HospitalInspections.org

Based on document review, interview and observation, the facility's Governing Body failed to ensure the chief executive officer (CEO) was responsibly managing the facility.

Findings include:

On 06/11/19 at 10:30 AM, the CEO with Corporate Associates present, verbalized the responsibility for overseeing Patient Rights, Quality Assurance and Performance Improvement, Nursing Services, Therapy Services and Medical Records. The CEO also indicated being responsible for the resources to ensure safe/quality care, treatment and services and for implementing policies and training. Regardless of the policies and stated responsibilities, failures occured in Abuse/Neglect and Incident Reporting and Investigating, Critical Event Analysis, Staff Competency and Training, Observation/Monitoring by Mental Health Techs/Nursing, Patient Contraband, Medication Administration, Electronic Medical Records, Treatment Plans and Nursing/Physician/Therapist requirements. These failures were acknowledged by the CEO.

Article 3 Bylaw areas not met:
3.1 (f) To provide for the resources needed to maintain safe, quality care, treatment and services (See Tags A 0144, A 0145 and A 309).

3.2 Authority and responsibility for quality of care and performance improvement mechanisms (See Tags A 0286 and A 0309).

Article 4 Bylaw areas not met:
4.5.3.1 The CEO is responsible for the implementation of established policies in the operation of the facility (Cross-Reference Tags A 0144, A 0145, A 0164, A 0196, A 0286, A 0353, A 0392, A 0395, A 0396, A 0397, A 0405, A 0438, A 0449, A 0450, A 0458 and A 0467).

4.5.3.4 The CEO must organize the administrative functions of the facility, delegated duties and established formal means of accountability on the part of subordinates (Cross-Reference Tags A 0144, A 0145, A 0286, A 0392, A 0395, A 0397, A 0405, A 0438 and A 0450).

4.5.3.5 The CEO is responsible for selecting, employing and controlling employees and for developing and maintaining personnel policies and practices for the facility (Cross-Reference Tags A 0144, A 0145, A 0196, A 0286, A 0392, A 0395, A 0397, A 0405, A 0438, A 0450 and A 0467).

Article 5 Bylaw areas not met:
5.7 Ultimate responsibility for the safety and quality of care, treatment and services at the Hospital and provide oversight of all review functions of the Hospital by serving the following functions:

5.7.1 Oversight of facility compliance with the laws and regulations of federal, state and local governmental agencies...including the Centers for Medicare and Medicaid Services (Cross-Reference Tags A 0043, A 0115, A 0263, A 0385 and A 0431).

5.72 Provision for the resources necessary to maintain safe, quality care, treatment and services (Cross-Reference Tags A 0144, A 0145, A 0164, A 0196, A 0286, A, 0309, A 0353, A 0392, A 0395, A 0396, A 0397, A 0405, A 0438, A 0449, A 0450, A 0458 and A 0467).

5.74 Oversight of the safety and quality of care, treatment and services through quarterly review of reports on key quality measures and safety indicators as well as any safety and quality issues specific to the population served (Cross-Reference Tags A 0144, A 0145, A 0164, A 0196, A 0286, A 0353, A 0392, A 0395, A 0397, A 0405, A 0438, A 0449, A 0450, A 0458 and A 0467).

Based on interview and record review, the facility failed to determine less restrictive interventions were ineffective prior to the use of restraint or seclusion for one sampled patient(Patient #21).

Findings include:

The facility policy and procedure titled Seclusion and Physical or Chemical Restraint, revised 08/2018, indicated the facility would utilize the least restrictive measures to prevent a patient from injuring self or others in an emergency safety situation.

-A debriefing would be conducted within 24 hours of the emergency safety intervention. Any changes that result from this debriefing must be incorporated into the patient's Treatment Plan, as appropriate, to delineate strategies to prevent future episodes of physical/chemical restraint no later than 5 days after a patient had been subject to an emergency safety intervention, physical or chemical restraint or seclusion.

-The policy indicated an emergency treatment team convened within 5 calendar days of the triggering event. The treatment team included but was not limited to the patient, the psychiatrist, therapist, nurse, and other direct care staff as needed. The purpose was to review the events leading up to the seclusion and/or restraint with specific focus on prevention as well as the development of newly identified treatment interventions and strategies that will be helpful for the patient. These strategies would encompass client specific, agreed upon strategies promoting de-escalation of patient.

-The Registered Nurse must notify the Chief Executive Officer, the Clinical Director, and the Medical Director if the patient experiences two or more separate episodes of an emergency safety intervention, physical/chemical restraint or seclusion within a 12 hour period. This notification must be documented in the clinical record.

-The Quality/PI Council, the Medical Executive Committee, and the Governing Board would review whether the emergency safety intervention was the least intrusive intervention and appropriate. Compliance with the requirement to hold an emergency treatment team meeting no later than five calendar days had been subjected to an emergency safety intervention, with review the incident and revision of the treatment plan as appropriate, would be monitored.


Patient #21
Patient #21 was admitted to the facility on 04/17/19 with diagnoses including unspecified psychosis.

A review of hospital seclusion and restraint reports titled Commission on Behavioral Health Report Form, Seclusion and Restraint Orders [these will be referred to herein as emergency safety intervention reports] indicated Patient #21 was given emergency medications and/or placed in seclusions/restraint as follows:

-On 04/19/19 at 10:15 PM, the patient was aggressive and combative towards staff. Methods used to avoid restraint and seclusion included ventilation of feelings, verbal reassurance/redirection, and limit setting. The patient received intramuscular (IM) emergency medications and was placed in seclusion for 15 minutes.

-On 04/19/19 at 10:53 PM, the patient was aggressive and combative towards staff. Methods used to avoid restraint and seclusion included ventilation of feelings, verbal reassurance/redirection, and limit setting. The patient was given IM emergency medication and placed in seclusion for 7 minutes.

-On 04/20/19 at 11:45 AM, the patient was threatening staff and peers, spitting at staff, and banging on walls. There was no documentation less restrictive methods were used to avoid restraint and seclusion. The patient received oral emergency medications and was placed in seclusion for 5 hours and 15 minutes. There was no documentation the report was reviewed by the Medical Director and the Chief Executive Officer.

-On 04/21/19 at 9:00 AM, the patient was threatening staff, shouting at a peer, and spitting at staff. Methods used to avoid restraint and seclusion included ventilation of feelings, verbal reassurance/redirection, 1:1 interaction with staff, reduction of stimuli, and limit setting. The patient received oral emergency medications and was placed in seclusion for 1 hour. There was no documentation the report was reviewed by the Chief Nursing Office, the Medical Director, or the Chief Executive Officer.

On 04/21/19 at 1:30 PM, the patient attempted to hit staff, and would not follow directions and was verbally threatening staff. Methods used to avoid restraint and seclusion included verbal reassurance/redirection, reduction of stimuli, and limit setting. The patient was placed in seclusion for 2 hours and 10 minutes. There was no documentation the report was reviewed by the Chief Nursing Office, the Medical Director, or the Chief Executive Officer.

On 04/22/19 at 1:58 AM, the patient was aggressive, throwing things at the nurses station, and threatening staff. Methods used to avoid restraint and seclusion included ventilation of feelings, verbal reassurance/redirection, and reduction of stimuli. The patient was given emergency medication IM and placed in seclusion for 3 hours and 52 minutes.

On 04/22/19 at 9:09 AM, the patient attacked staff and was attempting to harm other patients. Methods used to avoid restraint and seclusion included ventilation of feelings, verbal reassurance/redirection, 1:1 interaction with staff, reduction of stimuli, and environmental change. The patient was given emergency medication IM and placed in seclusion for 39 minutes.

On 04/22/19 at 4:45 PM, the patient was in a physical altercation with another patient and was placed in seclusion for 15 minutes. Methods used to avoid restraint and seclusion included ventilation of feelings, verbal reassurance/redirection, 1:1 interaction with staff, and environmental change. There was no documentation the report was reviewed by the Chief Nursing Office, the Medical Director, or the Chief Executive Officer.

On 04/24/19 at 10:00 AM, the patient attempted to attack another patient. Methods used to avoid restraint and seclusion included ventilation of feelings, verbal reassurance/redirection, 1:1 interaction with staff, and limit setting. The patient was placed in seclusion for 45 minutes.

On 04/27/19 at 10:55 AM, the patient was punched by a peer and was put in a physical hold and moved to the seclusion room for safety. There was documentation of less restrictive interventions tried prior to the use of the physical hold. There was no documentation the report was reviewed by the Chief Nursing Office, the Medical Director, or the Chief Executive Officer.

Patient #21's record lacked documentation of a Treatment Team Meeting following any of the emergency safety incidents.

On 06/20/19 at 3:45 PM, the Chief Executive Officer (CEO) reported being responsible for reviewing all emergency safety intervention reports to ensure facility policy and procedure was followed, including ensuring staff tried less restrictive interventions prior to the use of restraint or seclusion. The CEO acknowledged not reviewing 5 out of the 10 reports for Patient #21.

On 05/21/19 at 1:00 PM, the Interim Chief Nursing Officer (CNO) stated the amount of restraint/seclusion used for the patient was excessive. Less restrictive interventions which could have been tried prior to use of emergency safety interventions would include putting the patient on line of sight observations, housing in a room closest to the nurses station, looking for trends with a specific staff member, day of the week, in order to better predict the causative factors, and augment the staff. The reviews of some reports were not completed because these occurred before 03/14/19, the starting date for this CNO. The prior CNO was not performing this function.

On 05/23/19 at 10:05 AM, the Nurse Manager of Adult Services revealed Patient #21 was admitted on 04/17/19. Patient #21 had severe psychosis and the patient had a high usage of restraint, seclusion, and emergency medications. The Treatment Plan did not reflect any changes or revisions were added following episodes of restraint/seclusion occurring on 04/19/19, 04/20/19, and 04/22/19. The Nurse Managerreported the Treatment Plan should have been updated following each specific incident of restraint, seclusion, or use of emergency medications. Different actions steps and interventions should be listed.

On 05/23/19 at 4:25 PM, the Director of Compliance, Quality, and Risk (DCQR) revealed after detection of a patient with a high incidence of use of restraints and seclusion, the DCQR would talk to the treatment team as to what could be done differently. If there was oversight of the treatment team it would spur more action. The DCQR verbalized staff were supposed to file a separate incident report in the electronic incident reporting system following every use of restraint or seclusion. The DCQR acknowledged not being aware of some of the emergency safety intervention reports due to staff failure to submit incident reports following episodes on 04/20/19, 04/21/19, 04/22/19, 04/24/19, and 04/27/19. The DCQR reported not receiving the emergency safety intervention reports directly. The DCQR described only getting knowledge of the reports after staff filed the related incident reports which were sent directly to the DCQR. The DCQR indicated there was no system to cross reference incident reports and the emergency safety intervention reports. The DCQR verified lack of documentation in the record of Emergency Team Meetings within 5 days for any of the incidents. The DCQR reviewed Patient #21's emergency safety intervention reports and verbalized staff did not consistently implement less restrictive interventions.

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

1) Ensure there was adequate therapist coverage to ensure the needs of the patients were met including the timely completion of patient Therapy Initial Contact Notes (See Tag A 0392)

2) Ensure patients were not cheeking and/or hiding medications, and giving medication to peers (See Tag A 0405).

3) Ensure nursing staff adhered to the process of implementing and updating patient care plans in a timely manner based on patient care needs, documented patient behaviors and the care provided to patients, a physician or physician extender was notified of a suspected unwitnessed fall and an assessment was completed after a patient's suspected unwitnessed fall (See Tag A 0396)

4) Ensure staff competencies were completed in a timely manner (See Tag A 0397).

The cumulative effect of these systematic practices resulted in the failure of the facility to deliver statutory-mandated care to patients.

Based on interview, record review and document review the facility failed to ensure the nursing component of the treatment plans were initiated and consistent with the plan for care of the described realistic patient goals as part of the patient's nursing care assessment and revisions to the plan were completed in a timely manner for 3 of 94 sampled patients (Patient #1, #5 #2).

Findings include:

Patient #1
Patient #1 was admitted on 05/08/19, and readmitted on 05/18/19 with diagnoses including schizophrenia, bipolar type and unspecified psychosis.

A History and Physician Examination dated 05/18/19 documented the patient had hypertension. Vital signs measurements revealed the blood pressure was 175 millimeters of mercury (mmHg)/ 81 mmHg. The H&P indicated to add blood pressure medications.

A Nursing Admission Assessment dated 05/18/19 documented the patient had hypertension.

A Fall Risk Assessment dated 05/18/19 documented the patient had a score of 12 identified the patient as a moderate risk for falls.

Patient #1's treatment plan initiated on 05/19/19 lacked documented evidence of the patient's medical diagnoses related to blood pressure and a fall risk

On 06/04/19 at 3:58 PM, a Nurse Manager indicated the patient's treatment plan should have included the patient was a fall risk.

Patient #5
Patient #5 was admitted on 05/13/19, with diagnoses including alcohol dependence and major depressive disorder.

A Initial Psychiatric Evaluation dated 05/14/19 documented the patient had three psychiatric hospitalizations and was diagnosed with bipolar II and depression.

The Treatment Plan initiated on 05/14/19 lacked documented evidence of the bipolar II and depression diagnoses.

Patient #2
Patient #2 was admitted on 05/17/19 with diagnoses including unspecified dementia with behavior disturbance.

1) A History and Physical Examination dated 05/17/19 documented Patient #2 had past medical history of diabetes mellitus, hypertension, anemia, and fall risk debility. Vital signs measured on the patients left arm revealed the blood pressure was 178 millimeters of mercury (mmHg) /70 mmHg. The examining provider's impressions revealed diagnoses including diabetes mellitus (DM), hypertension (HTN), hyperlipidemia (HLD), anemia, fall risk, debility, general weakness and multiple skin issues/wounds.

A Fall Risk Assessment -Adult dated 05/17/19 documented the patient had moderate impaired - limited vision, but could identify objects. The Fall Risk Assessment documented the patient's fall risk score as a 26; which the score key identified as 13 plus as "High Risk". The assessment indicated to initiate fall precautions and treatment plan for moderate or high risk patients, and to consider environmental risk factors in patient's interventions.

The Medication Administration Record dated 05/17/19 - 05/28/19 revealed Patient #29 had orders for the following medications:
-Mupirocin topical 2 % ointment (Bacitracin) 22 gram twice daily for wound care
-Glimepiride (Amaryl) 4 milligrams (mg) use two each for DM
-Insulin Lispro solution (Humalog) 2 -15 units subcutaneous sliding scale and needed.
Blood Sugar Dose
151-200 2 units
201-250 4 units
251-300 6 units
301-350 8 units
351-400 10 units
401-450 12 units
Greater than 400 15 units and call Medical Doctor

A Treatment Plan Assessment dated 05/17/19 documented due to dementia Patient #2 was unable to express a goal for treatment and the patient had a poor memory. The Treatment Plan Assessment dated 05/17/19 was signed by a nurse on 05/17/19.

A Treatment Plan with a start date of 05/17/19 documented under medical "Above Ideal Body Weight (BMI 30.7). The clinical long term goal indicated to maintain diet and exercise regimen conductive to a healthy lifestyle. The target date was listed as 05/24/19.

The Treatment Plan lacked documented evidence of Patient #2's medical diagnoses related to diabetes mellitus, hypertension, hyperlipidemia, anemia, fall risk, debility, general weakness and multiple skin issues/wounds.

On 05/29/19 at 9:31 AM, a Registered Nurse (RN) Patient #2 was aggressive and sometimes compliant with medications. The RN indicated the patient attended groups but did not participate. Patient #2 was provided handouts when the patient did not attend the group therapy the nurse went over the hand out the patient. The nurse indicated attempting to get the patient to answer The RN verbalized, "I think she understands some of the handouts but do know how much. I don't think she fully understands what's fully going on".

The RN explained not going through dementia training at the facility. The RN verbalized, "It's something you usually learn along the way". The RN indicated the physician discussed the different phases of dementia when she had questions.

On 05/29/19 11:56 am, the CNO explained the medical diagnoses whether under control or not were required to be on the treatment plans. The CNO acknowledged a patient had a high risk for falls and utilizing devices should have been placed on the treatment plan.

On 05/29/19 in the afternoon, The CNO verbalized the electronic medical record was not meeting the needs for the required documentation. The CNO indicated the system did not allow the for the input of templates for specific documentation. The CNO indicated there were only two nursing diagnoses in the system.

The RN identified Patient #2 as a fall risk and a one person assist.

2) The RN updated on 05/29/19 the patients Treatment Plan to include the diagnosis of diabetes mellitus. The The Treatment Plan included to following clinical long term goals with the target date of 05/31/19 for Patient #29:

-Patient will demonstrate how to take own blood glucose levels and self-administer oral medications or insulin.
-Patient will discuss possible complications of diabetes.
-Patient will state dietary and exercise goals.

The treatment plan included unrealistic goals for a patient with dementia and poor memory who is unable to express a goals for treatment as noted in the patient's Treatment Plan Assessment.

The treatment plan lacked documented evidence it was updated with the patient's diagnoses including hypertension, hyperlipidemia, anemia, fall risk, debility, general weakness and multiple skin issues/wounds.

On 05/31/19 at 10:46 AM, the Interim CNO acknowledged the treatment plan goals for Patient #2 were unrealistic. The verbalized a more appropriate goal would have been the patient would agree or allow the nurse to give the medications or test the glucose as a short-term goal.

On 06/04/19 at 3:58 PM, a RN indicated the patient's treatment plan would have needed to be updated based on the patient's cognition. The RN indicated the treatment plan is updated after the treatment team meeting or if there are any changes.

The Facility policy Assessment & Reassessment of the Patient, Policy #1300.1A, effective June 2016 indicated the purpose was to collect data based on an assessment of the relevant needs of the patient to be able to devise a patient plan of care. And, to ensure that after reassessment of the patient the treatment planning and patient care were updated to meet the changes/condition of the patient. The nurse initiated the preliminary treatment plan based upon findings of the assessment. Treatment Plan Meeting were held weekly and during this meeting the patient's condition was reassessed and the treatment plans and goals evaluated.

Based on interview, employee file review and document review the facility failed to ensure an Employee Job-related Competency Checklist (Self-Assessments) was completed for one nurse employee.

Findings include:

A Registered Nurse/LPN - Competency Checklist (Self-Assessment) for Employee #5 dated 05/20/19 indicated staff must complete, prior to or during orientation, a competency checklist of this or her position, The checklist is a self-assessment of current level of knowledge and skill. Current competencies should be rated accordingly.

The competency checklist indicated the supervisor/manager within 30 days of the employment would assess and rate the employee competency based upon demonstration and/or verbalization of the employee's ability to perform skills which included response to critical incidents and emergency procedures.

Review of Employee #5's record revealed the employee was hired in November 2018 and the competency was not completed until 05/20/19.

On 06/07/19 in the morning, the Human Resources Director acknowledged the Registered Nurse was hired in the staff RN position and transitioned to an Interim Nurse Manager position and the competency was not completed. The Director of Human Resources verbalized the competency should have been done. The RN was not due for an annual evaluation until November 2019. The Human Resources Director indicated an audit was done and confirmed competencies were not done. This information was forwarded to the unit managers who were responsible for ensuring the competencies were done for their area.


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The facility Guidelines for Measuring Staff Competency policy #1300.30, last revised 09/2017, revealed Performance Evaluation and Review of Competency Education Requirements would be completed annually for all employees.

Based on observation, record review, interview and document review the facility failed to ensure the physician was notified of patient medication refusals for 2 of 94 patients (Patient #4, #6), failed to prevent patient medication diversion for 4 of 94 patients (Patient #12, #37, #39, #40) and failed to perform a mouth check on patients after administering medications 3 of 94 (Patient #46, #30, #31).

Findings include:

Physicians Not Notified of Patients Medication Refusal:

Patient #4
Patient #4 was admitted on 05/18/19 with diagnoses including unspecified psychosis, out of contact with reality and diabetes.

A Medication Administration Record (MAR) dated 05/18/19 - 05/27/19 revealed an order for Haloperidol 5 milligrams (mg) twice daily for psychosis and Benztropine 1 mg twice daily for side effects.

The MAR indicated Haloperidol was scheduled to be administered at 9:00 AM and 9:00 PM. The MAR revealed Patient #4 refused the Medication 05/18/19 - 05/23/19 for a total of 12 doses prior to the Nurse Practitioner being made aware.

The MAR indicated Benztropine was scheduled to be administered at 9:00 AM and 9:00 PM. The MAR revealed Patient #4 refused the Medication 05/18/19 - 05/23/19 for a total of 12 doses prior to the Nurse Practitioner being made aware.

On 05/31/19 at 10:46 AM, the Interim CNO verbalized the physician should have been notified regarding the patient refusal. The physician could have done an early intervention or court order. The provider should have been made aware at the first refusal.

On 06/04/19 at 3:18 PM, a RN indicated when a patient refused medications it needed to be documented and the physician informed. The RN indicated this could have been done verbally and documented. The RN verified there was no notification to the physician regarding the patient's refused medication.

On 06/04/19 in the afternoon, a RN indicated if the patient refused medication they were encouraged to take it. The risk and benefits are discussed. If the patient still refuses notify the physician and document on the MAR. The RN indicted we usually notify the physician right away because they come in every day. The RN indicated they should let the provider know verbally if the patient refused medications. The RN indicated physician providers have access to the patient's record.

Patient #6
Patient #6 was admitted on 04/29/19, and readmitted on 05/15/19 with diagnoses including schizophrenia affective disorder bipolar type, alcohol abuse, uncomplicated, post traumatic stress disorder, potential for self-harm and candidias of skin and nails.

Physician Medication Orders - Final included the following medications with a start date of 05/15/19 and stop date of 06/14/19:

Nystatin topical powder 100,000 units/gram, one application three times a day for fungal rash bilateral groin and below breast. Start date 5/18/19, Stop date 05/22/19.

Guaifenesin liquid 100 milligram/5 milliliter (200 ml), every six hours by mouth for cough. Start date 5/16/19, Stop date 06/14/19.

The Medication Administration Record (MAR) dated 05/15/19 - 05/28/19 revealed the following:

Nystatin was scheduled to be administered at 9:00 AM, 3:00 PM and 9:00 PM. The MAR revealed Patient #6 refused the 9:00 AM, 3:00 PM and 9:00 PM dose on 05/17/19, 05/18/19, 05/19/19, 05/20/19 05/21/19 and 05/22/19. On 05/21/19, the MAR documented at 9:00 AM Patient #6 said, "I don't need any more" (sic).

Guaifenesin was scheduled to be administered at 12:00 PM, 6:00 PM, 12:00 AM and 6:00 AM. The MAR documented Patient #6 refused the medication from 05/17/19 - 05/20/19 at 6:00 AM, 05/21/19 - 05/23/19 at 12:00 PM, and 05/23/19 at 12:00 AM -05/28/19 at 6:00 AM.

The medical record lacked documented evidence the physician was notified of the medication refusals.

On 05/31/19 at 10:49 AM, the Interim CNO verbalized if a patient refused medications the nurse should have tried to find someone to help the patient to be more agreeable with taking medications.

Facility policy entitled Medication Administration, Policy number: 1000.42 last revised August 2017, indicated the Nurse will handle the refusal of the patient medication accordingly:
-Return the unopened packet to the patient's medication drawer.
-Notify the physician that the patient refused the medication and the reason for refusing.
-Circle the schedule dosage times on the Medication Sheet and write "ref" in the site space, and initial.
-The nurse will handle missed does due to nursing error according to the Medication Variance Policy.



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Patient Medication Diversion:

Patient #12
Patient #12 was admitted on 05/13/19, with diagnoses including bipolar disorder without psychotic features.

On 05/20/19 at 1:18 PM, an incident report revealed Patient #12 reported receiving Seroquel medication from a peer and swallowing it. The report showed Patient #12 verbalized the medication came from a recently discharged patient who hid the medication in a Chapstick container. Patient #12 felt tired.

The DCQR's documentation characterized the incident as a medication error that reached the patient but did not cause patient harm.

Patient #37
Patient #37 was admitted on 05/02/19, with diagnoses including bipolar disorder and major depressive disorder with psychotic features: hearing voices.

On 05/20/19, an incident report showed Patient #37 received a Seroquel tablet from another patient and swallowed it. Patient #37 indicated it came from a recently discharged patient who hid the medication in a Chapstick container. Patient #37 felt tired.

As of 06/04/19 at 1:31 PM, Patient #37's treatment plan lacked documented evidence medication diversion was addressed.

Patient #39
Patient #39 was admitted on 04/26/19, with diagnoses including severe, recurrent major depressive disorder without psychosis.

On 05/28/19 at 10:40 AM, Patient #39 verbalized receiving Seroquel from Patient #46 just prior to Patient #46's discharge. Patient #46 hid the Seroquel in a Chapstick container, which was left on a shelf when Patient #46 left.

The daily unit census worksheet showed Patient #39 and #46 were roommates on 05/17/19, the last day Patient #46 was on the unit.

On 06/04/19, a record review yielded the following nursing progress note:

On 05/31/19 at 4:30 PM, the Milieu Manager reported the patient confessed to cheeking night medication and gave it to other patients in the residential hall. A Registered Nurse spoke to the patient about the situation. The patient indicated cheeking medication for a while and flushed some down the toilet. Patient #39 further indicated giving a medication to another patient and finding another patient's medication and offering it to two other patients. The Clinical Therapist, Psychiatrist and Nursing Supervisor were notified.

The Registered Nurse signed the note at 11:35 AM on 06/01/19.

On 06/03/19 at 9:10 AM, the Patient Advocate interviewed Patient #39. Patient #39 indicated cheeking medication for 4-5 weeks. Patient #39 pretended to drink water and spit medication into the water cup. Patient #39 acknowledged providing medication to Patient #12, #37 and #40.

Patient #40
Patient #40 was discharged on 05/31/19. On 06/04/19, a Clinical Therapist documented a statement regarding a phone call received by a second Clinical Therapist about Patient #40. The parent of Patient #40 had indicated unprescribed medication was provided by another patient (Patient #39) to Patient #40. The Clinical Therapist saw Patient #39 on 06/03/19. Patient #39 admitted not taking medication for some time time and provided medication to other patients instead.

Nursing Staff Failed To Perform Mouth Checks After Medication Administration:


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Patient #30 was admitted on 06/03/19 with diagnoses including anxiety disorder.
Patient #31 was admitted on 06/02/19 with diagnoses including major depressive disorder with psychotic symptoms.

On 06/06/19 at 8:45 AM, a Registered Nurse (RN) was administering medication at the Adult Acute Unit nursing station. Patients #30 and #31 were given oral medications from across a counter-top. The patients were not wearing identification arm bands. The RN identified the patients by asking their names and looking at a photograph on Electronic Health Record. After giving the medications the RN did not ask the patients to open their mouths to check if the medications were swallowed. The patients brought their own white Styrofoam water cups and also left the desk area with the same cups after taking the medications. The RN stated a mouth check was not usually done when giving medications on the Adult Acute unit unless a patient had a known behavior cheeking medications. The RN reported on the Chemical Dependency Unit, a mouth check was done, particularly if narcotics were given. The The RN acknowledged not doing a mouth check for Patient #30 and #31, as they did not have any issues related to cheeking medications. The RN stated patients filled cups with water from a day room water source and brought it to the nursing station for medication pass, and were allowed to take the cup away with them afterward.

On 06/06/19 at 9:10 AM, a Nurse Manager reported per facility policy nurses were to perform a mouth check on all patients after administering medications, not just for patients with a known behavior of cheeking medications. The Nurse Manager stated the facility practice was patients would bring their own water cups for medication pass and could take these away with them.

On 06/06/19 at 11:45 AM, the Interim Chief Nursing Officer revealed patients should have been wearing arm bands and nurses should check for the arm band to identify patients during medication administration.

The facility policy Medication Administration dated 03/26/2006, indicated the nurse would confirm the patient's identity before offering medication by verification of two patient identifiers. The nurse would check to make sure the patient swallowed the medication. The policy did not address checking water cups to see if patients were spitting medications back into the cup instead of swallowing them.

Based on record review, interview and policy review, the facility failed to use a system of author identification and record maintenance that ensured the integrity of the authentication and protected the security of all record entries. Specifically, the facility failed to:

1) Ensure staff securely signed off assigned tablet while on break to prevent another staff member from documenting an incident under their name (Patient #21)

2) Ensure patient therapy notes were note predated (Patient #10).

3) Ensure a Clinical Therapist and a nurse included their titles when signing off notes (Patient #33) and a Psychiatrist signed a therapy note (Patient 15).

Findings include:

Patient #21
Patient #21 was admitted to the facility on 04/17/19 with diagnoses including unspecified psychosis.

Incident Report #14865 dated 04/22/19, indicated there was an allegation of abuse. Patient #21 was found in a room unconscious with abrasions on the neck and arms after being assaulted another patient.

The Incident Investigation Worksheet dated 04/25/19, included staff interviews. The incident occurred in the Adult South Hall. The summary of an interview conducted on 04/22/19 with a Mental Health Technician (MHT) documented one MHT was on break and only one MHT was on duty for that hallway at the time of the incident.


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On 05/22/19 in the morning, the MHT on break during the incident was interviewed regarding observations this MHT documented during the incident. Observations were documented as occurring while the MHT was on break and off the unit. The MHT indicated the electronic tablet was handed off (without logging out) to another MHT prior to leaving for break. The second MHT then likely documented under the first MHT's name. The summary of an interview conducted on 04/25/19 with a different MHT documented that MHT was in the dayroom area after finishing 15 minute checks.

The Incident Investigation Worksheet lacked documented evidence the DCQR interviewed the MHT who was on break and failed to identify a second MHT documented under the first MHT's name.

The facility Mobile Device policy, IT120 2.0, last reviewed 10/17/17, revealed under the Supplied Tablet section: 5. "Tablets should be secured at all times from theft or unauthorized use".

Patient #10
Patient #10 was admitted on 05/13/19, with diagnoses including major depressive disorder without psychosis.

On 05/10/19 at 8:04 AM, a Clinical Therapist entered an electronic therapy group note which predated the admission date. The note was signed at 8:20 AM on 05/19/19.

On 05/18/19, Patient #10 lacked documented evidence of therapy group notes.

On 05/22/19, a psychiatric progress note lacked a signature.

On 05/31/19 at 3:35 PM, the Medical Records Director acknowledged the above.

Many clinicians documented without proper authentication. The following examples are a few:

A Clinical Therapist electronically signed therapy group notes for Patient #33 without using a clinician title on 04/27/19, 05/02/19, 05/04/19, 05/09/19, 05/17/19 and 05/18/19.

A Registered Nurse electronically signed nursing progress notes for Patient #33 without using a clinician title on 04/21/19.

As of 05/31/19, a Psychiatrist failed to sign a psychiatric progress note for Patient #15 entered for 10:36 AM on 05/23/19.

On 6/4/19 at 3:20 PM, the facility's electronic medical records representatives acknowledged:

The corporation endorsed the electronic medical records system used, which had to be retrofitted for the facility. The Information Technology Representative provided system logins for all employees, which showed multiple employees with multiple logins. A Nurse Practitioner, for example, had two accounts: one with the title and one without. A Clinical Therapist had an account without a title. The system allowed employees to add additional logins after the initial account set-up in orientation unbeknownst to the facility's hierarchy. Other issues included patients being electronically placed in the same room/bed in the medical records, the daily room census worksheet and therapy assignments.

On 06/05/19 at 1:15 PM, the Information Technology Representative indicated audit trails were comprehensive and it was possible the Director of Medical Records did not know how to access the real time origination of some documentation.

The facility Documentation and Documentation Retention Policy #1400.6, last revised 9/2017, revealed under "procedure #3. The Physician was responsible for the history and physical examination records. #5.2 The attending Physician would complete and sign the psychiatric evaluation within 24 hours. The psychiatric evaluation must also be dictated within 24 hours. 9. Group Therapist would document daily the issues discussed in Group Therapy and the affect/behavior as noted by the Therapist".

The facility General Guidelines EMR Documentation policy, #1400.90, effective 6/1/2018, revealed under "procedure #2. Entries must be accurate, relevant, timely and complete. #9. Authentication included the identity and professional discipline of the author, the date, and the time signed".

Based on record review, interview and document review the facility failed to ensure a code record was completed after a code was called for an unresponsive patient with respiratory distress (Patient #29) and to document a Code Blue after Cardiopulmonary Resuscitation (CPR) was initiated on a patient (Patient #21).

Findings include:

The facility Code Blue Policy #1000.13 last revised September 2017 included the Code Blue Leader would assign documentation of emergency support care activities using Code Blue Report.

The facility Code White, Rapid Medical Response Team Policy and Procedure #1000.56, effective 09/10/15, and revised 12/20/18 included the Code Team documentation will be completed by Code White Team members and the staff nurse including completion of the Code Team Record. The Code White Team Record will be completed and signed by all involved practitioners. Documentation will be completed on the medical response record and maintained in the patient's permanent record, a copy will be sent to the Quality Improvement (QI) department for periodic review by the medical response members for a continued quality improvement and education.

Patient #29
Patient #29 was admitted on 02/23/19 with diagnoses including intermittent explosive disorder, major depressive (MDD) disorder, recurrent, sever with psychotic symptoms, and selective mutism.

A Nursing Progress Note dated 02/27/19 documented the RN went to Patient #29's room to give medications and found the patient unresponsive to verbal commands, tapped the patient on the shoulder and had no response. The RN noticed the patient had gargled breath and agonal breathing. The nurse began sternal rub and called a "code white". The RN indicated the patient had a palpable pulse. The head of bed was elevated. Oxygen applied via mask. Vitals signs BP 122/85, pulse 50 and O2 sats 98 % on 10 liters, blood glucose 126. The RN indicated the patient was suctioned and food residue was removed from the patient's mouth. The ambulance was called and patient remained unresponsive. The patient was transferred to an acute care hospital and the physician was notified.

On 06/04/19 at 3:14 PM, the Interim CNO verbalized a code report was not done.

On 06/06/19 at 1:58 PM, a Nurse Manager confirmed there was no Code Blue report for Patient #29. The Nurse Manager verbalized a code report should have been completed.



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Patient #21
Patient #21 was admitted to the facility on 04/17/19 with diagnoses including unspecified psychosis.

Incident Report #14865 dated 04/22/19, indicated Patient #21 was found in a room unconscious with abrasions on the neck and arms from another patient. An emergency ambulance was called and the patient was sent to a local hospital for further treatment.

The summary of an interview conducted on 04/25/19 with the Registered Nurse (RN) documented the patient did not have a pulse. Cardiopulmonary Resuscitation (CPR) was started. The patient had return of pulse and breathing after one minute of CPR.

A Nursing Note dated 04/22/19, indicated the patient was found unresponsive and unable to communicate after being attacked by another patient. The patient was lying on the floor in Room 123 with multiple abrasions. The patient was sent out to the hospital for treatment. The record lacked documentation of a Code Blue.

On 06/06/19 at 8:50 AM, the Registered Nurse (RN) confirmed on 04/22/19 Patient #21 was found unresponsive, a Code Blue was called, and the RN gave chest compressions for a short duration. The patient was revived. The RN did not recall documenting the Code Blue for the patient's record.

On 06/06/19, the Director of Health Information Management reported Patient #21's record lacked documentation of a Code Blue. The documentation was done on a paper form which was located in the emergency bag. The form would then be retained in the paper record and also scanned into the Electronic Health Record. A nursing note should also be documented.

The facility policy and procedure titled Code Blue, revised 09/2017, indicated staff would document the emergency support care using the Code Blue Record.

Based on record review and interview, a physician failed to enter a history and physical within 24 hours as required for 1 of 94 patients (Patient #11).

Findings include:

Patient #11
Patient #11 was admitted on 05/10/19, with diagnoses including major depressive disorder without psychosis and potential for self-harm.

Patient #11's medical record revealed the History and Physical was initiated on 05/12/19.

On 06/04/19 at 10:40 AM, the Medical Records Director acknowledged the following late history and physical.