HospitalInspections.org

Based on record review and interview, the Governing Body failed to ensure all contracted services employees complied with the hospital's contracted agreement and the hospital's policy by failing to ensure the contracted employees' background check was from an approved OSP agency for 1 (S15DM) of 1 contracted employee's personnel records reviewed.
Findings:

Review of contract services for "Food Management Services Agreement", effective 10/10/17, revealed: (l) All Company A employees must have background checks, drug tests, demonstrated competency exams and participate in hospital orientation efforts as required by Client's employed staff.

Review of the hospital policy titled "Human Resources", Policy Number: HR.01.02 and dated 01/11/2016, revealed in part: Employee Background Checks, In addition to thorough reference checks, additional background checks are required utilizing an approved company vendor prior to extending an offer of employment.

Review of the personnel record for S15DM revealed a date of hire of 07/29/18. She was a contracted employee through Company A. S15DM's background history check dated 12/06/17 was not from an approved agency by the OSP.

Interview on 10/31/18 at 11:00 a.m. with S3RDCS confirmed that S15DM was a contracted employee for the hospital and should have had a background history check from an OSP approved agency.

Based on record reviews and interviews, the hospital failed to ensure the patient or his/her representative had the right to make informed decisions regarding his/her care as evidenced by failing to have documented evidence of a discussion with a patient, his/her primary care physician, and/or his/her family regarding the DNR order and the decision to have the DNR order written in accordance with hospital policy for 1 (#6) of 1 patient record reviewed with an order for DNR from a sample of 14 patients.
Findings:

Review of the policy titled "Do Not Resuscitate-Louisiana", presented as a current policy by S3RDCS, revealed the physician discusses a DNR request with the patient/Personal Healthcare Representative and/or family as indicated or as desired by the patient, and consults with the patient's primary care physician if appropriate. The physician documents the discussions in the patient's medical record.
Review of Patient #6's physician orders revealed an order written by S8PSYCH on 08/06/18 at 10:40 a.m. to "make pt (patient) DNR."

Review of Patient #6's medical record revealed no documented evidence of a discussion by S8PSYCH with Patient #6, Patient #6's primary care physician, or family members regarding the decision regarding the DNR order in accordance with hospital policy.

In an interview on 10/31/18 at 9:05 a.m., S8PSYCH indicated Patient #6 was on hospice, and hospice discharged him to be able to admit him at Oceans behavioral Hospital of Lake Charles. He further indicated "that's the standard protocol." He indicated Patient #6 was never able to respond other than to say yes or no ... "he was obviously in bad shape." After reviewing the chart, S8PSYCH indicated he knew he "didn't have a meaningful conversation with him (Patient #6)" and didn't think there was any family involvement with "this fellow." After reviewing the medical record, S8PSYCH confirmed he could find no documentation of a discussion with Patient #6 or his family.

Based on observations, record reviews, and interviews, the hospital failed to ensure patients received care in a safe setting as evidenced by having a plastic trash liner in the garbage can located in a patient care area, having electrical cords approximately 3 to 4 feet long hanging from the television and cable box in Room "k", having sink faucets in the bathrooms of Rooms "g" and "i" that presented a ligature risk, having a non-tamper-resistant screw on the wall in Rooms "h" and "i", having the plastic covering on pillows with tears that allowed the stuffing to protrude and presented a risk for suffocation in Rooms "e", "f", and "g", having missing floor tiles in Room "b" that presented a risk for falls, and having a zipper on the underside of the mattress in Room "a" that presented a risk for suffocation.
Findings:

Observation on 10/29/18 from 11:35 a.m. through 1:00 p.m. revealed the following risks to patient safety:
Room "o" had a plastic liner in the large trash can.
Room "k" had an approximately 4 feet electrical cord hanging from the wall-mounted television and an approximately 3 feet cord hanging from the wall-mounted cable box.
Room "i" had a protruding faucet in the bathroom sink that presented a ligature risk. During the observation, S4DON tied a bed sheet around the faucet that did not release when pulled. Further observation revealed there was a non-tamper-resistant screw on the wall next to the sink. Patient #1 was assigned to this room and was ordered to be on suicide precautions.
Room "h" had a non-tamper-resistant screw in the sheetrock next to the window. Patient #2 was assigned to this room and was ordered to be on suicide precautions.
Room "g" had a protruding faucet in the bathroom sink that presented a ligature risk. The plastic covering on the pillow on the patient's bed was torn which presented a risk for suffocation.
Room "f" had the plastic covering on the pillow on the patient's bed that was torn which presented a risk for suffocation.
Room "c" had the plastic covering on the pillow on the patient's bed that was torn which presented a risk for suffocation.
Room "b" had 5 missing floor tiles to the left of the entrance into the room that presented a risk for falls.
Room "a" had a zipper at the underside of the mattress on 1 of 2 beds in the room that presented a risk for suffocation.

Observation during the tour on 10/29/18 from 11:35 a.m. through 1:00 p.m. revealed patients were allowed to walk unattended by staff in the hall and to remain in their bed unattended in their room.

Review of the "Daily Census Report" for 10/29/18, presented as the current list of admitted patients by S5QD, revealed there were 27 patients admitted. Review of "Precautions Sheet", presented as the current precautions for each patient by S5QD, revealed 12 patients were suicidal or on suicide precautions, 8 patients were on fall precautions, and 5 patients were on assault or violence precautions.

In an interview on 10/29/18 at 1:00 p.m., S4DON confirmed the above findings during the tour.

Based on record reviews and interview, the hospital failed to ensure its QAPI program measured, analyzed, and tracked quality indicators and other aspects of performance that assess processes of care, hospital service, and operations, including services provided by contract, and must use the data collected to monitor the effectiveness and safety of services and quality of care. The hospital did not have quality indicators developed for all services provided by contract and did not develop/revise action plans for identified areas that were below targeted goals.
Findings:

Review of the "Quality Compass", presented as the list of quality indicators being measured, analyzed, and tracked by S5QD, revealed no documented evidence quality indicators had been developed for contracted services for linen, biohazard waste, pharmacy, ambulance, LOPA, and radiology services. Further review revealed the quality indicator of "treatment planning - appropriateness" had 44% compliance in July 2018, 67% compliance in August 2018, and 35% compliance in September 2018.

Review of the action plan that addressed the treatment plan, initiated 08/11/18 and presented by S5QD, revealed the Clinical Director would educate staff on treatment plan appropriateness and required elements. Further review revealed no documented evidence the action plan was revised in September 2018 when the compliance dropped to 35%.

Review of the "Performance Improvement Committee Meeting" minutes dated 10/24/18 revealed no documented evidence the findings related to the treatment plan had been discussed.

In an interview on 10/31/18 at 2:15 p.m., S5QD indicated they have had turnover in staff and are trying to do education. She confirmed the meeting minutes did not include a discussion of the treatment plan findings. She confirmed the action plan for the treatment plan had not been revised when the compliance had decreased in September to 35%. She confirmed the contracted services of linen, biohazard waste, pharmacy, ambulance, LOPA, and radiology did not have quality indicators developed and were not being monitored through the hospital's QAPI program.

Based on record review and interview, the hospital failed to ensure it documented measurable progress achieved on its PI project and revised the plan when improvement did not occur as evidenced by having a total of 83 patient falls in 2017 and 61 falls in 2018 as of 07/31/18 with no documented evidence of a revision to the interventions.
Findings:

Review of the "2018 Performance Improvement Project - Falls", presented by S5QD, revealed the purpose of the project was to focus on patient safety and make staff aware of fall risks. The methodology included education of staff on the hospital's policies on fall risk, prevention and alarms, and the DON put fall packets together for staff to complete documentation. Further review revealed the hospital had 83 falls in 2017. Through July 2018 there have been 61 falls. Documentation revealed an increase in falls in July resulted from 5 falls attributed to one patient who recently had a cerebrovascular accident and had not learned the limitations of the residual effects. There was no documented evidence the methodology and interventions had been revised to seek measurable improvement/progress.


In an interview on 10/31/18 at 2:15 p.m., S5QD indicated the PI project chosen was falls. She confirmed she had no documented evidence to present that the interventions were revised with the increase in falls as of July 2018.

Based on record reviews and interviews, the hospital failed to ensure the medical staff examined the credentials of all eligible candidates for medical staff appointment and reappointments in accordance with the medical staff by-laws as evidenced by failure to have documented evidence of peer references and/or searches of the NPDB, exclusion search, and AMA prior to appointment for 5 (S8PSYCH, S10NP, S11PMHNP, S13RAD, S14RAD) of 6 (S8PSYCH, S9MD, S10NP, S11PMHNP, S13RAD, S14RAD) credentialing files of credentialed physicians and AHPs reviewed from a total of 17 credentialed physicians/AHPs. The hospital failed to present documented evidence that it was within the scope of practice for S10NP, who was licensed as an Adult NP and a Gerontological NP, to conduct psychiatric examinations.
Findings:

Review of the Medical Staff By-laws, presented as the current by-laws by S3RDCS, revealed the procedure for appointment and reappointment required the Medical Staff, through the Medical Executive Committee or designee, to investigate, verify, and consider each application for membership and clinical responsibilities and appointment or reappointment to any staff category and each request for modification of the staff category using the standards set forth in the by-laws and to transmit recommendations to the Board. The hospital shall query the NPDB, the state licensing authority, and the applicable federal and state exclusion databases for all physicians and non-physician practitioners who are applying or re-applying for membership or clinical responsibilities. Information requested on the application shall include, but not be limited to, peer references (3 recommendations from persons other than family or affiliated by marriage for initial appointment, and 1 recommendation for reappointment). Within 60 days following the determination that the application is complete, the voting members of the Medical executive Committee shall review the application and conduct any interviews as it deems appropriate and shall submit the written recommendation to the Board relating to membership, staff category, clinical responsibilities, and any special requirements or conditions.

S8PSYCH
Review of S8PSYCH's credentialing file revealed he was appointed for the period of 01/24/17 through 01/24/19. Further review revealed his AMA Profile and NPDB query was reviewed on 01/31/17, and his exclusions search was conducted on 01/26/17, all of which were done after he had been appointed on 01/24/17.

S10NP
Review of S10NP's credentialing file revealed she was reappointed for the period of 01/24/17 through 01/24/19. Review of her application for reappointment revealed it was signed 02/14/17, 21 days after she had been reappointed by the Board. Review of her NPDB query revealed it was conducted on 01/31/17, 7 days after she was reappointed. Review of her exclusions search revealed it was conducted on 01/26/17, 2 days after she was reappointed. Further review revealed the 3 peer references were dated 02/16/17, 04/07/17, and 12/01/17, all after she had been reappointed. Review of S10NP's license verification revealed she was licensed as a Gerontological Nurse Practitioner and an Adult Nurse Practitioner. There was no documented evidence that she was licensed as a PMHNP. Review of her "Clinical privileges Form" signed by S10NP on 02/14/17 and by her sponsoring physician on 02/16/17 (both after she had been reappointed) revealed she was privileged to conduct psychiatric evaluations.

Review of S10NP's "Collaborative Practice Agreement" between S10NP, S8PSYCH, and 2 additional non-credentialed physicians, signed by S10NP and S8PSYCH on 07/06/06, revealed no documented evidence that her responsibilities and functions included conducting psychiatric evaluations. No documented evidence was presented to the surveyor as of the time of exit of the survey on 10/31/18 at 3:45 p.m. of documentation by the LSBN that revealed that conducting psychiatric evaluations was within S10NP's scope of practice.

Patient #5's (active patient) and Patient #10's (closed record) psychiatric evaluations were performed by S10NP.

S11PMHNP
Review of S11PMHNP's credentialing file revealed she was appointed for the period of 07/28/17 through 07/28/19. Further review revealed 2 of 3 of her peer references were signed on 08/14/17, 17 days after she had been appointed by the Board.

S13RAD
Review of S13RAD's credentialing file revealed he was reappointed for the period of 02/09/18 through 02/09/20. Further review revealed no documented evidence of a peer reference as required by the by-laws at the time of reappointment.

S14RAD
Review of S14RAD's credentialing file revealed he was reappointed for the period of 02/09/18 through 02/09/20. Further review revealed no documented evidence of a peer reference as required by the by-laws at the time of reappointment.

In an interview on 10/31/18 at 11:28 a.m., S10NP confirmed she is not a PMHNP. She indicated she can do geri-psychiatric evaluations that have been approved by the LSBN (no documented evidence of a stated approval by the LSBN was included in the documentation presented).

In a telephone interview on 10/31/18 at 1:25 p.m., S20RHIA indicated she manages the employee who does the credentialing for the hospital. She further indicated that employee was off and not available to be interviewed. S20RHIA indicated she is the corporate director of RHIA and is familiar with requirements for credentialing. She indicated peer references and database queries should be obtained prior to the physicians' and AHPs' credentialing file being taken to the Board for appointment and reappointment.

Based on record reviews and interviews, the hospital failed to meet the requirements of the Condition of Participation for Nursing Services as evidenced by failing to ensure the RN supervised and evaluated the care of each patient. The RN failed to ensure physician orders were obtained for admission as evidenced by having the RN or LPN complete a standing admission order based on information received from the referring hospital and not calling the admitting physician to receive admission orders for 8 (#1, #2, #3, #4, #5, #8, #11, #13) of 8 active patient records reviewed for admission orders from a sample of 14 patients. (see findings in tag A0395)

Based on record reviews and interviews, the hospital failed to ensure the RN supervised and evaluated the care of each patient as evidenced by:
1) The RN failed to ensure physician orders were obtained for admission as evidenced by having the RN or LPN complete a standing admission order based on information received from the referring hospital and not calling the admitting physician to receive admission orders for 8 (#1, #2, #3, #4, #5, #8, #11, #13) of 8 active patient records reviewed for admission orders from a sample of 14 patients.
2) The RN failed to ensure elevated BPs at the time of the admission assessment were reported to the physician for 2 (#11, #13) of 8 (#1, #2, #3, #4, #5, #8, #11, #13) patient records reviewed for reporting of problems identified at admission from a sample of 14 patients.
Findings:

1) The RN failed to ensure physician orders were obtained for admission:
Review of the "Medical Staff Rules And regulations", presented as the current rules and regulations by S3RDCS, revealed patients may be admitted and discharged only on an order of a credentialed and privileged licensed independent practitioner. Further review revealed all orders for treatment must be in writing. An order will be considered to be in writing if it is dictated to authorized personnel. Orders dictated by telephone shall be signed by the person to whom the order was dictated with the name of the ordering medical staff member and then signed by the person to whom it was dictated.

Review of the "Admit Orders/Initial Plan of Care", admit orders completed for all patients admitted to the hospital, revealed the following items were included: height; weight; allergies; admit to the care of ___ (physician's name); patient's social security number; AIMS (abnormal involuntary movement scale) Test upon initiation of antipsychotic and weekly thereafter; legal status; admitting diagnosis; vital signs; weight on admit then 3 times weekly; diet; dietary consult; precautions (choice of suicide, elopement, seizure, assault, falls, infection control/wound, bleeding, choking); observation level (choice of close observation every 15 minutes, one-to-one observation, routine on admit, other); therapeutic recreation to assess/evaluate and implement recreational groups per patient assessment; activity; social services for psychosocial assessment/individual therapy and group psychotherapy as needed; education groups per schedule; medical consult for physical examination/for any medical conditions; lab and diagnostics (choice of 29 blanks/labs/tests to check); levels of medications to test; medications upon admit reconciled with physician on Admission Medication reconciliation Order; initial treatment plan problems; space for nurse receiving orders with read back verification of order to sign; date/time; space for physician signature, date, and time.

Patient #1
Review of Patient #1's medical record revealed the "Admit Orders/Initial Plan of Care" was completed and signed by S17LPN on 10/28/18 at 5:30 p.m. There was no documented evidence of the name of the physician from whom S17LPN received the verbal order.

Patient #2
Review of Patient #2's medical record revealed the "Admit Orders/Initial Plan of Care" was completed and signed by S17LPN on 10/28/18 at 1:45 p.m. There was no documented evidence of the name of the physician from whom S17LPN received the verbal order.

Patient #3
Review of Patient #3's medical record revealed the "Admit Orders/Initial Plan of Care" was completed and dated 10/28/18 at 6:45 a.m. There was no documented evidence of a signature by the nurse who obtained verbal orders for admission and the name of the physician who gave the verbal order for admission.

Patient #4
Review of Patient #4's medical record revealed the "Admit Orders/Initial Plan of Care" was completed and signed by S27RN on 10/28/18 at 2:45 p.m. There was no documented evidence of the name of the physician from whom S27RN received the verbal order.

Patient #5
Review of Patient #5's medical record revealed the "Admit Orders/Initial Plan of Care" was completed and dated 10/24/18 at 2:45 p.m. There was no documented evidence of a signature by the nurse who obtained verbal orders for admission and the name of the physician who gave the verbal order for admission.

Patient #8
Review of Patient #8's medical record revealed the "Admit Orders/Initial Plan of Care" was completed and signed by S27RN on 10/28/18 at 4:45 p.m. There was no documented evidence of the name of the physician from whom S27RN received the verbal order.

Patient #11
Review of Patient #11's medical record revealed the "Admit Orders/Initial Plan of Care" was completed and signed by S28LPN on 10/28/18 at 10:45 p.m. There was no documented evidence of the name of the physician from whom S28LPN received the verbal order.

Patient#13
Review of Patient #13's medical record revealed the "Admit Orders/Initial Plan of Care" was completed and signed by S28LPN on 10/28/18 at 8:00 p.m. There was no documented evidence of the name of the physician from whom S28LPN received the verbal order.

In an interview on 10/31/18 at 8:04 a.m., S24RN indicated she is the only RN on the unit when she works. When asked by the surveyor what the process was for getting MD orders at admit, she indicated she would call the MD to report what's going on. She further indicated the MD would give orders for the observation level. She then indicated the admit orders are filled out by the LPN based on the information that comes with the patient from the referring hospital. She indicated the MD reviews these orders "whenever he sees them." When asked by the surveyor if she meant the next day when she indicated "whenever he sees them", S24RN answered "yes." When asked again how physician orders were obtained at admit, she indicated she doesn't call the physician to get the orders. She further indicated the intake nurse had received acceptance of the patient from the MD.

In an interview on 10/31/18 at 9:05 a.m., S8PSYCH indicated the nurses have a standard admission order. He further indicated after the RN assesses the patient, the nurse will ask him if he/she needs additional orders. S8PSYCH confirmed if the nurse finds no reason to call him, he just sees the patient the next day and signs the admission orders that were completed by the nurses.

In an interview on 10/31/18 at 9:45 a.m., S18RN indicated she has not worked alone since she was hired on 10/02/18. She further indicated she worked on 10/28/18 with another RN. She indicated she documented Patient #2's intake assessment from information received from the hospital's intake person who was on-call. She indicated she didn't gather any of that information on her own. She indicated she texts S9MD (the medical doctor) to let him know there was a new admit and what room she was in. She indicated she's not sure if S8PSYCH was contacted, because she hasn't been shown that part yet. She indicated unless the patient is 1:1, everyone is put on every 15 minute observation. She indicated S8PSYCH is not called "right away" to get admit orders. She doesn't know when he gives the orders. She indicated "I'm not going to lie to you, I've never met him yet." She indicated she doesn't know if they have standing orders for admit ... "I haven't got into it that deep yet."

In an interview on 10/31/18 at 11:00 a.m., S25IC indicated she gets a fax from the referring hospital with the packet of information on the patient. Intake requests the pertinent records to determine the patient meets the admission criteria. They then verify benefits. If the patient meets criteria, she types a synopsis for S8PSYCH (age, sex, insurance, legal status, currently what's going on [what's on the PEC], psychiatric history, medical history diagnoses, therapeutic drugs, whether the patient is compliant with medications) from the information received in the packet. She indicated it is understood that when she sends the synopsis, and he reads it and sends back that the admission is approved, it means admit with standing orders. If he wants anything such as checking a drug level or level of observation other than every 15 minutes, S8PSYCH will let her know. S25IC indicated she does not write verbal or telephone orders for admission. She further indicated she never sees the patient. S25IC indicated she faxes the intake sheet and the packet to the unit and texts the synopsis that was sent to S8PSYCH to the admit nurse.

In an interview on 10/31/18 at 1:55 p.m., S17LPN indicated they use the admit orders as standing orders, unless the RN gets more orders from the doctor. She remembered Patient #2 wasn't violent, and no further orders were needed beside the standing order. She confirmed she did not call to get any orders from any physician. She indicated the same procedure for Patient #1's admission as she did for Patient #2, because Patient #1 wasn't violent or anything. She indicated the items she checked on the "Admit Orders/Initial Plan of Care" were "standing orders and I know what the patient needs and what the psychiatrist requires." She confirmed she did not call S8PSYCH to get admit orders for Patients #1 and #2 on 10/28/18.

2) The RN failed to ensure elevated BPs at the time of the admission assessment were reported to the physician:
Patient #11
Review of the medical record for Patient #11 revealed he was a 52 year old male admitted to the hospital on 10/28/18 at 10:45 p.m. with a diagnosis of Depression.

Review of the Admit Nursing Assessment documented by S24RN, dated 10/28/18 at 10:45 p.m., revealed a documented BP of 160/108.

Review of Multi-Disciplinary Note by S26RN with dated entry of 10/29/18 at 11:30 p.m. revealed Patient #11's BP has been elevated since admission ranging from 160/108 - 170/111. S9MD notified awaiting further orders.

There was no documented evidence the physician was notified of Patient #11's elevated BP at the time of admission.

Patient #13
Review of the medical record for Patient #13 revealed the patient was a 52 year old male admitted to the hospital on 10/28/18 at 8:00 p.m. with a diagnosis of Psychosis.

Review of the Admit Nursing Assessment noted by S24RN, dated 10/28/18 at 8:00 p.m., revealed a documented BP of 154/111. Further review of the medical record revealed no documentation that the physician was notified of the elevated BP on admit.

In an interview on 10/31/18 at 8:05 a.m. with S24RN, she confirmed Patient #11 and Patient #13 had an elevated BP upon admission. S24RN stated that she should have contacted the physician for the elevated BP.



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39791

Based on observations, record reviews, and interview, the hospital failed to ensure medical records were stored in secure locations where they were protected from water damage as evidenced by having 68 completed medical records stored on top of a file cabinet and 21 medical records stored on a rolling cart in Room "q" with no protection from potential water damage if the sprinkler system in the room became activated as observed on 10/29/18 at 11:25 a.m.
Findings:

Observation on 10/29/18 at 11:25 a.m. in Room "q" revealed 68 completed medical records stored on top of a file cabinet and 21 medical records stored on a rolling cart. Further observation revealed there was no protection from potential water damage if the sprinkler system in the room became activated.

Review of the policy titled "Retention & (and) Destruction", presented as a current policy by S3RDCS, revealed it was hospital policy to maintain complete, accurate, and high-quality records. Further review revealed records may be stored at one or more appropriate and approved contracted offsite storage facilities, which should be safe, secure locations protected from environmental and other potential harm. There was no documented evidence the policy addressed maintaining medical records onsite in a manner to protect them from potential water damage.

In an interview on 10/29/18 at 11:25 a.m. with S6HIMD and S2COO present, S6HIMD confirmed the 21 medical records on the cart and the 68 medical records on top of the file cabinet were not protected from potential water damage. She confirmed Room "q" has a sprinkler system in place.

Based on record review and interview, the hospital failed to ensure the contracted lab services were provided by a certified laboratory as evidenced by failing to have documented evidence of a current CLIA certification for Hospital A which was contracted to provide laboratory services.
Findings:

Review of the contracts presented by S3RDCS revealed laboratory services were provided through a contract with Hospital A.

No current CLIA certificate for Hospital A was presented for review by the surveyor as of the time of exit on 10/31/18 at 3:45 p.m.

In an interview on 10/30/18 at 3:55 p.m., S3RDCS indicated they didn't have a copy of the CLIA certificate from Hospital A.

39791

Based on observations, record reviews, and interviews, the infection control officer failed to develop and/or implement a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel as evidenced by:
1) Failure to maintain a sanitary environment in the hospital, evidenced by multiple observations of breaches in environmental and equipment infection control practices during a hospital tour on 10/29/18 from 11:20 a.m. to 1:00 p.m.;
2) Failure to ensure the hospital glucometer was cleaned and disinfected after performing a capillary blood glucose in accordance with hospital policy;
3) Failure to ensure hand hygiene practices were implemented in accordance with hospital policy or CDC guidelines as evidenced by observation of breaches in hand hygiene during the performance of 2 (R1, R2) of 2 accuchecks observed on 10/29/18 at 4:50 p.m.; and
4) Failure to ensure expired supplies were not available for use as observed during the hospital tour on 10/29/18 at 11:50 a.m. and 11:55 a.m.
Findings:

1) Failure to maintain a sanitary environment in the hospital:
Observations on 11/29/18 between 11:29 a.m. and 1:00 p.m. in the presence of S4DON, who verified the findings, revealed the following:
Room "b" revealed 5 missing floor tiles, peeling paint to the doorframes, and a torn mattress covering.
Room "c" revealed a torn plastic covering which exposed the filling of the pillow and the doorframes had peeling paint.
Room "d" revealed peeling paint to the doorframes.
Room "e" revealed two pillows which exposed the filling of the pillows and peeling paint to the doorframes.
Room "g" revealed a torn plastic covering which exposed the filling of the pillow and peeling paint to the doorframes.
Room "h" revealed peeling paint to the window ledge and the doorframes.
Room "i" revealed peeling paint to the doorframes.
Room "j" revealed two biohazard bins on the floor with non-locking yellow tops.
Room "k" revealed a garbage can without a liner and spilled and dirty with food and drinks.
Room "p" revealed a sink filled with art supplies, a cluttered counter, and 4 cardboard boxes on the floor.
Room "r" revealed S8PSYCH, a patient, and 3 large dogs.

On 10/31/18 at 9:05 a.m. in an interview with S8PSYCH regarding Room "r" findings he indicated "I do not have an office. The dogs belong to me. I keep the dogs with me. The patients interact with the dogs. If a patient does not like dogs, or only likes little dogs, I keep the dogs at the nursing station." S8PSYCH verified there is no policy regarding dogs with the exception of service dogs, which does not pertain to his personal dogs.

2) Failure to clean and disinfect the hospital glucometer after performing a capillary blood glucose:
On 10/29/18 at 4:50 p.m. an observation, in the presence of S3RDCS, revealed after checking an accucheck, S7RN cleaned the accucheck with alcohol.

Review of the hospital policy tiled Glucometer Method for Obtaining CBG's dated 01/11/16 revealed to clean the meter between patients and per manufacturer's instructions.

Review of the Medline Enencare G3 accucheck monitor revealed cleaning and disinfecting the monitor includes Medline Micro-Kill, which is what the hospital refers to as "purple top" cleaner.

On 10/29/18 at 5:00 p.m., an interview with S7RN revealed she cleans the accucheck machine with alcohol between patients.

On 10/29/18 at 5:05 p.m. in an interview with S4DON, she indicated "we clean the accucheck with the purple top cleaners, and S7RN should have known, because we just had an in-service last week, and we went over that". S4DON also stated we use the "purple top" cleaner which was identified as Medline Micro-Kill. S4DON verified the above observations revealed S7RN did not follow the hospital policy.

3) Failure to ensure hand hygiene practices were implemented in accordance with hospital policy or CDC guidelines:
On 10/29/18 at 4:40 p.m. an observation of S7RN, in the presence of S3RDCS, revealed after checking an accucheck, she removed her gloves and did not perform hand hygiene for Patient R1's and Patient R2's accucheck procedure.

Review of the policy titled "Hand Hygiene in a Healthcare Setting" dated 05/01/16 revealed to wash hands after removing gloves and after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient.

Review of the CDC's "Guideline for Hand Hygiene in Health-Care Settings" revealed hands should be washed or an alcohol-based hand rub should be used before having direct contact with patients, before inserting an invasive device (peripheral anesthesia block needle), after contact with a patient's intact skin, after contact with inanimate objects including medical equipment, and after removing gloves.

On 10/29/18 at 4:55 p.m. in an interview with S3RDCS, she verified S7RN did not perform hand hygiene after removing gloves as stated above.

4) Failure to ensure expired supplies were not available for use:
Observation on 10/29/18 at 11:50 a.m. in Room "l" revealed 6 disposable Betadine Solution Swabsticks that were expired. One had expired on 01/31/17, and 5 had expired 02/28/17. Further observation revealed Aplicare ¾ fluid ounce Povidone-Iodine Solution had expired 11/30/16. These observations were confirmed by S4DON who was present at the time of the observation.

On 10/29/18 at 11:55 a.m., a tour of Room "l" revealed a plastic bin containing more than 50 medline intravenous hubs. All hubs contained the date 2011.

On 10/31/18 at 7:30 a.m. in an interview with S3RDCS, she indicated the hubs (prn adaptors) were expired. She further indicated the hubs were recently received from the medical supply company. When the medline manufacturer was called, she stated the hubs were manufactured in 2011, and they are now expired.

Based on record review and interview, the hospital failed to ensure the patients' H&P documentation included a descriptive neurological examination indicating what tests had been performed to assess patient neurological functioning for 5 (#4, #5, #8, #11, #13) of 8 (#1, #2, #3, #4, #5, #8, #11, #13) patient records comprehensively reviewed for neurological assessments from a total sample of 14 patients. The absence of this information limits the clinician's ability to accurately diagnose the patient's condition and to provide a measure of baseline function, thereby potentially adversely affecting care.
Findings:

Review of the Medical Staff Bylaws revealed, in-part, in Article XIII, a complete admission history and physical examination on each patient must be written or dictated and transcribed within 24 hours of admission and no more than 30 days prior to the admission. The H&P may be performed by a practitioner ... In all cases the admitting Physician must sign for and assume responsibility for the performance of the H&P and content of the medical record.
The minimum content of the H&P's medical history will include, at a minimum, the following: Chief complaint; Description of the present illness; Past medical history; Family history; A psychological and social status; Allergies; A physical examination and review of symptoms; a neurological examination, when indicated; A statement of impression; Treatment plan; and Signature of the physician (which authenticates the H&P).

Patient #4
Review of Patient #4's medical record revealed an admit date of 10/28/18 with a diagnosis of Psychosis.
Review of Patient #4's H&P and Neurological Examination revealed the following documented neurological assessment of the patient's cranial nerves:
Cranial Nerve I. Difficulty Distinguishing Various Odors: marked "No" with no indication of how the patient's ability to smell had been assessed.
Cranial Nerve II: Vision- Near: Good; Vision - Far: Good with no indication of how the patient's vision had been assessed.
Cranial Nerve III: Extraocular Movements: marked "Intact" with no indication of how the patient's extraocular movements had been assessed.
Cranial Nerve IV: Ptosis of eyelids: "No" with no indication of how the patient's eyelids had been assessed. Pupils: marked PERRL.
Cranial Nerve V: Mastication of Muscles: marked "Yes" with no indication of how the patient's ability to masticate had been assessed. Tactile Loss - Upper Forehead: marked "Present" with no indication of how the patient's tactile loss had been assessed. Tactile Loss - Anterior Scalp: marked "Present" with no indication of how the patient's tactile loss had been assessed.
Cranial Nerve VII. Face Symmetrical at rest: marked "Yes" with no indication of how the patient's facial symmetry had been assessed.
Cranial Nerve VIII: Hearing: Left Ear and Right Ear: both marked "Good" with no indication of how the patient's ability to hear had been assessed.
Cranial Nerve's IX, X, and XI: Palate rises normally: marked "Yes" with no indication of how the patient's palate movement had been assessed. Sternocleidmastoid contract well: marked "Yes" with no documentation to indicate how the patient's Sternocleidmastoid contraction had been assessed. Trapezius Muscles Contract Well: marked "Yes" with no documentation to indicate how the patient's Trapezius Muscles had been assessed.
Cranial Nerve XII: Tongue Protrudes Midline: marked "Yes" "with no documentation to indicate how the patient's Tongue Protrudes had been assessed. Atrophy: marked "No" with no documentation on how Atrophy had been assessed. Fibrillary Movements Present: marked "No" with no documentation on how Fibrillary Movements had been assessed.

Patient #5
Review of Patient #5's medical record revealed an admit date of 10/24/18 with a diagnosis of Neurocognitive Disorder with Psychosis.
Review of Patient #5's H&P and Neurological Examination revealed the following documented neurological assessment of the patient's cranial nerves:
Cranial Nerve I. Difficulty Distinguishing Various Odors: marked "No" with no indication of how the patient's ability to smell had been assessed.
Cranial Nerve II: Vision- Near: Good; Vision - Far: Good with no indication of how the patient's vision had been assessed.
Cranial Nerve III: Extraocular Movements: marked "Intact" with no indication of how the patient's extraocular movements had been assessed.
Cranial Nerve IV: Ptosis of eyelids: "No" with no indication of how the patient's eyelids had been assessed. Pupils: marked R Reactive, but could not finish exam.
Cranial Nerve V: Mastication of Muscles: marked "Yes" with no indication of how the patient's ability to masticate had been assessed. Tactile Loss - Upper Forehead: blank. Tactile Loss - Anterior Scalp: blank.
Cranial Nerve VII. Face Symmetrical at rest: marked "Yes" with no indication of how the patient's facial symmetry had been assessed.
Cranial Nerve VIII: Hearing: Left Ear and Right Ear: both marked "Good" with no indication of how the patient's ability to hear had been assessed.
Cranial Nerve's IX, X, and XI: Palate rises normally: marked "Yes" with no indication of how the patient's palate movement had been assessed. Sternocleidmastoid contract well: blank. Trapezius Muscles Contract Well: blank.
Cranial Nerve XII: Tongue Protrudes Midline: marked "Yes" "with no documentation to indicate how the patient's Tongue Protrudes had been assessed. Atrophy: marked "No" with no documentation on how Atrophy had been assessed. Fibrillary Movements Present: marked "No" with no documentation on how Fibrillary Movements had been assessed.

Patient #8
Review of Patient #8's medical record revealed an admit date of 10/23/18 with a diagnosis of Dementia.
Review of Patient #8's H&P and Neurological Examination revealed the following documented neurological assessment of the patient's cranial nerves:
Cranial Nerve I. Difficulty Distinguishing Various Odors: blank.
Cranial Nerve II: Vision- Near: blank. Vision - Far: blank.
Cranial Nerve III: Extraocular Movements: marked "Intact" with no indication of how the patient's extraocular movements had been assessed.
Cranial Nerve IV: Ptosis of eyelids: "No" with no indication of how the patient's eyelids had been assessed. Pupils: marked R Reactive, but could not finish exam.
Cranial Nerve V: Mastication of Muscles: blank. Tactile Loss - Upper Forehead: blank. Tactile Loss - Anterior Scalp: blank.
Cranial Nerve VII. Face Symmetrical at rest: marked "Yes" with no indication of how the patient's facial symmetry had been assessed.
Cranial Nerve VIII: Hearing: Left Ear and Right Ear: both blank.
Cranial Nerve's IX, X, and XI: Palate rises normally: blank. Sternocleidmastoid contract well: blank. Trapezius Muscles Contract Well: blank.
Cranial Nerve XII: Tongue Protrudes Midline: blank. Atrophy: blank. Fibrillary Movements Present: blank.

Patient #11
Review of Patient #11's medical record revealed an admit date of 10/28/18 with a diagnosis of Depression.
Review of patient #11's H&P and Neurological Examination revealed the following documented neurological assessment of the patient's cranial nerves:
Cranial Nerve I. Difficulty Distinguishing Various Odors: marked "No" with no indication of how the patient's ability to smell had been assessed.
Cranial Nerve II: Vision- Near: Good; Vision - Far: Good with no indication of how the patient's vision had been assessed.
Cranial Nerve III: Extraocular Movements: marked "Intact" with no indication of how the patient's extraocular movements had been assessed.
Cranial Nerve IV: Ptosis of eyelids: "No" with no indication of how the patient's eyelids had been assessed. Pupils: marked PERRL.
Cranial Nerve V: Mastication of Muscles: marked "Yes" with no indication of how the patient's ability to masticate had been assessed. Tactile Loss - Upper Forehead: marked "Present" with no indication of how the patient's tactile loss had been assessed. Tactile Loss - Anterior Scalp: marked "Present" with no indication of how the patient's tactile loss had been assessed.
Cranial Nerve VII. Face Symmetrical at rest: marked "Yes" with no indication of how the patient's facial symmetry had been assessed.
Cranial Nerve VIII: Hearing: Left Ear and Right Ear: both marked "Good" with no indication of how the patient's ability to hear had been assessed.
Cranial Nerve's IX, X, and XI: Palate rises normally: marked "Yes" with no indication of how the patient's palate movement had been assessed. Sternocleidmastoid contract well: marked "Yes" with no documentation to indicate how the patient's Sternocleidmastoid contraction had been assessed. Trapezius Muscles Contract Well: marked "Yes" with no documentation to indicate how the patient's Trapezius Muscles had been assessed.
Cranial Nerve XII: Tongue Protrudes Midline: marked "Yes" "with no documentation to indicate how the patient's Tongue Protrudes had been assessed. Atrophy: marked "No" with no documentation on how Atrophy had been assessed. Fibrillary Movements Present: marked "No" with no documentation on how Fibrillary Movements had been assessed.

Patient #13
Review of Patient #13's medical record revealed an admit date of 10/28/18 with a diagnosis of Psychosis.
Review of Patient #13's H&P and Neurological Examination revealed the following documented neurological assessment of the patient's cranial nerves:
Cranial Nerve I. Difficulty Distinguishing Various Odors: marked "No" with no indication of how the patient's ability to smell had been assessed.
Cranial Nerve II: Vision- Near: Good; Vision - Far: Good with no indication of how the patient's vision had been assessed.
Cranial Nerve III: Extraocular Movements: marked "Intact" with no indication of how the patient's extraocular movements had been assessed.
Cranial Nerve IV: Ptosis of eyelids: "No" with no indication of how the patient's eyelids had been assessed. Pupils: marked PERRL (pupils equal, round, react to light).
Cranial Nerve V: Mastication of Muscles: marked "Yes" with no indication of how the patient's ability to masticate had been assessed. Tactile Loss - Upper Forehead: marked "Present" with no indication of how the patient's tactile loss had been assessed. Tactile Loss - Anterior Scalp: marked "Present" with no indication of how the patient's tactile loss had been assessed.
Cranial Nerve VII. Face Symmetrical at rest: marked "Yes" with no indication of how the patient's facial symmetry had been assessed.
Cranial Nerve VIII: Hearing: Left Ear and Right Ear: both marked "Good" with no indication of how the patient's ability to hear had been assessed.
Cranial Nerve's IX, X, and XI: Palate rises normally: marked "Yes" with no indication of how the patient's palate movement had been assessed. Sternocleidmastoid contract well: marked "Yes" with no documentation to indicate how the patient's Sternocleidmastoid contraction had been assessed. Trapezius Muscles Contract Well: marked "Yes" with no documentation to indicate how the patient's Trapezius Muscles had been assessed.
Cranial Nerve XII: Tongue Protrudes Midline: marked "Yes" "with no documentation to indicate how the patient's Tongue Protrudes had been assessed. Atrophy: marked "No" with no documentation on how Atrophy had been assessed. Fibrillary Movements Present: marked "No" with no documentation on how Fibrillary Movements had been assessed.

In an interview on 10/29/18 at 10:45 a.m. with S4DON, she confirmed the Cranial Nerves examination documented for the above-listed patients did not reveal how each one had been assessed.







39791

Based on record reviews and interview, the hospital failed to ensure each patient received a psychiatric evaluation that described attitudes and behavior with a statement that described behavior(s) which require change in order for the patient to function in a less restrictive setting as evidenced by having attitudes and behavior stated in an interpretive manner for 3 (#1, #2, #3) of 8 (#1, #2, #3, #4, #5, #8, #11, #13) active patients' psychiatric evaluations reviewed for attitudes and behavior from a sample of 14 patients.
Findings:

Review of the policy titled "Psychiatric Evaluation", presented as a current policy by S3RDCS, revealed a comprehensive psychiatric evaluation is conducted and documented in the medical record by an active staff psychiatrist/licensed independent practitioner with 60 hours following an inpatient admission. Further review revealed the psychiatrist reviews available information in the medical record, meets with the patient individually, and evaluates past/current emotional and behavioral status.

Review of the "Inpatient Psychiatric Evaluation" form used by S8PSYCH and S11PMHNP to document psychiatric evaluations revealed choices with a check box for behavior included bizarre, guarded, restless, cooperative, agitated, anxious, hyper vigilant, suspicious, hostile, calm, and other. Choices with a check box for affect included full, constricted, blunted, bizarre, labile, flat, worrisome, congruent, incongruent, elated, defensive, sad, other. Choices with a check box for mood included appropriate, depressed, anxious, elevated, hostile, manic, irritable, euphoric, expansive, cyclothymic, dysphoric, guarded, restless, and other. The choices to select were the same for all patients.

Patient #1
Review of patient #1's "Inpatient Psychiatric Evaluation" documented by S8PSYCH on 10/28/18 at 11:00 a.m. revealed his behavior was restless, his affect was constricted, and his mood was anxious. There was no documented evidence his attitude and behavior was documented as a description of behavior(s) which require change in order for him to function in a less restrictive setting.

Patient #2
Review of Patient #2's "Inpatient Psychiatric Evaluation" documented by S8PSYCH on 10/29/18 at 10:00 a.m. revealed her behavior was agitated, her affect was full, and her mood was depressed. There was no documented evidence her attitude and behavior was documented as a description of behavior(s) which require change in order for her to function in a less restrictive setting.

Patient #3
Review of Patient #3's "Inpatient Psychiatric Evaluation" documented by S11PMHNP on 10/28/18 at 9:15 a.m. revealed her behavior was cooperative, her affect was congruent, sad, and tearful, and her mood was depressed. There was no documented evidence her attitude and behavior was documented as a description of behavior(s) which require change in order for her to function in a less restrictive setting.

In an interview on 10/31/18 at 9:05 a.m., S8PSYCH indicated he doesn't have the time to do "all that documentation", that's why they have the form they have (meaning the psychiatric evaluation with check boxes). He indicated he documents after reviewing the psychosocial evaluation, but it's not always done and on the chart when he does his evaluation. He confirmed the evaluation form is formatted in an interpretive fashion rather than descriptive.

Based on record reviews and interview, the hospital failed to ensure each patient received a psychiatric evaluation that estimated intellectual functioning, memory functioning, and orientation as evidenced by having no documented evidence of the manner used to assess intellectual and memory functioning and orientation for 3 (#1, #2, #3) of 8 (#1, #2, #3, #4, #5, #8, #11, #13) active patients' psychiatric evaluations reviewed for intellectual and memory functioning and orientation from a sample of 14 patients.
Findings:

Review of the policy titled "Psychiatric Evaluation", presented as a current policy by S3RDCS, revealed a comprehensive psychiatric evaluation is conducted and documented in the medical record by an active staff psychiatrist/licensed independent practitioner with 60 hours following an inpatient admission. Further review revealed the psychiatrist performs a systematic mental status examination emphasizing immediate recall and recent and remote memory appropriate to age. Further review revealed the psychiatrist documents an assessment of cognitive functioning, memory, and estimated intellectual function in a sufficient manner to establish a diagnosis and an objective baseline.

Patient #1
Review of Patient #1's "Inpatient Psychiatric Evaluation" documented by S8PSYCH on 10/28/18 at 11:00 a.m. revealed education was documented as "good family ... would never steal." His orientation was documented as oriented to time, place, person, and situation. His recent memory was documented as intact, and his remote memory was documented as impaired. His insight and judgment were documented as limited. His attention and concentration were documented as impaired. There was no documented evidence how S8PSYCH assessed Patient #1's memory, insight, judgment, attention, and concentration.

Patient #2
Review of Patient #2's "Inpatient Psychiatric Evaluation" documented by S8PSYCH on 10/29/18 at 10:00 a.m. revealed the blank next to "education" was blank. Her orientation was documented as oriented to time, place, person, and situation. Her recent and remote memory were documented as intact. Her insight and judgment were documented as fair. Her attention and concentration were documented as intact. There was no documented evidence how S8PSYCH assessed Patient #2's memory, insight, judgment, attention, and concentration.

Patient #3
Review of Patient #3's "Inpatient Psychiatric Evaluation" documented by S11PMHNP on 10/28/18 at 9:15 a.m. revealed her recent and remote memory were documented as intact. Her insight and judgment were documented as limited. Her attention and concentration assessment was no documented whether it was intact or impaired. There was no documented evidence how S11PMHNP assessed Patient #3's memory, insight, judgment, attention, and concentration.

In an interview on 10/31/18 at 9:05 a.m., S8PSYCH indicated the intellectual functioning is easy to determine based vocabulary, understanding of concepts, the patient's ability to understand timeframes and whether or not they readily comprehend their behavior at the ED. He further indicated if they know what medications they've been on and how they've responded to what they've been on, they will be at least average or above average intelligence. S8PSYCH indicated he doesn't have the time to do "all that documentation", that's why they have the form they have (meaning the psychiatric evaluation with check boxes). He indicated he documents after reviewing the psychosocial evaluation, but it's not always done and on the chart when he does his evaluation. He confirmed the evaluation form is formatted in an interpretive fashion rather than descriptive.

In an interview on 10/31/18 at 3:00 p.m., S3RDCS indicated she spoke with S11PMHNP, and she confirmed she wasn't documenting psychiatric evaluations in accordance with certification regulations for psychiatric hospitals.

25119

Based on record review and interview, the hospital failed to ensure each patient received a psychiatric evaluation that included an inventory of the patient's assets in a descriptive manner and not an interpretive fashion for 8 (#1, #2, #3, #4, #5, #8, #11, #13) of 8 current patient records reviewed for strengths/assets in the psychiatric evaluation from a sample of 14 patients.
Findings:

Review of the policy titled "Psychiatric Evaluation", presented as a current policy by S3RDCS, revealed a comprehensive psychiatric evaluation is conducted and documented in the medical record by an active staff psychiatrist/licensed independent practitioner with 60 hours following an inpatient admission. Further review revealed the psychiatrist identifies specific strengths and assets to enable the multidisciplinary treatment team to choose treatment modalities that best utilize these strengths and assets in the patient's treatment.

Review of the "Inpatient Psychiatric Evaluation" used by S8PSYCH and S11PMHNP to document the psychiatric evaluation revealed check boxes with choices for strengths and assets included insight, education, motivated for treatment, supportive family/friends, capable of independent living, insight into problem, employment, articulate, adequate finances, community support, stable physical health, and other.

Patient #1
Review of Patient #1's "Inpatient Psychiatric Evaluation" documented by S8PSYCH on 10/28/18 at 11:00 a.m. revealed his strengths and assets were education, supportive family/friends, capable of independent living, insight into problem, articulate, and adequate finances. There was no documented evidence his strengths and assets were documented in a descriptive fashion.

Patient #2
Review of Patient #2's "Inpatient Psychiatric Evaluation" documented by S8PSYCH on 10/29/18 at 10:00 a.m. revealed her strengths and assets were documented as insight, motivated for treatment, capable of independent living, insight into problem, and articulate. There was no documented evidence her strengths and assets were documented in a descriptive fashion.

Patient #3
Review of Patient #3's "Inpatient Psychiatric Evaluation" documented by S11PMHNP on 10/28/18 at 9:15 a.m. revealed her strengths and assets were documented as insight, education, and motivated for treatment. There was no documented evidence her strengths and assets were documented in a descriptive fashion.

Patient #4
Review of the medical record for Patient #4 revealed the patient was a 58 year old admitted to the hospital on 10/28/18 with a diagnosis of Psychosis. Review of the Psychiatric Evaluation conducted on 10/29/18 by S8PSYCH revealed the section for strength and assets were check off boxes. Patient #4's strength and assets were documented as motivated for treatment and articulate.

Patient #5
Review of Patient #5's medical record revealed an admit date of 10/24/18 with a diagnosis of Neurocognitive Disorder with Psychosis. Review of the Psychiatric Evaluation conducted on 10/25/18 by S10NP revealed the section for strength and assets were check off boxes. Patient #5's strength and assets were left blank.

Patient #8
Review of the medical record for Patient #8 revealed the patient was a 66 year old admitted to the hospital on 10/23/18 with a diagnosis of Dementia. Review of the Psychiatric Evaluation conducted on 10/25/18 by S8PSYCH revealed the section for strength and assets were check off boxes. Patient #8's strength and assets were documented as supportive family/friends.

Patient# 11
Review of the medical record for Patient #11 revealed the patient was a 52 year old admitted to the hospital on 10/28/18 with a diagnosis of Depression. Review of the Psychiatric Evaluation conducted on 10/29/18 by S8PSYCH revealed the section for strength and assets were check off boxes. Patient #11's strength and assets were documented as insight, education, motivated for treatment, supportive family/friends, insight into problem, employment, articulate, adequate finances, and stable physical health.

Patient #13
Review of the medical record for Patient #13 revealed the patient was a 52 year old admitted to the hospital on 10/28/18 with a diagnosis of Psychosis. Review of the Psychiatric Evaluation conducted on 10/29/18 by S8PSYCH revealed the section for strength and assets were check off boxes. Patient #13's strength and assets were documented as motivated for treatment, capable of independent living, insight into problem, and articulate.

In an interview on 10/31/18 at 9:05 a.m. with S8PSYCH, he confirmed the strength and assets are only check boxes and not descriptive terms. S8PSYCH further indicated he doesn't have the time to do "all that documentation", that's why they have the form they have (meaning the psychiatric evaluation with check boxes). He indicated he documents after reviewing the psychosocial evaluation, but it's not always done and on the chart when he does his evaluation. He confirmed the evaluation form is formatted in an interpretive fashion rather than descriptive.

In and interview on 10/31/18 at 11:30 a.m., S10NP verified the strength and assets were left blank on Patient #5's medical record and stated, "I forgot to go back and do that. I usually get that information from the Social Worker".




39791

25119

Based on record review and interview, the hospital failed to ensure each patient had a comprehensive individualized treatment plan which addressed all psychiatric and medical diagnoses for 3 (#1, #4, #5) of 8 (#1, #2, #3, #4, #5, #8, #11, #13) active patient records reviewed for treatment plans from a sample of 14 patients.
Findings:

Review of the hospital policy titled, "Treatment Planning; Integrated/Multidisciplinary", Policy Number CS-02, revised 05/01/2017 revealed in part: Policy: The multidisciplinary treatment team, under the direction and supervision of the attending physician, shall develop an integrated, written, comprehensive treatment plan with specific goals and objectives necessary to address deficits identified in the assessment process. The treatment plan shall be initiated as a component of the admission process with continual development and formulation by the attending physician and multidisciplinary treatment team, with the patient's involvement, throughout the course of treatment. The treatment plan includes defined problems and needs, measurable goals and objectives based on assessed needs, strengths and limits, frequency of care, treatment and services, facilitating factors and barriers, and transition criteria to lower levels of care.
Procedure: 2. The admitting nurse is responsible for the following: *Revising and developing nursing and medical components of the treatment plan based on additional findings from patient assessments, problems, needs, strengths, limitations, and physician's orders. Revising the plan based on changes in condition and physician's orders received. All physician's orders will be added to the treatment plan.

Review of Patient #1's medical record revealed he was admitted on 10/28/18 with a diagnosis of depression. Review of his "Inpatient Psychiatric Evaluation" documented by S8PSYCH on 10/28/18 revealed admitting diagnoses of Methamphetamine Use Disorder, Anorexia, and Gastroenteritis. Review of his "Multidisciplinary Integrated treatment Plan initiated on 10/28/18 revealed no documented evidence that a treatment plan was developed for anorexia, and gastroenteritis.

Patient #4
Review of Patient #4's medical record revealed an admit date of 10/28/18 with admission diagnosis of Psychosis. Further review revealed medical diagnosis of End Stage Renal Disease, Diabetes, Hypertension, and Status/Post Renal Transplant as documented on the Psychiatric Evaluation dated 10/29/18.

Review of the Multidisciplinary Integrated Treatment Plan Problem List dated 10/28/18 revealed problem #1- Alteration in perception related to Psychosis, #2- Risk for Falls, #3- Alteration in Health Maintenance of Hypertension, CCR, and #4 Alteration in Health Maintenance of Chronic Renal Failure and Kidney Transplant. Further review revealed there was no documented evidence of treatment plans developed for Hypertension, CCR, Chronic Renal Failure and Kidney Transplant.

Patient #5
Review of Patient #5's medical record revealed an admit date of 10/24/18 with a psychiatric diagnosis of Neurocognitive Disorder with Psychosis and a medical diagnosis of Hypertension, Atrial fibrillation, Congestive Heart Failure, and Diabetes Mellitus II as documented on the H&P dated 10/25/2018.

Review of the Multidisciplinary Integrated Treatment Plan Problem List dated 10/24/18 revealed problem #1 - Alteration in thought process related to psychosis as evidence by sleep pattern disturbance, appetite disturbance, and visual hallucination; problem #2 - High risk for falls related to effects in mobility as evidence by ARF 31 and unsteady gait; problem #3 - Alteration in health maintenance related to cardiac deviation output as evidence by history of Hypertension, Diabetes Mellitus II, and history of Congestive Heart Failure.

In an interview on 10/29/18 at 2:45 p.m., S4DON confirmed the treatment plan for patient #4 was not complete and did not include a treatment plan for the medical diagnoses and should include all aspects of the patient care.

In an interview on 10/31/18 at 3:00 p.m., S3RDCS confirmed the medical diagnoses should be included in the treatment plans.




39791

39791

Based on record review and interview, the hospital failed to ensure that each patient who was discharged had a discharge summary that was accurate and dictated within 30 days of discharge for 2 (#6, #9) of 4 (#6, #9, #10, #14) closed records reviewed for a discharge summary from a sample of 14 patients.
Findings:

Review of the Medical Staff Rules and Regulations, received as current Policy BLAW-03, revealed a final progress note must be written in the medical record, including a final diagnosis if it is not recorded on the face sheet. The discharge summary must be dictated and filed in the medical record within 30 days. A medical record shall not be permanently filed until it is completed by the attending medical staff member or is ordered filed by the medical staff committee.

Patient #6
Review of Patient #6's medical record revealed he was admitted on 08/03/18 and expired on 08/20/18. Further review revealed no documented evidence that a discharge summary had been documented by S8PSYCH.

In an interview on 10/31/18 at 9:05 a.m., S8PSYCH indicated there should be a discharge summary and an order to release Patient #6's body to the funeral home.

Patient #9
Review of Patient #9's clinical record revealed he was a 65 year old male admitted to the hospital on 05/29/18 with a diagnosis of Psychosis. The record revealed the patient was discharged on 06/12/18 to an acute care hospital.

Review of the record revealed there was no documented evidence of a discharge summary. Further review of the record revealed a discharge order dated 06/12/18 at 4:30 p.m. received by S23LPN and signed by S8PSYCH on 09/19/18 at 11:00 a.m.

On 10/31/18 at 9:15 a.m. in an interview with S8PSYCH, he reviewed the medical record of Patient #9 and verified no discharge summary on the chart. He further revealed if the chart was not flagged for him to complete a discharge summary, he would not know a discharge summary was needed.

On 10/30/18 at 3:20 p.m. in an interview with S3RDCS, she verified there is no discharge summary with an admission date of 05/29/18 and a discharge date of 06/12/18 in the medical record of Patient #9.

On 10/30/18 at 4:00 p.m. in an interview with S3RDCS, she indicated Patient #9 was admitted on 05/29/18 and discharged on 06/12/18. She further indicated the Discharge Summary with an admission date of 06/15/18 and a discharge date of 07/02/18 was not a valid discharge summary for the admission of 05/29/18.