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Based on interview and record review the facility failed to formulate advance directives for one (1) of eleven (11) patients. (Patient #6)

Findings Included:
An observation on 1/26/15 at 10:30 a.m. revealed Patient #6 sitting in a group therapy meeting. Patient #6 was observed wearing a purple band on his left wrist.
Patient #6's medical Chart reflected a DNR (Do Not Resuscitate) sticker placed on the outside of the chart. Review of Patient #6's Out of Hospital DNR form dated 9/12/2012 reflected Patient #6's signature.

During an interview on 1/26/16 at 2:10 p.m. Staff #11, RN Charge Nurse stated, "I determined the patient's DNR status based on his Out of Hospital DNR."


Review of the facility provided policy DNR, Withholding of Life Sustaining Treatment (dated 9/1/09) reflected: Nursing responsibility regarding DNR orders.
A. All patients with cardiac or respiratory arrest will have cardiopulmonary resuscitation attempted unless the physician's orders specify "do not resuscitate".
C. The nurse will assure that DNR orders are transcribed and implemented accurately and other staff members are made aware of this DNR order ... Place a DNR Sticker on the Cart Back, and daily nursing notes. A PURPLE DNR armband will be placed on the patient's wrist ....


During an interview on 1/26/16 at 2:20 p.m., in the conference room, Staff #3, RN Chief Nursing Officer confirmed Patient #6 did not have a Physician's DNR order and stated, "Patient #6 should be a full code."

Based on observation and tour of the facility, it was determined that the facility failed to protect patient's privacy.

Findings were:

During a tour of the facility on the afternoon of 01/26/15 the following was observed:
· Patient first and last names were posted on the outside of the patient bedroom door.
· Medical Records in the nurse's station were labeled with the patient's first and last name on the spine of the chart.
Patients first and last name could easily be seen by persons not involved in the care of the patients, such as service persons delivering patient trays and patient's visitors.
Patient Handbook - Patient Rights: "Allegiance Behavioral Health encourages respect for the personal preferences and values of each individual. The Hospital supports the patient's participation in treatment decisions and the patient's open communication with their physician and other health care professionals. The hospital supports policies, procedures, plans and activities that provide a secure environment for patients.
i. Personal privacy and confidentiality of information in accordance with the law to expect that any discussion or consultation involving the care will be conducted privately. The Hospital will assure reasonable visual and auditory privacy.

This deficit was acknowledged by the Chief Nurse Officer (CNO). The patient names were removed from the bedroom door by the CNO on the afternoon of 01/26/2015.

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Based on observation and interview, it was determined that the facility failed to provide care in a safe and sanitary environment for its staff and patients.

Findings included:

"OSHA/Blood Borne Pathogen Regulations Policy #138-030-060" stated in part "The facility provides sufficient housekeeping and maintenance personnel to maintain the interior and exterior of the facility in a safe, clean, orderly, and attractive manner."

Hospital policy titled "Environmental Services Rest Room Cleaning 815" stated in part, "daily cleaning schedule:
1. Empty all trash receptacles. Wipe inside/outside with germicidal detergent cleaning solution on a clean cloth ...
3. Dip a clean cloth or sponge in a diluted germicidal detergent solution and clean all of the following:
a. sinks and fixtures
b. shower stall surfaces, faucets, spray-heads, doors and doorknobs or handles.
c. Any spots or smudges on walls. All light switches.
d. Stubborn stains may require a solvent-based detergent for removal."

Tour of the hospital on 01/26/16 revealed the following:
· Several tears in the carpet in the seclusion room
· Vent cover missing in hallway
· Holes in wall of main hallway
· Thick layers of dust on several ceiling tiles and vents in main hallway
· Wall between 429 and 431 chipping and flaking off
· In room 421 sink laminate peeling with sharp edges
· In room 422B dark brown/black stain in bathroom shower stall floor caulking and rust on door frame
· In room 423 caulking around counter missing
· In shower room: dirty linens on the floor and shower stall floor dirty
· In dining room cracked laminate on countertop by hand sink
In an interview with the Chief Nursing Officer on 01/26/16, the above deficits were acknowledged.

Based on observation, interview and record review the facility Nursing Services failed to provide care in an organized manner when:

A. The facility nurse staff did not complete physician's orders and did not reconcile a patient's medication list. (Patient #10);

B. The facility nurse staff did not inform Patient#6's primary physician or receive orders for wound treatment following a skin tear and the facility nurse did not document the wound or the treatment in Patient #6's clinical record; and

C. The facility nurse staff placed Patient#6 on a Do Not Resuscitate (DNR) status without a Physician's Order.

Findings Include:

A. Review of Patient #10's Routine Orders reflected 7. Lab: UA (Urinalysis test) w/micro (if unable to obtain specimen via clean catch, may obtain via in and out catheterization)
Review of Patient #10's History and Physical Exam, dated 10/1/15, reflected an 85 year old female admitted on 9/30/15 with a Chief Complaint: Increased Confusion. Labs/ EKG/X-Ray reflected: Pending UA.


Review of Patient#10's Emergency Room Admission on 9/30/15 at 3:39 p.m. reflected Ciprofloxacin HCL (CIPRO)(An Antibiotic) 500mg(milligram) tablet PO (by mouth) twice daily. Issued on 9/30/15.
Review of the facility provided Meds brought from Home list (signed and dated 10-5/15): reflected CIPRO 500 MG 1 PO x 5 days- UTI (urinary tract infection)?
Review of the Patient #10's Medication Administration (Treatment) Sheet dated 9/30/15 and 10/1/2015 did not reflect the administration of the CIPRO or the order to obtain a UA.

Review of the facility provided Customer Complaint Record dated 10/5/15 reflected Patient #10's daughter reported Patient #10 should be on CIPRO.

During an interview on 1/26/16, in the afternoon in the conference room, Staff #3 confirmed the UA was not completed as the physician had ordered and Staff #3 was not sure why the CIPRO had not been transcribed to the Admission Orders.

Staff #3 further stated, "The facility does not have a specific policy and procedure for reconciling patient's medication."


B. An observation on 1/26/15 at 10:30 a.m. revealed Patient #6 sitting in a group therapy meeting. Patient # 6 was observed with a 2 inch by 3 inch gauze dressing under a clear tegaderm (a type of bandage) on his right elbow. The dressing was soaked with a dark brown serosanguinous fluid (old blood and clear fluid). The tegaderm did not have a date written on it, to document when and by whom it was placed.

During an interview on 1/26/16 at 2:20 p.m. Staff #11, RN Charge Nurse stated, "Patient #6's elbow was bleeding yesterday (1/25/16). I cleaned Patient #6's elbow." Staff #11 confirmed she did not call the physician to get treatment orders, did not document the treatment and did not complete an Incident Report.

Review of Patient #6's Physician's Orders did not reflect instructions on the treating of the wound. Review of Patient #6's Nursing Progress notes dated 1/25/16 and 1/26/16 did not reflect the physician or family was contacted regarding the wound.

Review of the facility provided policy Interdisciplinary Progress Notes 210.0 (dated 09/01/09) reflected: The progress notes should document the implementation of the treatment plan, all treatment rendered to the patient, the patient's clinical course, changes in the patient's conditions...


C. Review of Patient #6's medical Chart reflected a DNR (Do Not Resuscitate) sticker placed on the outside of the chart. Review of Patient #6's Out of Hospital DNR form dated 9/12/2012 reflected Patient #6's signature.


During an interview on 1/26/16 at 2:10 p.m. Staff #11, RN Charge Nurse stated, "I determined the patient's DNR status based on his Out of Hospital DNR."


Review of the facility provided policy DNR, Withholding of Life Sustaining Treatment (dated 9/1/09) reflected: Nursing responsibility regarding DNR orders.
A. All patients with cardiac or respiratory arrest will have cardiopulmonary resuscitation attempted unless the physician's orders specify "do not resuscitate".

During an interview on 1/26/16 in the afternoon, in the conference room, Staff #3, Chief Nursing Officer confirmed the findings.

Based on review of staff records, it was determined that the facility failed to ensure that the hospital policy was followed relating to infection control-tuberculin skin testing for all direct patient care staff.


Findings were:


The Centers for Disease Control and Prevention (CDC) article, Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005, stated in part:" Every health-care setting should conduct initial and ongoing evaluations of the risk for transmission of M. tuberculosis, regardless of whether or not patients with suspected or confirmed TB disease are expected to be encountered in the setting. "

Review of employees' personal files on the afternoon of 01/20/15 in the facility conference room revealed the following;

· (4) Four out of (11) eleven patient care staff did not have a current TB Skin Tests on file.
Staff # 6, # 7, # 8, and # 12, TB Skin Tests were past due.
Facility Policy- TB Exposure Control Plan stated in part, "It is the policy of ABH (Allegiance Behavioral Health) to properly screen all employees for the presence of inactive or active tuberculosis at the time of employment and at least annually thereafter. To properly screen all employees it is necessary to have an ongoing tuberculosis program. This program will also include any employee who is exposed to a non-isolated patient having active tuberculosis.

These deficits were confirmed by the Infection Control Nurse, she stated "we had some problems obtaining the PPD (purified protein derivative) from the pharmacy, but we now have it and plan to give to employees."