even though this patient was admitted with suicide ideation and refused much of his/her assigned treatment activities, there were no specific interventions for this patient's specialized needs documented in the treatment plan.

5. During discussion of this patient's treatment at the treatment team conference on 1/22/14 at 10:00 a.m., the team members stated that this patient's treatment plan should include specific treatment based on his/her treatment needs.

C. Patient 14 was a 60 year old patient admitted on 1/17/14 with the diagnosis of Major Depression with suicidal ideation.

1. During an observation of the scheduled "Exercise" time on 1/21/14 from 11:40 a.m. to 12:00 noon, Patient 14 was observed reclining in a geri-chair, watching television, separate from other patients. No staff were observed interacting with Patient 14 during this time period. During an interview with Patient 14 at 11:50 a.m., Patient 14 stated that s/he had "been in bed until today. They made me get up today."

2. During ward rounds on 1/21/14 at 1:50 p.m., Patient 14 was observed reclining in a geri-chair, watching television, separate from other patients even though an activity (Psychosocial /Music) was scheduled at this time period for all patients. At this time, Patient 14 complained about having to stay in the reclining chair for such long periods of time, stating, "It makes my hip sore."

3. Observations on 1/22/14 at 9:55 a.m. revealed Patient 14 to be lying in bed. S/he reported that s/he had not been out of bed today. When asked if s/he had attended the Psychosocial session conducted for all patients this morning at 8:30 a.m., s/he replied "No. I don't usually attend that."

4. During telephone interview on 1/23/14 at 11:45 a.m., the DON stated that Patient 14 has refused to attend activities. She added, "(S/he) has a social dysfunction."

5. Review of the master treatment plan (1/20/14) revealed a list of general modalities for the treatment of Patient 14. These were stated as "Supportive Therapy," "Group Therapy," Medication Management," "Personal History," "Cognitive Rehabilitation," "Coordination of Care," "Disease Process Education" and "Structured Activities." Even though this patient was admitted with suicide ideation and refused most of his/her assigned treatment activities, there were no specific interventions for this patient's specialized needs documented in the treatment plan.

6. During discussion of this patient's treatment at the treatment team conference on 1/22/14 at 10:00 a.m., the team members stated that this patient's treatment plan should include specific treatment based on his/her treatment needs.

IV. Structured individual and/or group therapies:

A. Observations of the unit on 1/21/14 and 1/22/14 revealed that all 20 hospitalized patients presented specialized treatment needs. All patients functioned at low cognitive and social levels, interfering with their placement in a less restrictive setting, yet adequate modalities to address the problems were not provided. This practice affected all patients in this unit, including 7 of 7 active sample patients (2, 6, 9, 12, 14, 16 and 19).

1. Observations of the activities offered and a review of the "Tentative Group Schedule" for the unit revealed that the programming was designed for a general psychiatric population rather than for patients with significant cognitive impairment. The patients admitted to these wards required more specialized treatment including activities to improve cognitive functioning and a structured treatment environment.

2. Observations of the unit on 1/21/14 and 1/22/14 revealed that most of the groups/activities are conducted in the large day room where patients who are not actively participating are sitting and walking about in the room. Some patients are "hollering out" at intervals and staff are assisting other patients in the immediate area.

3. Review of the Group Schedule revealed that all activities on the Saturday and Sunday schedule are leisure and relaxation oriented. During telephone interview with the DON and AT8 on 1/23/14 at 11:25 a.m. AT8 stated, "The week-end activities are current events and leisure oriented." She added, "Remember our patients have cognitive and social skills needs. It is hard to give individualized treatment." AT8 reported that patients' attendance and participation in the week-end activities is not documented. The DON stated, "The need for more focused treatment based on individual needs has been recognized. We have had discussions about alternative treatment models."

Based on interview and record review, the facility failed to provide a discharge summary for each patient who has been discharged that included a recapitulation of the patient's hospitalization including the circumstances and rationale for admission and a synopsis of accomplishments achieved as reflected through the treatment plan for 6 out of 6 discharged patients (D1, D2, D3, D4, D5, and D6). This deficiency results in a failure to communicate final diagnosis in a timely manner, current medications, course of treatment, summary of relevant labs and testing and discharge plan with providers providing follow-up care.

Findings include:

A. Record Review

1. Patient D1 (date of discharge, 12/11/13) and Patient D3 (date of discharge, 12/11/13): No summary of the hospital course and treatment was included.

2. Patient D2 (date of discharge, 12/11/13): The "Hospital Course" only included a description of the medical issue that arose during the hospitalization. No description of the psychiatric presentation and course of treatment was included.

3. Patient D4 (date of discharge, 12/11/13): The "Hospital Course" stated: "[S/he was not eating, [s/he] was developing fevers. There was some speculation that it might be related to getting Geodon. [S/he] was considered medically unstable and more appropriate to be at our [outside facility name], so [s/he] was transferred there. [His/her] diagnosis for transfer included chronic subdural, anorexia, delirium and fever." There was no other summary of the hospital course and treatment to include psychiatric symptoms and treatment, and patient response.

4. Patient D5 (date of discharge, 12/11/13): The "Hospital Course" stated "The patient was noted to have anemia and there was some debate over whether to actively treat that. It was decided on the 11th to transfer [him/her] to [outside facility name] to receive transfusions as [s/he] had a 6.3 g/dL (gram/deciliter) hemoglobin. To reiterate, there was debate over [him/her] low hemoglobin as it was chronic, in whether to treat it. [S/he] was given EPO (erythropoietin). Behavior however, [s/he] was doing well. [S/he] was eating at one point, over the hospitalization for example, [s/he] had engaged in such extreme behavior as throwing feces. There were some minor issues behaviorally, but nothing significant. So the main reason for the transfer as (sic) medical." There was no summary of the hospital course and treatment to include psychiatric symptoms and treatment, and patient response.

5. Patient D6 (date of discharge, 1/8/14): The "Hospital Course" stated the following: "The patient leading up to and around the day of discharge started showing what appeared to be cascading microvascular events. [S/he] appeared to be dehydrated. We were going to move [him/her] to our [facility name], but [his/her] [spouse] wanted [him/her] transferred to a general hospital in Michigan closer than our [facility name] Long-Term Care Facility. [S/he] was discharged to hospital; I believe it was [facility name] in Niles."

B. Staff Interview

During an interview with the Medical Director on 1/22/14 at 3:40 p.m., he acknowledged that the discharge summaries for these patients did not a recapitulation of the patient's hospitalization including the circumstances and rationale for admission and a synopsis of accomplishments achieved as reflected through the treatment plan.

Based on interview and record review, the facility failed to provide a discharge summary for each patient who has been discharged that included recommendations from appropriate services concerning follow-up or aftercare for 3 out of 6 discharged patients (D1, D3, and D5). The lack of aftercare information compromises efforts to assure appropriate and timely follow-up care for patients.

Findings include:

A. Record Review

For the following discharge summaries (dates of discharge in parentheses), contained no recommendations for appropriate services concerning psychiatric follow-up or aftercare following discharge: Patient D1 (date of discharge, 12/11/13), Patient D3 (date of discharge, 12/11/13), and Patient D5 (date of discharge, 12/11/13).

B. Staff Interview

During an interview with the Medical Director on 1/22/14 at 3:40 p.m., he acknowledged that these discharge summaries did not include recommendations from appropriate services concerning follow-up or aftercare.

Based on interview and record review, the facility failed to provide an assessment of the condition of patients on the day of discharge, including psychiatric, physical and functional conditions for 6 out of 6 discharged patients (D1, D2, D3, D4, D5, and D6). This results in critical clinical information documenting the patient's level of psychiatric and medical symptoms and risk at the time of discharge not being available to the aftercare providers.

Findings include:

A. Record Review

For the following discharge summaries (dates of discharge in parentheses), contained no assessment of the condition of the patient on the day of discharge, including physical and functional conditions: Patient D1 (date of discharge, 12/11/13), Patient D2 (date of discharge, 12/11/13), Patient D3 (date of discharge, 12/11/13), Patient D4 (date of discharge, 12/11/13), Patient D5 (date of discharge, 12/11/13), and Patient D6 (date of discharge, 1/8/14).


B. Staff Interview

During an interview with the Medical Director on 1/22/14 at 3:40 p.m., he acknowledged that these discharge summaries did not include an assessment of the condition of patients on the day of discharge, including psychiatric, physical, and functional conditions.

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

I. Assure that the Medical Director met the training and experience requirements for examination by the American Board of Psychiatry and Neurology, or the American Osteopathic Board of Neurology and Psychiatry. (Refer to B143)

II. Provide a Director of Social Work to monitor and evaluate the appropriateness of social services, to provide social work assessments that included an evaluation of current baseline social functioning (strengths and deficits) of the patient from which treatment interventions and discharge plans could be formulated, and to ensure the development of Master Treatment Plans that identified social work interventions to address the specific treatment needs. (Refer to B152)

III. Assure that the Medical Director and the Director of Nursing monitored active treatment and took needed corrective actions. Specifically,

A. The Medical Director failed to:

1. Ensure that psychiatric evaluations were completed by or reviewed by a physician for 6 of 8 active sample patients (2, 9, 12, 14, 16, and Patient 19). Instead, psychiatric evaluations for these patients were completed by advanced practice nurses without documented physician review. This results in the failure to have patient care provided under the direction of a physician. (Refer to B144)

2. Develop and document comprehensive treatment plans to include physician interventions based on the individual needs of 7 of 7 sample patients (2, 6, 9, 12, 14, 16 and 19). This failure resulted in absence of specific plans to direct staff in the implementation, evaluation and revision of care based on individual patient findings. (Refer to B144)

3. Assure that medical staff assessed and treated the medical problems of 1 discharged patient (D6) reviewed for medical care, in order to identify potentially treatable medical etiologies of mental status changes, and identify potential concurrent medical illnesses. Failure to address medical issues and obtain a correct diagnosis and treatment results in a potential risk to patients' lives/health and prevents patients from achieving an optimal level of functioning. (Refer to B144)

4. Ensure that active individualized psychiatric care was provided for 2 of 7 active sample patients (16 and 19) based on their specialized treatment needs. These patients functioned at low cognitive and social levels, yet adequate modalities to address their specific problems/needs were not provided. This results in patients being hospitalized without all interventions for recovery being provided in a timely fashion, delaying improvement. (Refer to B144)

5. Ensure that patients attended programming or received alternative treatment based on individualized treatment needs for 3 of 7 active patients (6, 9 and 14). These patients spent much of their time in bed or sitting idly in front of the television, oftentimes missing assigned programming. This prevented patients from achieving their optimal level of functioning during hospitalization. (Refer to B144)

6. Provide structured and/or group treatment based on the individual needs of all patients on this unit, including 7 of 7 active sample patients (2, 6, 9, 12, 14, 16 and 19). This unit served up to 20 patients (20 on the first day of the survey-1/21/14), most with severe cognitive and social skill needs. This failure hindered patient ' s participation in active treatment and resulted in patients remaining in bed, roaming the wards, sleeping in chairs and idly sitting around on the units. (Refer to B144)

7. Ensure that discharge summaries included a recapitulation of the patient's hospitalization including the circumstances and rationale for admission and a synopsis of accomplishments achieved as reflected through the treatment plan recapitulation of the patient's hospitalization including the reasons for admission, treatment achieved during hospitalization, a baseline of the psychiatric, physical and social functioning of the patient at the time of discharge, and evidence of the patient/family response to the treatment interventions, that discharge summaries included recommendations from appropriate services concerning follow-up or aftercare, and that discharge summaries included an assessment of the condition of patients on the day of discharge, including psychiatric, physical and functional conditions. (Refer to B144)


II. The Director of Nursing failed to:


A. Develop and document comprehensive treatment plans that included specific nursing interventions based on the individual 7 of 7 active sample patients (2, 6, 9, 12, 14, 16 and 19). In addition, there were no nursing interventions to address the suicide behaviors presented by 3 of the 7 sample patients (6, 9 and 14). This failure resulted in absence of specific plans to direct nursing personnel in the implementation, evaluation and revision of care based on individual patient findings. (Refer to B148)

II. Ensure that patients attended programming or received alternative treatment based on individualized treatment needs for 3 of 7 active patients (6, 9 and 14). These patients spent much of their time in bed or sitting idly in front of the television, oftentimes missing assigned programming. This prevented patients from achieving their optimal level of functioning during hospitalization. (Refer to B148)

Based on interview and document review, the Medical Director failed to meet the training and experience requirements for examination by the American Board of Psychiatry and Neurology, or the American Osteopathic Board of Neurology and Psychiatry.

Findings include:

A. Document Review

The curriculum vitae for the Clinical Director did not indicate the training or experience requirements for examination by the American Board of Psychiatry and Neurology, or the American Osteopathic Board of Neurology and Psychiatry. The curriculum vitae indicated training and board certification in internal medicine.

B. Staff Interview

During an interview with the Medical Director and MD1, the attending psychiatrist for the ward, on 1/22/14 at 1:40 p.m., the Medical Director stated that he supervised the clinical treatments on the ward provided by the psychiatrist, nursing, and social work staff.

During an interview with the Medical Director on 1/22/14 at 3:40 p.m., he stated that he did not complete training in psychiatry and was board certified in internal medicine.

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

I. Ensure that psychiatric evaluations were completed by or reviewed by a physician for 6 of 8 active sample patients (2, 9, 12, 14, 16, and Patient 19). Instead, psychiatric evaluations for these patients were completed by advanced practice nurses without documented physician review. This results in the failure to have patient care provided under the direction of a physician. (Refer to B110)

II. Develop and document comprehensive treatment plans to include physician interventions based on the individual needs of 7 of 7 sample patients (2, 6, 9, 12, 14, 16 and 19). This failure resulted in absence of specific plans to direct staff in the implementation, evaluation and revision of care based on individual patient findings. (Refer to B118)

III. Assure that medical staff assessed and treated the medical problems of 1 discharged patient (D6) reviewed for medical care, in order to identify potentially treatable medical etiologies of mental status changes, and identify potential concurrent medical illnesses. Failure to address medical issues and obtain a correct diagnosis and treatment results in a potential risk to patients' lives/health and prevents patients from achieving an optimal level of functioning. (Refer to B125 Part I)

IV. Ensure that active individualized psychiatric care was provided for 2 of 7 active sample patients (16 and 19) based on their specialized treatment needs. These patients functioned at low cognitive and social levels, yet adequate modalities to address their specific problems/needs were not provided. This results in patients being hospitalized without all interventions for recovery being provided in a timely fashion, delaying improvement. (Refer to B125 Part II)

V. Ensure that patients attended programming or received alternative treatment based on individualized treatment needs for 3 of 7 active patients (6, 9 and 14). These patients spent much of their time in bed or sitting idly in front of the television, oftentimes missing assigned programming. This prevented patients from achieving their optimal level of functioning during hospitalization. (Refer to B125 Part III)

VI. Provide structured and/or group treatment based on the individual needs of all patients on this unit, including 7 of 7 active sample patients (2, 6, 9, 12, 14, 16 and 19). This unit served up to 20 patients (20 on the first day of the survey-1/21/14), most with severe cognitive and social skill needs. This failure hindered patient ' s participation in active treatment and resulted in patients remaining in bed, roaming the wards, sleeping in chairs and idly sitting around on the units. (Refer to B125 Part IV)

VII. Ensure that discharge summaries included a recapitulation of the patient ' s hospitalization including the circumstances and rationale for admission and a synopsis of accomplishments achieved as reflected through the treatment plan for 6 out of 6 discharged patients (D1, D2, D3, D4, D5, and D6). This deficiency results in a failure to communicate in a timely manner final diagnosis, current medications, course of treatment, summary of relevant labs and testing and discharge plan with providers providing follow-up care. (Refer to B133)

VIII. Ensure that discharge summaries included recommendations from appropriate services concerning follow-up or aftercare for 3 out of 6 discharged patients (D1, D3, and D5). The lack of aftercare information compromises efforts to assure appropriate and timely follow-up care for patients. (Refer to B134)

IX. Ensure that discharge summaries included an assessment of the condition of patients on the day of discharge, including psychiatric, physical and functional conditions for 6 out of 6 discharged patients (D1, D2, D3, D4, D5, and D6). This results in critical clinical information documenting the patient's level of psychiatric and medical symptoms and risk at the time of discharge not being available to the aftercare providers. (Refer to B135)

Findings include:

Staff Interview

During an interview with the Medical Director on 1/22/14 at 3:40 p.m., he stated that he did not have any written documentation of the monitoring as Medical Director of clinical activities in the facility.

Based on observation, interview and document review the Director of Nursing failed to monitor and take corrective action. Specifically the DON failed to:

I. Develop and document comprehensive treatment plans that included specific nursing interventions based on the individual 7 of 7 active sample patients (2, 6, 9, 12, 14, 16 and 19). In addition, there were no nursing interventions to address the suicide behaviors presented by 3 of the 7 sample patients (6, 9 and 14). This failure resulted in absence of specific plans to direct nursing personnel in the implementation, evaluation and revision of care based on individual patient findings. (Refer to B118)

II. Ensure that patients attended programming or received alternative treatment based on individualized treatment needs for 3 of 7 active patients (6, 9 and 14). These patients spent much of their time in bed or sitting idly in front of the television, oftentimes missing assigned programming. This prevented patients from achieving their optimal level of functioning during hospitalization. (Refer to B125 Part III)

Based on record review and interviews, the Director of Social Services failed to:

I. Monitor and evaluate the appropriateness of social services.

The facility did not have a Director of Social Work to monitor and evaluate the appropriateness of social services.

Staff Interviews:

During an interview with the CEO on 1/21/14 at 11:00 a.m., they stated that the facility did not employ a Director of Social Work.

During an interview with the DON on 1/23/14, she stated that she supervised social work services in the hospital.

II. Provide social work assessments that included an evaluation of current baseline social functioning (strengths and deficits) of the patient from which treatment interventions and discharge plans could be formulated for 8 of 8 sample patients (2, 4, 6, 9, 12, 14, 16, and 19). As a result, the treatment team did not have a social functioning level for these patients for establishing treatment goals and interventions. (Refer to B108)

III. Ensure the development of Master Treatment Plans that identified social work interventions to address the specific treatment needs of 7 of 7 active sample patients (2, 4, 6, 9, 12, 14 and 19). The social work interventions were stated as generic role functions. The absence of individualized interventions on master treatment plans potentially hampers the staff's ability to provide individualized care to patients.