HospitalInspections.org

Based on observation, interview, and record review, the Governing Body failed to effectively discharge its oversight responsibilities in the overall operation of the hospital

Findings included:

The Governing Body failed to:

1. establish a process for prompt resolution of patient grievances. Specifically, the facility failed to inform each patient of the name of the individual to contact to file a grievance. In addition, there was no documentation that the facility applied what it learned from the grievances as part of its continuous quality improvement activities.

Cross reference Tag A0118 - Patient Rights: Grievances - CFR 482.13(a)(2)


2. promote the personal privacy of patients by posting their full names on a window at the nurse's station.

Cross reference Tag A0143 - Patient Rights: Personal Privacy - CFR 482.13(c)(1)


3. ensure that bedrooms and bathrooms were free of tie-off points; beds were secured to the floor; electrical outlets were safe; "Environment of Care Safety Rounds" were completed; an environment of care risk assessment was conducted; a suicidal patient was monitored closely in the Intake Department by properly trained staff in the management of suicidal patients; a wall-mounted TV was free of exposed electrical wiring and tie-off points; the seclusion room bathroom was a safe environment; and oxygen cylinders were properly secured.

Cross reference Tag A0144 - Patient Rights: Care in Safe Setting - CFR 482.13(c)(2)


4. ensure an order was obtained from a physician to restrain a patient.

Cross reference Tag A0168 - Patient Rights: Restraint or Seclusion - CFR 482.13(e)(5)


5. ensure that medications used in emergency situations were not ordered as a standing order or on as needed basis (PRN).

Cross reference Tag A0169 - Patient Rights: Restraint or Seclusion - CFR 482.13(e)(6)


6. ensure that patients were seen face-to-face within one hour after the initiation of restraint or seclusion by a physician, or a registered nurse trained to conduct the one-hour face-to-face assessment. In addition, the facility failed to properly train registered nurses on the rules and regulations governing restraint, seclusion, and use of medications in emergency situations, as well as competency-based training for conducting the one-hour face-to-face assessment for a patient in restraints or seclusion.

Cross reference Tag A0178 - Patient Rights: Restraint or Seclusion - CFR 482.13(e)(12)


7. ensure that the registered nurse assigned the nursing care of patients to other nursing personnel.

Cross reference Tag A0397 - Patient Care Assignments - CFR 482.23(b)(5)


8. ensure that seclusion and restraint packets were accurately written and properly filed as evidenced by patient identifier (name).

Cross reference Tag A0438 - Form and Retention of Records - CFR 482.24(b)

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

1. ensure that bedrooms and bathrooms were free of tie-off points; beds were secured to the floor; electrical outlets were safe; "Environment of Care Safety Rounds" were completed; environment of care risk assessment was conducted; suicidal patient was monitored closely in the Intake Department; wall-mounted TV was free of exposed electrical wiring and tie-off points; seclusion room bathroom was a safe environment; and oxygen cylinders were properly stored and secured.

Cross reference Tag A0144 - Patient Rights: Care in Safe Setting - CFR 482.13(c)(2)


2. ensure that restraints were not ordered as a standing order or as needed basis (PRN

Cross reference Tag A0169 - Patient Rights: Restraint or Seclusion - CFR 482.13(e)(6)


3. ensure an order was obtained from a physician to restrain a patient.

Cross reference Tag A0168 - Patient Rights: Restraint or Seclusion - CFR 482.13(e)(5)


4. ensure that patients were seen face-to-face within one hour after the initiation of restraint or seclusion by a physician or a registered nurse trained to conduct the one-hour face-to-face assessment. In addition, the facility failed to properly train registered nurses on the rules and regulations governing restraint, seclusion, and use of medications in emergency situations, as well as competency-based training for conducting the one-hour face-to-face assessment for patient in restraints or seclusion.

Cross reference Tag A0178 - Patient Rights: Restraint or Seclusion - CFR 482.13(e)(12)


5. promote the personal privacy patients by posting their full names on a window at the nurse's station.

Cross reference Tag A0143 - Patient Rights: Personal Privacy - CFR 482.13(c)(1)


6. establish a process for prompt resolution of patient grievances. Specifically, the facility failed to inform each patient of the name of the individual to contact to file a grievance. In addition, there was no documentation that the facility applied what it learned from the grievances as part of its continuous quality improvement activities.

Cross reference Tag A0118 - Patient Rights: Grievances - CFR 482.13(a)(2)

Based on interview, record review, and observation, the facility failed to establish a process for prompt resolution of 10 of 10 randomly selected patient grievances. These ten grievances were made by seven patients (Patient #21, 23, 24, 25, 26, 27, and #28). Specifically, the facility failed to inform each patient of the name of the individual to contact to file a grievance. Finally, there was no documentation that the facility applied what it learned from the grievances as part of its continuous quality improvement activities. This was evidenced by five complaints against one nurse made by five different patients with no documentation that there had been an investigation into the allegations.

Findings included:

Record review of Policy RI.005, "Patient and Family Grievance Guidelines," revised 12/8/2020, showed the facility "will provide an effective mechanism for handling patient/family grievances as an important part of providing quality care and service to our patients ... All patients and families will be informed of the grievance process upon admission ...

[The facility] requires all personnel to promptly alert the program leadership and the ... Patient Advocate concerning any patient grievance ...

The hospital has an established grievance resolution process ...

Data collected regarding patient grievances, as well as other complaints that are not defined as grievances, will be included in the hospital's Performance Improvement Plan ...

PROCEDURE

1.0 Patients and their family members are informed of the patient's rights and responsibilities upon admission, and the process by which they can voice any concerns related to their rights and/or treatment ...

9.0 Leaders and medical staff follow a process for collecting, investigating, and addressing clinical practice concerns."


Staff J (Intake Coordinator) provided a copy of the "Patient & Family Resource Guide." Record review of the "Patient & Family Resource Guide' stated: "COMPLAINT PROCESS ...

If you or your family feels that your concerns are not being resolved ... you can inform any staff member that you wish to speak to ... the patient advocate."


In an interview with Staff J (Intake Coordinator) on 6/21/2021 at 11:45 am, she stated that she did not know who had been appointed as the patient advocate. She stated, the name of the patient advocate, along with a phone number, was not being provided to new admissions in the Intake Department.


In an interview with Staff P (Unit RN) on 6/22/2021 at 11:00 am, he stated that he did not know who had been appointed as the patient advocate. He also stated that name and phone number of the patient advocate was not displayed on the unit. At that time, observation of the inpatient unit revealed that the name of the patient advocate and information on how to contact the patient advocate was not displayed on the unit for the patients to see.


In an interview with Staff A (CNO) and Staff B (Director of Quality) on 6/17/2021 at 11:00 am, Staff A stated that there was no patient advocate to address patient complaints and grievances. He then appointed Staff B as the "Patient Advocate" to oversee the grievance process. Staff A stated that he could not produce a complaint or grievance log for 2021.


In an interview with Staff B (Director of Quality) on 6/22/2021 at 1:3, she stated that she had reviewed the QAPI minutes for 2021, adding that complaints and grievances had not been reviewed and analyzed through the hospital's QAPI process.


Record review of the QAPI binder for 2021 showed no reports to QAPI from the Patient Advocate on complaints and grievances, thus no review or analysis of the data found in the complaint binder for 2021.


Record review of the "Complaint" binder showed numerous complaints on a form titled, "Quality Improvement Complaint Form." A sampling of ten random complaints/grievances was taken from the binder. These ten complaints/grievances were made by seven patients (Patient #21, 23, 24, 25, 26, 27, and #28). A review of each complaint/grievance is outline below.


Record review of the "Separation Record" for Staff Q (RN) dated 5/10/2021 showed that Staff Q voluntarily resigned for another job. Would you rehire this employee? "Yes." The form was signed by Staff A (CNO) and witnessed by Staff U (HR).


Patient #21.
Review of Quality Improvement Complaint Form dated 3/16/2021 at 8:34 am for Patient #21 showed the complaint was received on 3/16/2021. There is no documentation as to who received the complaint form. Patient #21 stated, she felt "unsafe with Patient #22, adding that Patient #22 made "uncalled for remarks," stared at her, and "came far too close to touching my breast." There was no documented follow-up by any staff at the facility.


Patient #23.
Review of Quality Improvement Complaint Form for Patient #23 showed the complaint was dated 2/16/2021 (not timed) but signed by the patient on 2/18/2021 (not timed). Patient #21 made a complaint against Staff Q (RN), stating that Staff Q did not respond appropriately to her elevated blood pressure of 176/100 and pulse of 140. Staff Q offered the patient Atarax. At the request of the patient, vital signs were taken a second time. BP was 160/100 and pulse 148. Patient #23 stated Staff Q asked the medication nurse what to do. They contacted Staff R (RN). Staff R called the physician. He ordered clonidine. Patient #23 also stated, she could hear Staff Q discussing "personal business" of other patients. There was no documented follow-up by any staff at the facility.


Patient #24 - three complaints.
Review of Quality Improvement Complaint Form for Patient #24 showed the complaint was dated 2/16/2021 at 8:00 (unsure if AM or PM) but signed by the patient on 2/19/2021 (not timed). Patient #24 complained that Staff Q spoke to his mother about his treatment, adding he had not given consent for staff to speak with his mother. He also complained about the wound care he received from Staff Q. There was no documented follow-up by any staff at the facility.

Review of Quality Improvement Complaint Form for Patient #24 showed the complaint was dated 2/18/2021 at 3:1. Patient #24 filed a complaint against Staff T (Recreation Therapist). The complaint was illegible. There was no documented follow-up by any staff at the facility.

Review of Quality Improvement Complaint Form for Patient #24 showed the complaint was dated 3/8/2021 (not timed). Patient #24 complaint that Staff S (Unit RN) threatened to send him to a psychiatric intensive care unit if he did not stop self-harming, "meanwhile another patient was throwing things, ... yelling, masturbating in front of the of other patients, showing his penis to the other patients, and threatening everyone around him." There was no documented follow-up by any staff at the facility.


Patient #25.
Review of Quality Improvement Complaint Form for Patient #25 showed the complaint was dated 3/9/2021 at 10:15 am. The complaint was filed against Staff Q. The patient stated, she woke up around 4:30 am and told Staff Q that she "was not feeling good." Patient #25 alleged that Staff Q told her that she was "fine" and to "go lay down." There was no documented follow-up by any staff at the facility.


Patient #26.
Review of Quality Improvement Complaint Form for Patient #26 showed the complaint was dated 2/4/2021 (not timed). The complaint was filed against Staff Q. The content of the complaint is illegible. There was no documented follow-up by any staff at the facility.


Patient #27.
Review of Quality Improvement Complaint Form for Patient #27 showed the complaint was dated 2/5/2021 at 12:fpm. The complaint was filed against Staff Q for being "rude" and "gossiping." Much of the content of the complaint is illegible. There was no documented follow-up by any staff at the facility.


Patient #28 - two complaints.
Review of Quality Improvement Complaint Form for Patient #28 showed the complaint was dated 4/7/2021 at 12:2. Patient #28 requested "access to board games, puzzles, coloring books, and other things of therapeutic means." There was no documented follow-up by any staff at the facility.

Review of Quality Improvement Complaint Form for Patient #28 showed the complaint was dated 4/8/2021 at 12:5. Patient #28 stated the TV in the front dayroom was not working and "having only one TV in the back is starting to become an issue with people wanting to see different television programs." There was no documented follow-up by any staff at the facility.

Based on observation, record review, and interview, the facility failed to ensure the personal privacy of patients by posting the full names of 2 of 4 patients (Patient #12 and Patient #13) on the "6/17/2021 Shower List" displayed on a window at the nurse's station.

Findings included:

Observation of the nurse's station on the adult psychiatric unit on 6/17/2021 at 11:00am showed the "6/17/2021 Shower List had been taped to a widow at the nurse's station.

Review of the shower list showed the full names of 2 of 4 patients (Patient #12 and Patient #13).

In an interview with Staff A (CNO) on 6/17/2021 at 11:00am, he stated that the full names of the patients should not be on display on this list at the nurse's station for the other patients to see.

Based on interview, record review, and observation, the facility failed to ensure that patients received care in a safe setting. Specifically,

A. The facility failed to ensure that 10 of 17 bedrooms (bedroom #100, 101, 103, 202, 204, 205, 206, 207, 208, and#209) were free of tie-off points between the headboard and the wall. This failure resulted in 7 of 19 patients (patient #1, 2, 13, 15, 17, 18, and#19), admitted with suicidal ideation, were assigned to one of the 10 bedrooms that had observable ligature risks.

B. The facility failed to ensure that 1 of 17 bedrooms (bedroom #203) had 2 beds that were bolted to the floor. This failure resulted in 1 of 19 patients (patient #3), admitted with suicidal ideation, was assigned to bedroom 203. The unbolted beds can be moved against the bedroom door, blocking entry into the bedroom from the hallway.

C. The facility failed to ensure that the PVC cover that enclosed the tankless plumbing system on 4 of 19 toilets was free of tie off points. This failure resulted in 3 of 19 patients (patient #1, #18, and #19), admitted with suicidal ideation, were assigned to one of the bedrooms that had toilets with a PVC cover that created a tie-off point.

D. The facility failed to ensure that 17 of 17 bedrooms (bedroom #100, 101, 102, 103, 104, 105, 106, 107, 108, 202, 203, 204, 205, 206, 207, 208 and #209) had safe electrical outlets. This failure resulted in 19 of 19 patients (patients 1-19) being placed in a bedroom with numerous "live" electrical outlets. "Live" electrical outlets can be a fire and safety hazard.

E. The facility failed to ensure that the "Environment of Care Safety Rounds" were completed each shift. This failure resulted in the following safety issues not documented: 10 of 17 bedrooms having ligature risks (tie-off points) in the bedrooms, 1 of 17 bedrooms with unbolted beds, 4 of 17 toilets with ligature risks (tie-off points), and 17 of 17 bedrooms with "live" electrical outlets.

F. The facility failed to ensure that an environment of care risk assessment was conducted. This failure resulted in the following safety issues not documented: 10 of 17 bedrooms having ligature risks (tie-off points) in the bedrooms, 1 of 17 bedrooms with unbolted beds, 4 of 17 toilets with ligature risks (tie-off points), and 17 of 17 bedrooms with "live" electrical outlets.

G. The facility failed to ensure that 1 of 1 suicidal patient (patient #20) in the Intake Department was monitored closely during the admission process by properly trained staff on the management of suicidal patients. The patient was placed alone in an ED bay with numerous pieces of equipment that could be used for hanging or strangulation.

H. The facility failed to ensure that the wall-mounted TV in the commons area on the back hallway was free of exposed electrical wiring and tie off points that could be used for hanging or strangulation.

I. The facility failed to ensure that the seclusion room bathroom was a safe environment as evidenced by a lightweight two-drawer wooden cabinet on wheels, a lightweight chair, and a trash receptacle with a plastic bag liner in the space. The cabinet and chair can be used as a weapon. The plastic bag can used for suffocation. In addition, there were no video surveillance cameras in the seclusion anteroom.

J. The facility failed to ensure that stored oxygen cylinders were secured with a rack or chains to prevent tipping, falling, or rolling. Should the cylinder fall over, it might break, causing the pressurized oxygen to escape rapidly. This pressure can cause the tank to fly through the air.


Findings included:

A, B, C - ligature risks.

During a tour on June 17, 2021 at 10:00 am with Staff A (CNO) and Staff B (Director of Quality), the following interviews was conducted, and the following items were observed:

1) 7 beds, bolted to the floor, created a gap between the headboard and the wall. These 7 beds were found in the following rooms: room #100, 101, 202, 203, 204, 205, and #206. Staff A removed a flat sheet from a patient's bed, tied a knot in one corner of the bedsheet, and wedged the knot between the headboard and the wall. He pulled on the bedsheet; the knot stayed wedged in the gap. He stated that the space between headboard and the wall created a tie-off point that could be used for the purpose of hanging. He further stated he did not know that there was a gap between the headboard and the wall in these bedrooms that could be used as an anchor point for hanging.

2) 2 beds were not bolted to the floor in room #103. Staff A stated that the top of the bedroom door could be used as a tie-off point. He also stated that the beds could be repositioned in such a way as to prevent staff from being able to get into the bedroom. He further stated, he did not know that there were beds that were not bolted to the floor.

3) Access to the tankless plumbing system of all 17 toilets had been altered with the installation of a white PVC cover. There were two one-inch holes in each cover, one on top of the toilet that provided access to a button that could be pushed to flush the toilet and one on the front of the cover that exposed the no touch sensor. The hole for the no touch sensor had been covered with a rectangular piece of clear plastic. The clear plastic rectangle had come off four toilets (room #101, 207, 208, and #209). A tie-off point was created by running a corner of a sheet through one hole and then the other. Staff A was reminded that the toilets had been cited in a previous survey for this ligature risk. He stated that it appeared the clear plastic rectangle had come off the four toilets in question. He pointed to sticky strips that had held the clear plastic rectangle in place over the hole. He also stated the two holes created a tie-off point. He further stated he did not know that there were anchor points on four of the patient toilets.


Record review of the Final Census Report, dated June 17, 2021 at midnight, showed a census of 19 patients. Each patient had been assigned to a room (rooms 100-108 and 202-208) and a bed number. The report showed the following 8 patient placements:

Patient #1 - Room 100
Patient #2 - Room 101
Patient #3 - Room 102
Patient #13 - Room 202
Patient #15 - Room 204
Patient #17 - Room 206
Patient #18 - Room 207
Patient #19 - Room 208


Record review of Policy PC.013, "Suicide Risk Assessment and Precautions," revised 12/30/2019, showed: "Patients will be assessed for suicide risk ... Staff responsible for monitoring patients on suicide precautions will maintain the patient in a safe environment and take measures to protect the patient from self-harm or self-injurious behavior ... "


The 8 patients with suicidal ideation placed in a bedroom with a ligature risk.

Patient #1
Room 100 - gap between headboard and wall, and anchor point on toilet.

Record review of the Pre-admission Evaluation by Staff C (MD), dated 6/10/2021 at 10:4, showed Patient #1 was an involuntary 60-year old male complaining of suicidal thoughts. He stated, he had a plan to shoot himself and die. His speech was pressured and rapid with flight of ideas. Insight and judgement were poor. It was further documented that the patient had a "current or potential threat to self, others, or property due to active manifestations of the psychiatric disorder, which warrants a controlled environment for continuous skilled observation, evaluation, and care, as is only available for the level of care chosen."

Record review of Physician's ... Orders and Preliminary Plan of Care by Staff C (MD), dated 6/10/2021 at 10:4, showed that Patient #1 had a preliminary diagnosis of Bipolar I disorder, mixed, severe. Orders: Admit to the inpatient psychiatric unit, suicide precautions, and Q15 minute observations.

Record review of Psychiatric Evaluation by Staff D (MD), dated 6/11/2021 at 9:12 am, showed that Patient #1 had a long history of depression and bipolar disorder, complicated by cancer and chronic pain which led to drug dependence. He had a previous history of suicide attempt. He was delusional and his mood was volatile. Insight and judgement were impaired.


Patient #2
Room 102 - gap between headboard and wall.

Record review of the Pre-admission Evaluation by Staff E (MD), dated 5/14/2021 at 5:5, showed that Patient #2 was an involuntary 40- year old female complaining of suicidal thoughts. She stated, she wanted to "take a bunch of pills." She was delusional, confused, and rambling. Her insight and judgement were poor. It was further documented that the patient had a "current or potential threat to self, others, or property due to active manifestations of the psychiatric disorder, which warrants a controlled environment for continuous skilled observation, evaluation, and care, as is only available for the level of care chosen."

Record review of Physician's ... Orders and Preliminary Plan of Care by Staff E (MD), dated 5/14/2021 at 5:5, showed that Patient #2 had a preliminary diagnosis of delusional disorder. Orders: Admit to the inpatient psychiatric unit, suicide and elopement precautions, and Q15 minute observations.

Record review of Psychiatric Evaluation by Staff D (MD), dated 5/15/2021 at 2:3, showed that Patient #2 had depressed mood, religious delusions, auditory hallucinations ("talking to God"), and threats of suicide. Insight and judgement were impaired.


Patient #3
Room 103 - beds not bolted to the floor.

Record review of the Pre-admission Evaluation by Staff E (MD), dated 6/11/2021 at 11:09 am, showed that Patient #3 was a voluntary 23-year old female complaining of suicidal thoughts. Insight and judgement poor. It was further documented that the patient had a "current or potential threat to self, others, or property due to active manifestations of the psychiatric disorder, which warrants a controlled environment for continuous skilled observation, evaluation, and care, as is only available for the level of care chosen."

Record review of Physician's ... Orders and Preliminary Plan of Care by Staff E (MD), dated 6/11/2021 at 11:09 am, showed that Patient #3 had a preliminary diagnosis of major depressive disorder, recurrent, severe. Orders: Admit to the inpatient psychiatric unit, suicide precautions, and Q15 minute observations.

Record review of Psychiatric Evaluation by Staff H (MD), dated 6/12/2021 at 12:2, showed that Patient #3 had depressed mood, mood swings, anger, and a "very tumultuous past including multiple sexual assaults and abuse." She had been engaged in cutting behavior in teenage years. History of methamphetamine use.


Patient #13
Room 202 - gap between headboard and wall.

Record review of the Pre-admission Evaluation by Staff F (MD), dated 6/11/2021 at 5:3, showed that Patient #13 was a voluntary 36-year old female complaining of suicidal thoughts with a plan to overdose. Her insight and judgement were fair. It was further documented that the patient had a "current or potential threat to self, others, or property due to active manifestations of the psychiatric disorder, which warrants a controlled environment for continuous skilled observation, evaluation, and care, as is only available for the level of care chosen."

Record review of Physician's ... Orders and Preliminary Plan of Care by Staff F (MD), dated 6/11/2021 at 5:3, showed Patient #14 had a preliminary diagnosis of major depressive disorder, recurrent, severe and generalized anxiety disorder. Orders: Admit to the inpatient psychiatric unit, suicide precautions, and Q15 minute observations.

Record review of Psychiatric Evaluation by Staff H (MD), dated 6/12/2021 at 11:30 am, showed that Patient #14 was suicidal with a plan to cut her wrist or overdose. Threatening suicide. History of cutting her inner thigh (2020).


Patient #15
Room 204 - gap between headboard and wall.

Record review of the Pre-admission Evaluation by Staff E (MD), dated 6/12/2021 at 8:6, showed that Patient #15 was a voluntary 51-year old male complaining of suicidal thoughts. He was tearful and not wanting to live. His pain level was 10 on a scale of 0-10. It was further documented that the patient had a "current or potential threat to self, others, or property due to active manifestations of the psychiatric disorder, which warrants a controlled environment for continuous skilled observation, evaluation, and care, as is only available for the level of care chosen."

Record review of Physician's ... Orders and Preliminary Plan of Care by Staff E (MD), dated 6/12/2021 at 8:6, showed that Patient #15 had a preliminary diagnosis of major depressive disorder, recurrent, severe. Orders: Admit to the inpatient psychiatric unit, suicide and seizure precautions, and Q15 minute observations.

Record review of Psychiatric Evaluation by Staff H (MD), dated 6/13/2021 at 10:11 am, showed that Patient #15 was delusional, hyperverbal, and manic. He had no insight and very poor judgement. He was threatening suicide.


Patient #17
Room 206 - gap between headboard and wall.

Record review of the Pre-admission Evaluation by Staff C (MD), dated 6/9/2021 at 12:5, showed that Patient #17 was an involuntary 19-year old female complaining of suicidal thoughts with intent. She was picked up by her parents from a motel known for heavy drug use. She tried to open the car door while the car was moving down a freeway. She told her parents they "should have left me there to die. If it's my time, it's my time." She had a history of cutting and use of street drugs. There was a history of borderline personality disorder. It was further documented that the patient had a "current or potential threat to self, others, or property due to active manifestations of the psychiatric disorder, which warrants a controlled environment for continuous skilled observation, evaluation, and care, as is only available for the level of care chosen."

Record review of Physician's ... Orders and Preliminary Plan of Care by Staff C (MD), dated 6/9/2021 at 12:5, showed that Patient #17 had a preliminary diagnosis of major depressive disorder, recurrent, severe. Orders: Admit to the inpatient psychiatric unit, suicide and elopement precautions, and Q15 minute observations.

Record review of Psychiatric Evaluation by Staff D (MD), dated 6/10/2021 at 10:11 am, showed Patient that #17 was recently jailed, with chemical dependency issues. Her mood was manic and volatile. She had paranoid and grandiose delusions and a previous suicide attempt. She had poor insight and impaired judgement. Diagnosis was changed to bipolar I disorder, moderate, manic.


Patient #18
Room 207 - anchor point on toilet.

Record review of the Pre-admission Evaluation by Staff E (MD), dated 6/13/2021 at 10:1, showed that Patient #18 was a voluntary 43-year old male with suicidal thoughts and auditory hallucinations. He had a history of paranoid schizophrenia. It was further documented that the patient had a "current or potential threat to self, others, or property due to active manifestations of the psychiatric disorder, which warrants a controlled environment for continuous skilled observation, evaluation, and care, as is only available for the level of care chosen."

Record review of Physician's ... Orders and Preliminary Plan of Care by Staff E (MD), dated 6/13/2021 at 10:1, showed that Patient #18 had a preliminary diagnosis of schizophrenia, disorganized type. Orders: Admit to the inpatient psychiatric unit, suicide precautions, and Q15 minute observations.

Record review of Psychiatric Evaluation by Staff D (MD), dated 6/14/2021 at 10:32 am, showed that Patient #18 had chemical dependency issues and a previous suicide attempt. Insight and judgement were impaired.


Patient #19
Room 208 - anchor point on toilet.

Record review of the Pre-admission Evaluation by Staff C (MD), dated 6/13/2021 at 9:9, showed that Patient #19 was a voluntary 56-year old male complaining of suicidal thoughts. He also verbalized homicidal intent toward female. He talked of stepping in front of traffic. He was verbally aggressive. It was further documented that the patient had a "current or potential threat to self, others, or property due to active manifestations of the psychiatric disorder, which warrants a controlled environment for continuous skilled observation, evaluation, and care, as is only available for the level of care chosen."

Record review of Physician's ... Orders and Preliminary Plan of Care by Staff C (MD), dated 6/13/2021 at 9:9, showed that Patient #19 had a preliminary diagnosis of bipolar I disorder, depressed, severe, with psychotic features. Orders: Admit to the inpatient psychiatric unit, suicide precautions, and Q15 minute observations.

Record review of Psychiatric Evaluation by Staff D (MD), dated 6/14/2021 at 3:2, showed that Patient #19 had severe depression and thoughts of dying. Insight and judgement impaired. Diagnosis changed to bipolar I disorder, depressed, recurrent, severe, without psychosis, and substance use, misuse, abuse (cocaine, severe).



D - Patients in rooms with "live" electrical outlets.

During a tour on June 17, 2021, at 10:00 am, with Staff A (CNO) and Staff B (Director of Quality), the following interviews were conducted, and observations were made. Staff B (Director of Quality) was observed testing one or two outlets in each of the 17 bedrooms with her phone charger. She stated all outlets were "live." There were 19 of 19 patients (patients 1-19) in the bedrooms with "live" electrical outlets. Staff A (CNO) stated that the electrical outlets should not be "live" because of potential fire and safety hazard. He further stated, he did not know that the electrical outlets were "live."

Record review of the Registration Admission form showed the following:
Patient #1 admitted 6/11/2021 at 12:02 am
Patient #2 admitted 5/14/2021 at 6:4
Patient #3 admitted 6/11/2021 at 11:28 am
Patient #4 admitted 6/11/2021 at 5:21 pm
Patient #5 admitted 6/11/2021 at 5:22 pm
Patient #6 admitted 6/8/2021 at 12:03 pm
Patient #7 admitted 6/8/2021 at 4:36 pm
Patient #8 admitted 6/11/2021 at 8:59 pm
Patient #9 admitted 6/16/2021 at 2:19 pm
Patient #10 admitted 6/1/2021 at 8:29 am
Patient #11 admitted 6/13/2021 at 5:27 pm
Patient #12 admitted 6/9/2021 at 5:15 pm
Patient #13 admitted 6/11/2021 at 5:57 pm
Patient #14 admitted 6/5/2021 at 1:05 pm
Patient #15 admitted 6/12/2021 at 7:42 pm
Patient #16 admitted 6/14/2021 at 11:42 pm
Patient #17 admitted 6/9/2021 at 12:38 pm
Patient #18 admitted 6/13/2021 at 10:11 pm
Patient #19 admitted 6/13/2021 at 10:55 pm

Record review of the Final Census Report, dated June 17, 2021 at midnight, showed a census of 19 patients. Each patient had been assigned to a room (rooms 100-108 and 202-208) and a bed number. The report showed the following 19 patient placements:
Patient #1 - Room 100
Patient #2 - Room 101
Patient #3 - Room 102
Patient #4 - Room 103
Patient #5 - Room 104
Patient #6 - Room 105
Patient #7 - Room 105
Patient #8 - Room 105
Patient #9 - Room 106
Patient #10 - Room 107
Patient #11 - Room 108
Patient #12 - Room 108
Patient #13 - Room 202
Patient #14 - Room 203
Patient #15 - Room 204
Patient #16 - Room 205
Patient #17 - Room 206
Patient #18 - Room 207
Patient #19 - Room 208


E - Environment of Care Safety Rounds

Record review of Policy PC.013, "Suicide Risk Assessment and Precautions," revised 12/30/2019, showed: "The environmental safety checks are conducted regularly to identify and minimize any environmental risks."

In an interview with Staff A (CNO) and Staff P (Unit RN) on 6/21/2021 at 1:00 pm, Staff A provided a blank copy of a "Daily Environmental Rounds Report" and stated the form was to be completed during the change of shift by the oncoming RN and the off-going MHT. Only one completed Environmental Rounds Reports was provided to the surveyor by Staff P. Staff A stated, the "Daily Environmental Rounds Report" needed to be revised.

Record review the "Daily Environmental Rounds Report" dated 6/21/2021 for the 7A to 7P shift showed the following areas were assessed by Staff P (Unit RN): Nurses Station - no food/drinks; Storage Rooms; Tub/Shower Rooms; Psych Consult Room; Exam Room; Laundry Room; Medical Equipment Storage; Seclusion Room;

Patient Rooms - no contraband found, no patient hazards or ligature risks, damage to room observed, infection control issues observed;

Recreation Therapy; Maintenance Issues - shower on the 100 hall is weak; window tint needs to be fixed in rooms 104, 105, and 203. A work order for the window tint was made.

NOTE: The Daily Environmental Rounds Report does not specify checking the patient bathrooms.


F - Environment of care risk assessment

During an interview with Staff A (CNO) and Staff B (Director of Quality) on June 17, 2021, at 10:00 am he stated that the facility did not have an environmental risk assessment. He further stated that an environmental risk assessment was an assessment, updated periodically, that documented all environmental risks throughout the facility. He concluded by stating that the environment risk assessment should also include mitigation strategies for those risks that could not be corrected or removed.

Record review of the policy EC.001, "Environment of Care Safety Rounds," revised 12/12/2020, showed:

"It is the policy of the Inpatient Behavioral Health Service to have a safe, functional and supportive environment for patients and staff. A systematic approach will be operational to proactively identify and manage environment risks and minimize the harm or risk to patients or others. Staff will actively participate in this approach by identifying and reducing environmental risks.

PROCEDURE

1.0 Environment of Care Safety rounds will be conducted by assigned staff every 12-hour shift and documented on checklist. The assignment will be performed by the Charge RN and a witness.

2.0 All patient rooms, common areas, and hallways are checked for ligature risks, non-tamper resistant screws, and any other environment of care hazards as well as contraband ...

3.0
4.0

5.0 Quarterly, a proactive environment of care risk assessment is conducted with Behavioral Health leadership as well as the Risk Manager and Safety Officer. A corrective action plan is developed based on the findings of the annual proactive EOC risk assessment. The quarterly EOC assessment and corrective action plan is submitted to ... QIC Committee."


G - Suicidal patient not monitored in the Intake Department.

Record review of Policy PC.003A, "Patient Awaiting Full Assessment in Lobby," revised 12/30/2019, showed: "[The facility] strives to provide patient care within a safe environment." The policy further states that if a patient is found to be highly suicidal, "a 1:1 for the individual will be arranged until the full assessment can be done."

Record review of Policy PC.013, "Suicide Risk Assessment and Precautions," revised 12/30/2019, showed: "Patients will be assessed for suicide risk ... Patients assessed to be at heightened risk of suicide or self-injurious behaviors will be placed on suicide precautions commensurate with the assessed level of risk ...

Staff responsible for monitoring patients on suicide precautions will maintain the patient in a safe environment and take measures to protect the patient from self-harm or self-injurious behavior ...

15.0 Upon initiation of suicide precautions, ... items that could pose a ligature risk or harm to patient are prohibited ...

19.0 The environmental safety checks are conducted regularly to identify and minimize any environmental risks.

20.0. All new employees responsible for patient care will receive orientation regarding Management of Suicidal Patients. All staff will successfully complete the Suicide Prevention competency annually."


Observation on 6/21/2021 at 11:35 am showed, Patient #20 was sitting on a bed in a bay of the "future" emergency department. The ED bay had 4-IV infusion pumps on poles with electrical cords, EKG machine with leads and an electrical cord, and a vital sign monitor with an electrical cord and blood pressure cord. There were numerous cords connected to the wall at the head of the bed. The bed had numerous tie-off points. There was a cotton sheet on the mattress. Two staff members were in the admission office: Staff I (Intake RN) and Staff J (Intake Coordinator). There was an ED bay between the admission office and the ED bay Patient #20 was sitting in. There were no other patients in the Intake Department awaiting assessment. There were no other patients in the lobby of the Intake Department awaiting assessment.


In an interview with Patient #20 on 6/21/2021 at 11:35 am, she stated that she had been seen by the nurse and was waiting to be evaluated by a physician.


Record review of the Medical Screening Exam for Patient #20, dated 6/21/2021 [not timed], by Staff I (Intake RN), showed: "A medical screening exam has been completed and an emergent medical condition does exist."

The Columbia Suicide Severity Rating Scale Screen with Triage Points for Primary Care (C-SSRS) for Patient #20 showed that she answered "Yes" to the following two questions:

Have you wished you were dead or wished you could go to sleep and not wake up?

Have you had any actual thoughts of killing yourself?

The admission Columbia score was 2, which indicated routine Q15 minute observations.


In an interview with Staff I (Intake RN) on 6/21/2021 at 11:37 am, she stated that she was the Intake RN on duty. She also stated, she had completed a suicide assessment on Patient #20 and was awaiting the tele-med assessment by a psychiatrist. She also stated a suicidal patient was not supposed to be in the ED bay alone, adding that she did not know the patient did not have someone with her. She also stated that the patient was waiting to be evaluated by a tele-med psychiatrist. She concluded by saying the patient was supposed to have a sitter with her.


In an interview with Staff J on 6/21/2021 at 11:38 am, she stated that she was the Intake Coordinator on duty. She also stated that Patient #20 was not supposed to be in the ED bay alone, adding that she too did not know the patient did not have someone with her.


In an interview with Staff A (CNO) on 6/21/2021 at 11:39 am, he stated that patients in the ED are supposed to be monitored and not left alone.


Record review of the HR personnel file for Staff I (Intake RN) showed no documentation of orientation regarding Management of Suicidal Patients or annual training on Suicide Prevention.


Record review of the Human Resources personnel file for Staff I (Intake RN) showed no job description for the Intake RN. There was no evidence of training on monitoring of patients on suicide precautions.


In an interview with Staff U (HR Director) on 7/1/2021 at 9:45 am, she stated that she had no other documentation in the personnel file for Staff I (Intake RN) other than what she had provided.

On the following day, 6/22/2021, the Pre-admission Evaluation, dated 6/21/2021 at 12:04 pm, by Staff F (tele-med MD) was reviewed. The evaluation showed that Patient #20 was a voluntary 46-year old female with complaints of depression. She had suicidal thoughts. She felt like she was just existing and could not find joy in life. She stated, she had a previous suicide attempt by overdose in 2007. She had been hearing voices "judging her" and felt like people were talking about her. She went without sleep for 2 days, two weeks earlier. She had thoughts of wanting to die. She had been isolating and felt hopeless. It was further documented that the patient had a "current or potential threat to self, others, or property due to active manifestations of the psychiatric disorder, which warrants a controlled environment for continuous skilled observation, evaluation, and care, as is only available for the level of care chosen."

Record review of the Physician's Pre-admission Examination Orders dated 6/21/2021 at 12:04 pm by Staff F (tele-med MD), showed a preliminary diagnosis of major depressive disorder, recurrent, with psychotic features. Orders: Admit to the inpatient psychiatric unit, suicide precautions, and Q15 minute observations. Staff I (Intake RN) signed off on the orders on 6/21/2021 at 12:24 pm.


H - Wall-mounted TV

During a tour of the unit on 6/22/2021 at 1:00 pm, it was observed that there were four hallways on the unit - two long hallways and two short hallways. Patient bedrooms were on the outside of the two long hallways. On one of the short hallways was the nurse's station. On the other short hallway was the common's area. In the commons area (on the back hallway) was a wall-mounted TV. The TV had not been enclosed, thus, exposing electrical and cable wires. The wall-mount hardware created tie off points that could be used for hanging or strangulation.

In an interview with Staff A (CNO) on 6/22/2021 at 1:00 pm, he stated that the wall-mounted TV should be enclosed to prevent patient access to the electrical and cable wires and tie off points created by the wall-mount hardware.


I - Seclusion room bathroom.

During a tour of the unit on 6/17/2021 at 10:00 am, the seclusion room bathroom was observed to have a lightweight two-drawer wooden cabinet on wheels in the corner adjacent to the toilet. There was also a lightweight chair in the doorway to the bathroom. The liner in the trash receptacle was a plastic bag.

In an interview with Staff A (CNO) on 6/17/2021 at 10:00 am, he stated that the lightweight cabinet and chair could be used as a weapon, and the plastic bag can be used for suffocation. He also stated these objects should not be in the seclusion room bathroom.

In an interview with Staff N (CNA) on 6/17/2021 at 11:25 am, she stated that the rolling cabinet should not be in the seclusion room bathroom because it could be used as a "weapon." Staff N also stated that a staff member will stay in the seclusion room area if a patient is in the quiet room. She concluded by saying that there were no video surveillance cameras in the seclusion area, adding, "there needs to be."

In an interview with Staff O (MHT) pm 6/17/2021 at 11:45 am, she stated that when a patient is in the quiet room, a "someone is there."


J - Oxygen cylinder.

Observation of the Medical Equipment Room on 6/17/2021 at 12:30 pm showed four oxygen cylinders were unsecured.

In an interview with Staff A (CNO) on 6/17/2021 at 12:30 pm, he stated that the oxygen cylinders are supposed to be secured with a stable base.

Record review of the National Fire Protection Association (NFPA) Standards 99 Health Care Facilities (2005 edition, updated 2017) showed that oxygen cylinders are to be secured with a rack or chain.

Based on record review and interview, the facility failed to ensure that an order was obtained from a physician to restrain 1 of 1 patient (Patient #31).

Findings included:

Record review of policy PC.025, "Restraint or Seclusion," revised 12/9/2020, showed: "[The facility] strives to ... uphold the dignity of each individual by protecting the patients' rights and well-being ...
3.0 ... Orders for restraint or seclusion are given by a physician or other authorized licensed independent practitioner primarily responsible for the patient's ongoing care ... 3.1.1 Use of restraint is based upon the order ... 3.1.3 When an RN initiates restraint, an order will be obtained from a physician as soon as possible after the restraint is initiated."


Patient #31.
Record review of Physician Order and Progress Note for Seclusion/Restraint dated 5/1/2021 showed that Staff K (RN) restrained Patient #31 10:27 am - 10:28 am and never obtained an order from the physician.


In an interview with Staff A (CNO) on 6/22/2021 at 2:fpm, he stated that a physician must provide an order for seclusion or restraint.


Record review of the Human Resources (HR) personnel file for Staff K (RN) showed that she started to work at the facility June 2017. The RN job description was signed 6/5/2017. The job description stated that the RN "Complies with physician orders." There was no evidence in the HR personnel file that Staff K had training on policy PC.025, "Restraint or Seclusion."

Based on interview and record review, the facility failed to ensure that restraints were never ordered as a standing order or as needed basis (PRN). This was evidenced by 6 of 6 randomly selected patients (Patient #32, 33, 34, 35, 36, and #37) with medications ordered as a "one unscheduled dose."

Findings included:

Record review of Policy PC.025, "Restraint and Seclusion," revised 12/9/2020 showed: "3.1 Physician Orders ... 3.1.5 Restraints and/or seclusion may NOT be ordered PRN or by standing orders."


In an interview with Staff X (Pharmacist) on 6/18/2021 at 9:00 am, she stated that the combination of Haldol, Ativan, and Benadryl is often ordered as "one unscheduled dose" for treatment of behavioral problems and is to be given if the patient needs it. She went on to say, "Technically, that's a PRN."


In an interview with Staff D (Medical Director) on 6/22/2021 at 10:18 am, he stated that an "unscheduled" dose of IM Haldol, Ativan, and Benadryl was a "PRN" medication, adding that these medications cannot be written as PRN medications.


In an interview with Staff W (RN) on 6/18/2021 at 10:00 am, she stated that calling a physician for an emergency medication can "sometimes be long." She also stated that an "unscheduled dose" is to be given "if you need it. It would be a PRN, but not like a normal PRN."


In an interview with Staff Y (LVN) on 6/18/2021 at 12:5, she stated:

1) A now dose for a combination of IM Haldol, Ativan, and Benadryl is good for up to four hours;

2) A one unscheduled dose of IM Haldol or Benadryl is good for up to 30 days; and

3) A one unscheduled dose of IM Ativan is good for up to 5 days.

She concluded, "In other words, an unscheduled dose of IM Haldol or Benadryl stays on the MAR (Medication Administration Record) for 30 days whereas IM Ativan would stay on the MAR for 5 days."
This information was then shared with Staff X (Pharmacist). She stated that Staff Y's explanation was accurate, adding that some patients were discharged with these medications still active on their MAR, as was the case with Patient #37.


Staff X (Pharmacist) provided a list of 22 instances in which Haldol, Ativan, and Benadryl were ordered and administered in combination as an unscheduled dose. There were 6 of 22 random instances (Patient #32, 33, 34, 35, 36, and #37) reviewed. The results of that review were.


Patient #32.
Record review of the Physician Orders for Patient #32 showed:

1) Orders 0177204, 0177205, and 0177206 (each medication had an order number): Haldol 5 mg, Ativan 2 mg, and Benadryl 50 mg IM ordered on 5/1/2021 at 10:06 am as one unscheduled dose for aggression and agitated [sic]. The stop date was 5/31/2021 for the Haldol and Benadryl; 5/6/2021 for the Ativan.

2) Order 0177207: Haldol 5 mg, Ativan 2 mg, and Benadryl 50 mg IM was again ordered on 5/1/2021 at 10:36 am as one unscheduled dose for aggression and agitation. The stop date was 5/31/2021 for all three medications.


Record review of the Medication Administration Record for Patient #32 showed that Haldol 5 mg, Ativan 2 mg, and Benadryl 50 mg (order 0177207) were administered IM on 5/1/2021 at 10:28 am. The patient was aggressive and had attacked staff. Orders 0177204, 0177205, and 0177206 were not documented on the MAR as having been administered.


Patient #33.
Record review of the Physician Orders for Patient #33 showed:

Orders 0178011, 0178012, and 0178013: Haldol 10 mg, Ativan 4 mg, and Benadryl 100 mg IM ordered on 5/19/2021 at 1:2 - 1:2 as one unscheduled dose. An indication for these medications was not documented. The stop date for these medications was 6/18/2021 for the Haldol and Benadryl; 5/24/2021 for the Ativan.

Record review of the Medication Administration Record for Patient #33 showed that Haldol 10 mg, Ativan 4 mg, and Benadryl 100 mg (orders 0178011, 0178012, and 0178013) were administered IM on 5/19/2021 at 1:3.


Patient #34.
Record review of the Physician Orders for Patient #34 showed:

Orders 0176871, 0176872, and 0176873: Haldol 10 mg, Ativan 4 mg, and Benadryl 100 mg IM ordered on 4/23/2021 at 4:1 - 4:14 pm as one unscheduled dose for agitation. The stop date for these medications was 5/23/2021 for the Haldol and Benadryl; 4/28//2021 for the Ativan.

Record review of the Medication Administration Record for Patient #34 showed that Haldol 10 mg, Ativan 4 mg, and Benadryl 100 mg (orders 0176871, 0176872, and 0176873) were administered IM on 4/24/2021 at 1:56 am - 1:58 am for extreme agitation and aggression without incident.
NOTE: The Haldol, Ativan, and Benadryl, ordered as one unscheduled dose, was given 9 ½ hours after it was ordered.


Patient #35.
Record review of the Physician Orders for Patient #35 showed:

Orders 0177466, 0177467, and 0177468: Haldol 10 mg, Ativan 4 mg, and Benadryl 100 mg IM ordered on 5/6/2021 at 5:57 pm - 5:59 pm as one unscheduled dose for aggression. The stop date for these medications was 6/5/2021 for the Haldol and Benadryl; 5/11/2021 for the Ativan.

Record review of the Medication Administration Record for Patient #35 showed that Haldol 10 mg, Ativan 4 mg, and Benadryl 100 mg (orders 0177466, 0177467, and 0177468) were administered IM on 5/6/2021 at 6:00 pm - 6:09 pm after Patient #35 attacked another patient.


Patient #36.
Record review of the Physician Orders for Patient #36 showed:

Order 0176555: Haldol 5 mg, Ativan 2 mg, and Benadryl 50 mg IM ordered on 4/17/2021 at 6:02 pm as one unscheduled dose for mania, psychosis, and agitation. The stop date for these medications was 4/22/2021.

Record review of the Medication Administration Record for Patient #36 showed that Haldol 5 mg, Ativan 2 mg, and Benadryl 50 mg (order 0176555) were administered IM on 4/17/2021 at 6:37 pm.


Patient #37.
Record review of the Medication Order Inquiry for Patient #37 showed:

IM Haldol 5 mg, Ativan 2 mg, and Benadryl 50 mg ordered 1/17/2021 at 8:00 pm by Staff D (Medical Director) as one unscheduled dose. The end date for the Haldol and Benadryl was 2/16/2021; for the Ativan, 1/22/2021. The discontinue date for all three medications was documented as 2/1/2021.

Record review of Medication Administration Record for Patient #37 showed that Haldol 5 mg, Ativan 2 mg, and Benadryl 50 mg were administered IM on 1/17/2021 at 7:37 pm - 8:00 pm.

Record review of the Discharge Order by Staff D (Medical Director) for Patient #37 showed: Discharge home 1/25/2021. As was indicated by Staff X (Pharmacist), the one unscheduled order for IM Haldol 5 mg, Ativan 2 mg, and Benadryl 50 mg ordered 1/17/2021 at 8:00 pm by Staff D (Medical Director) was still an active order at the time of discharge.

Based on interview and record review, the facility failed to ensure that 6 of 6 patients (Patient #29, 30, 32, 33, 34 and #36) were seen face-to-face within one hour after the initiation of restraint or seclusion by a physician or a registered nurse trained to conduct the one-hour face-to-face assessment. In addition, the facility failed to properly train 6 of 6 registered nurses (Staff K, Staff L, Staff P, Staff R, Staff S, and Staff W) on the rules and regulations governing restraint, seclusion, and use of medications for emergency situations, as well as competency-based training for conducting the one-hour face-to-face assessment for patient in restraints or seclusion.

Findings included:

Record review of Policy PC.025, "Restraint and Seclusion," revised 12/9/2020, showed, "The face-to-face assessment which is mandatory within one hour of the initiation of the restraint or seclusion must be done by a physician or RN other than the RN who initiated the action."


In an interview on 6/17/2021 with Staff L (RN) at 12:00 pm, she stated that the one-hour face-to-face by a qualified RN is to be done within an hour of release from restraint or seclusion.


In an interview with Staff K (RN) on 6/17/2021 at 12:25 pm, she stated that IM Haldol, Ativan, and Benadryl given in combination would not be considered an emergency-use medication if the patient took it "willingly."


In an interview with Staff L (RN) on 6/17/2021 at 12:00 pm, she stated that IM Haldol, Ativan, and Benadryl given in combination would not require a one-hour face-to-face if the patient was "willing" to take the medication. She also stated, "I do not know if we do things right or wrong," adding she had been an ICU nurse prior to coming to work in a psychiatric hospital "at the end of July 2020 - almost a year ago."


Record review of Human Resource personnel files for the following staff members were reviewed: Staff K (RN), Staff L (RN), Staff P (RN), Staff R (RN), Staff S (RN), and Staff W (RN). There was no evidence of current competency-based training for conducting the one-hour face-to-face assessment for patient in restraints or seclusion.


In an interview with Staff U (HR Director) on 6/22/2021 at 2:00 pm, she stated that none of the RNs were current with the required competency-based training for conducting the one-hour face-to-face assessment for patient in restraints or seclusion.


Six patients with no face-to-face completed within one hour after the initiation of restraint or seclusion.


Patient #29.
Record review of Physician Order and Progress Note for Seclusion/Restraint dated 5/7/2021 showed that Staff P (RN) obtained an order for Restraint (9:28 am - 9:30 am), Seclusion (9:30 am - 12:30 pm), and Haldol 10 mg, Ativan 4 mg, and Benadryl 100 mg IM one time for aggression from Staff G (MD) for Patient #29. Staff W (RN) provided a one-hour face-to-face on 5/7/2021 at 12:30 pm, three hours after the initiation of restraint.


Patient #30.
Record review of Physician Order and Progress Note for Seclusion/Restraint dated 5/12/2021 showed that Staff W (RN) obtained an order for Restraint (3:27 pm - 3:30 pm), Seclusion (3:30 pm - 3:35 pm), and Thorazine 50 mg, Ativan 2 mg, and Benadryl 50 mg IM one time for aggression from Staff G (MD) for Patient #30. A Progress Note, dated 5/12/2021 (not timed), was written by Staff L (RN). Staff L (RN) provided a one-hour face-to-face on 5/12/2021 at 6:00 pm, two and one-half hours after the initiation of restraint.


Patient #32.
Record review of Physician Order and Progress Note for Seclusion/Restraint dated 5/1/2021 showed that Staff K (RN) obtained an order for Restraint (9:47 am - 9:47 am) from Staff D (MD) for Patient #32. A one-hour face-to-face evaluation was not documented in the medical record.

In an interview with Staff B (Director of Quality) on 6/25/2021 at 2:00 pm, she stated the one-hour face-to-face evaluation was not completed for Patient #32 following restraint on 5/1/2021 at 9:47 am.


Patient #33.
Record review of Physician Order dated 5/19/2021, 1:24 pm - 1:25 pm, showed Haldol 5 mg, Ativan 2 mg, and Benadryl 50 mg IM ordered for Patient #33.

Record review of the Medication Administration Record for Patient #33 showed that Haldol 5 mg, Ativan 2 mg, and Benadryl 50 mg IM were given on 5/19/2021 at 1:35 pm. A one-hour face-to-face evaluation was not documented in the medical record.

In an interview with Staff B (Director of Quality) on 6/25/2021 at 2:00 pm, she stated that the one-hour face-to-face evaluation was not completed for Patient #33 after the administration of Haldol 5 mg, Ativan 2 mg, and Benadryl 50 mg on 5/19/2021, 1:24 pm - 1:25 pm.


Patient #34.
Record review of Physician Order dated 4/23/2021, 4:10 pm - 4:14 pm, showed Haldol 10 mg, Ativan 4 mg, and Benadryl 100 mg IM ordered for Patient #34.

Record review of the Medication Administration Record for Patient #34 showed that Haldol 10 mg, Ativan 4 mg, and Benadryl 100 mg IM were given on 4/24/2021, 1:56 am - 1:59 am. Further review showed that a one-hour face-to-face evaluation was not documented in the medical record.

In an interview with Staff B (Director of Quality) on 4/23/2021, 4:10 pm - 4:14 pm, she stated that the one-hour face-to-face evaluation was not completed for Patient #34 after the administration of Haldol 10 mg, Ativan 4 mg, and Benadryl 100 mg IM.


Patient #36.
Record review of the Physician Orders for Patient #36 showed:

Order 0176555: Haldol 5 mg, Ativan 2 mg, and Benadryl 50 mg IM ordered on 4/17/2021 at 6:02 pm as one unscheduled dose for mania, psychosis, and agitation. The stop date for these medications was 4/22/2021.

Record review of the Medication Administration Record for Patient #36 showed that Haldol 5 mg, Ativan 2 mg, and Benadryl 50 mg (order 0176555) were administered IM on 4/17/2021 at 6:37 pm. Administration Comment by Staff Y (LVN): Patient manic, psychotic. Took willingly.

In an interview with Staff B (Director of Quality) on 6/25/2021 at 2:00 pm, she stated the one-hour face-to-face evaluation was not completed for Patient #36 following restraint on 4/17/2021 at 6:37 pm.

Based on record review and interview, the facility failed to ensure that the registered nurse assigned the nursing care of 19 of 19 patients (patients 1-19) to other nursing personnel in 1 of 1 instance.

Findings included:

Record review of Policy PC.016, "Patient Care Assignments," revised 12/9/2020, showed, "It is the policy ... to assign patient care on inpatient each shift to the nursing staff based on staff specialized qualification, competence, level of training, preparation, and assessed patient needs. Nursing care capabilities shall be considered in assignment of patients. The Charge Nurse will assign the nursing care of patients each shift."

Record review of the "Hospital Unit Patient Care and Supervisory Report Sheet" for 6/17/2021, Staff K (Charge Nurse) did not assign the nursing care of 19 patients (patients 1-19) to any staff members, including Staff L (RN), Staff M (CNA/Tech), Staff N (CNA/Tech), and Staff O (CNA/Tech).

Record review of the "Final Census Report," dated 6/17/2021, showed a census of 19 patients (patients 1-19).

In an interview with Staff A (CNO) on 6/17/2021 at 2:00 pm, he stated that the nursing care of patients is not assigned to staff members by the charge nurse, adding that the report sheet would be revised to come into compliance with the regulation.

Based on record review and interview, the facility failed to ensure that 3 of 3 seclusion and restraint packets (Patient #29, #30, and #31) were accurately written and properly filed as evidenced by three seclusion and restraint packets with no patient identifiers (name). The three packets were found in a folder in an office.

Findings included:

Record review of Policy IM.002, "Documentation: Medical Record and Non-Medical Record," revised 12/11/2020, showed: "Documentation ... is to be ... accurate ... The medical record is a legal document; thus, it includes facts."


In an interview with Staff V (Medical Records Manager) on 6/18/2021 at 1:09 pm, she stated that each page of a patient's medical record is to have the patient's name on it.


In an interview with Staff U (HR Director) on 6/25/2021 at 2:00 pm, she stated that each page of a patient's medical record is to have the patient's name on it, adding that this was taught in the orientation of new employees. Staff U provided a portion of orientation entitled, "Documentation."


Record review of "Documentation" (not dated or timed) provided by Staff U (HR Director) showed: "When filing papers into the patient's chart, double check that all papers belong to that patient ... Every page of a medical record ... should have a patient label on it.


Patient #29.
Record review of Physician Order and Progress Note for Seclusion/Restraint dated 5/7/2021 showed that Staff P (RN) obtained an order for Restraint (9:28 am - 9:30 am), Seclusion (9:30 am - 12:30 pm), and Haldol 10 mg, Ativan 4 mg, and Benadryl 100 mg IM one time for aggression from Staff G (MD). Staff W (RN) provided a one-hour face-to-face on 5/7/2021 at 12:30 pm. Observations were documented every 5 minutes by Staff P (RN). Patient debriefing was documented by Staff L (LVN) on 5/7/2021 at 1:00 pm and Staff debriefing was documented by Staff P on 5/7/2021 at 1:00 pm. There is no documentation of the patient's name anywhere in the Seclusion/Restraint packet.


Patient #30.
Record review of Physician Order and Progress Note for Seclusion/Restraint dated 5/12/2021 showed that Staff W (RN) obtained an order for Restraint (3:27 pm - 3:30 pm), Seclusion (3:30 pm - 3:35 pm), and Thorazine 50 mg, Ativan 2 mg, and Benadryl 50 mg IM one time for aggression from Staff G (MD). A Progress Note, dated 5/12/2021 (not timed), was written by Staff L (RN). Staff L (RN) provided a one-hour face-to-face on 5/12/2021 at 6:00 pm. Observations were documented every 5 minutes by various staff members. Patient debriefing was documented by Staff P (RN) on 5/12/2021 (not timed). Staff debriefing was documented by Staff W (RN) on 5/12/2021 (not timed). There is no documentation of the patient's name anywhere in the Seclusion/Restraint packet.


Patient #31.
Record review of Physician Order and Progress Note for Seclusion/Restraint dated 5/1/2021 showed that Staff K (RN) obtained an order for Restraint (10:27 am - 10:28 am). The one-hour face-to-face is not documented. There is no documentation of the patient's name anywhere in the Seclusion/Restraint packet.