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Based on policy review, facility handbook review, observation, medical record review, and staff and patient interview, the facility staff failed to provide personal privacy to patients sleeping on a mattress on the floor for 2 of 12 patients observed (Patient #10, #2).

The findings include:

Review of facility policy "Patient Rights & Restriction of Patient Rights" reviewed 01/2019, revealed, "... Without limitation, patients shall be entitled to: ... To be treated with human dignity and in an environment that contributes to a positive self-image..."

Review of the facility handbook "Adult Services Handbook" revised 04/2019, revealed, "... All rooms are semi-private (2 patients per room)... As a Patient, you have the right: 1. To have considerate and respectful care in a safe environment with respect to personal dignity, values, beliefs, privacy, humane care, freedom from mental and physical abuse, neglect and exploitation, and to live as normally as possible while receiving treatment..."

1. Observation on 02/08/2022 at 1210 during a tour of unit A, an adult psychiatric inpatient building, revealed the seclusion room had a mattress on the floor. Observation revealed one pillow and a blanket on the mattress pad. Observation revealed a pair of pink slide-type shoes on the floor next to the mattress. Observation revealed the door did not open from the inside when closed.

Open medical record review on 02/09/2022 of Patient #10 revealed a 31-year-old female admitted to an overflow bed at the facility on 02/07/2022 at 1813. Medical record review revealed Patient #10 was admitted on Involuntary Commitment (IVC) orders to unit A of the adult psychiatric building. Review of the Psychiatric Evaluation and History and Physical dated 02/08/2022 revealed admitting diagnoses of Major Depressive Disorder-recurrent-severe, S/P(Status Post) overdose and previous medical history including spina bifida (spine/spinal cord malformation), asthma (condition with narrowing airway due to inflammation), POTS(Postural Orthostatic Tachycardia Syndrome - condition that impacts blood circulation with position changes). Review of Initial Nursing Assessment and Admission Data dated 02/07/2022 at 2327 revealed, "...Patient was oriented to the unit by writer, but asked to go directly to her room (EMTALA) instead of socializing..." Review of Patient Daily Self-Inventory (completed by Patient #10) revealed, "What is your goal for today? 'Get a room.' Medical record review revealed Patient #10 was transferred to a room on 02/08/2022 at 1844. Medical record review revealed Patient #10 failed to have a bed with personal privacy available for 24 hours and 31 minutes.

Interview with RN #16 on 02/08/2022 at 1158 revealed Patient #10 had been admitted into the seclusion room on 02/07/2022. Interview revealed when all of the beds were filled, nursing staff admitted patients to the mattress pad on the floor of the seclusion room. Interview revealed Patient #10 was going to move to an open bed when one became available on the unit.

Interview with CEO on 02/09/2022 at 1135 revealed she was aware of patients that were admitted into seclusion rooms. Interview revealed the decision to place patients in seclusion rooms and/or dayrooms was driven out of unexpected crisis "walk-in" patients. Interview revealed the facility accepted transfer patients based on the projected discharges for the day. Interview with the CEO revealed when discharges were delayed and the units were full, the facility staff utilized seclusion rooms to house patients until a room became available. Interview revealed patients were usually moved to a semi-private room in less than 2 days.



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2. Observation on 02/08/2022 at 1130 revealed the seclusion room with linens on the mattress of the mattress including top sheet and blanket and a pillow. Observation revealed sheets were used and partially attached to mattress.

Review of open medical record of Patient #2 revealed a 16 year old male admitted to this facility on 02/07/2022 for Suicide attempt after he drank a bottle of cough syrup and ingested 18 tablets of Benadryl. Patient #2 called the Suicide hotline and was transported to an outside local hospital for evaluation on 02/05/2022 where Patient #2 was placed under IVC (Involuntary Commitment). Past medical history is significant for Diabetes and Klippel-Feil syndrome (Cervical vertebral fusion syndrome--rare congenital condition characterized by the abnormal fusion of any two of the seven bones in the neck. It results in a limited ability to move the neck and shortness of the neck). Review of the observation sheet dated 02/07/2022 at 2032 through 2128 revealed Patient #2 was documented as being in community room. Review of the census tracking sheet revealed Patient #2 was placed in an overflow bed on 02/07/2022 at 2356 and transferred to a patient care floor bed on 02/08/2022 at 1847, over 18 hours and 51 minutes later.

Interview on 02/08/2022 at 1220 with Patient #2 revealed Patient #2 slept the prior night on mattress between two chairs. Interview confirmed there were no beds available.

Interview on 02/11/2022 at 1000 with MHT #37 revealed Patient #2 slept in the community room using a mattress between the two chairs. Interview revealed Patients slept in the day room when there were no rooms available.

Interview on 02/09/2022 at 1210 with an intake clinician revealed patients are accepted based on predicted discharges for the day. Interview revealed if the discharge is delayed, the new patient is assigned an overflow bed, which is a mattress on the floor in the community room or in the seclusion room.

Based on the adult services handbook, observations, medical record reviews, and staff interviews the facility staff failed to remove all non-approved items from patient's possession on the patient care units for three (3) patients (Patient #26, #23, and #24) on two (two) of nine (9) units observed (Unit 2 East and A Unit).

The findings include:

Review of the "Adult Services Handbook" revised 04/2019 revealed, "... 7. What about clothes and personal items? ...No boots, shoestrings, or clothing with strings or cords are permitted. ...Non-Approved Items ...Belts, strings, cords of any kind..."

1. Observation on 02/09/2022 from 1435 to 1630 in (Name building) on Unit 2 East revealed Pt #26 attending groups and interacting with the other patients on the unit. Observation revealed the patient had two pieces of silver-looking ropes (stretchy metallic cord strings) in her hair. Observation revealed the ropes measured approximately one and a half feet long each.

Open Medical record review conducted on 10/04/2021 revealed Patient (Pt) #26 was a 51-year-old female admitted to the (Named Building) unit 2 East on 02/04/2022 for major depressive disorder (MDD), severe alcohol use, and severe cocaine use. Review of the Psychosocial Assessment dated 02/05/2022 revealed, "Pt also reports SI [Suicidal Ideation], occurring 1-2 times daily and lasting for at least 1 minute."

Interview on 02/09/2022 at 1540 with Nurse Manager #1 during the observation revealed the ropes in the patient's hair were not allowed on the unit. Interview revealed Nurse Manager #1 asked the patient to remove the ropes from her hair and they were placed in a secure belonging's folder. The interview confirmed that the ropes measured approximately one and a half feet long each.

Interview on 02/09/2022 at 1620 with Registered Nurse (RN) #11 caring for patient #26 revealed "I did not notice the ropes in the patient's hair. The ropes should have been removed during the skin assessment and safety check by the nurse on admission." The interview revealed ropes or strings were not allowed on the unit.

Interview requested with RN #12, the admitting nurse for patient #26 revealed the RN was unavailable for an interview.



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2. Observation in (Name building) on 2 East on 02/09/2022 between 1430 and 1545 revealed Patient #23 was sitting in group therapy. Observation revealed Patient #23 was wearing a pair of grey shoes with grey shoestrings in the shoes.

Review on 02/10/2022 of the open medical record for Patient #23 revealed a 63-year-old male admitted under involuntary commitment (IVC) papers for suicidal ideation and major depression disorder. Review of the Patient's Possession List dated 02/08/2022 did not list shoes as an item the patient was wearing, the patient was going to keep, nor as an item the hospital was going to lock up until the patient was discharged.

Interview on 02/09/2022 at 1514 with NM #1 during the observation revealed the grey shoes Patient #23 was wearing contained shoestrings. Interview revealed NM #1 asked Patient #23 to either remove the shoestrings or change into facility provided slide on slippers. Interview revealed Patient #23 chose to change into the facility provided slide on slippers and his shoes were placed into his personal belongings storage.

Interview on 02/09/2022 at 1514 with RN #11 caring for Patient #23 revealed he was not aware Patient #23 had shoelaces in his shoes. Interview revealed the shoelaces should have been removed on admission or when the patient received his shoes. Interview revealed patients are not allowed to have shoestrings in their shoes.

Telephone interview on 02/10/2022 at 1204 with Mental Health Technician (MHT) #29 revealed he remembered Patient #23. Interview revealed MHT #29 inventoried Patient #23's bags and registered everything that he had with him. Interview revealed MHT #29 locked up Patient #23's belt, money, and wallet. Interview revealed MHT #29 returned Patient #23's clothes to him. Interview revealed MHT #29 did not recall and did not document Patient #23 had shoes on admission. Interview revealed if a visitor brings items in to a patient, the items are to be inventoried on another inventory sheet prior to them being given to the patient. Interview revealed patients are not supposed to have anything with strings. Interview revealed if MHT #29 noticed anyone with strings in their shoes or clothing, MHT #29 would pull the patient to the side and explain they could not have strings and get the strings from the patient or the item that contained the strings if they could not be removed. Interview MHT #29 would lock up the item, notify the RN and supervisor on duty.

Telephone interview on 02/10/2022 at 1219 with RN #17 revealed she did not remember Patient #23. Interview revealed RN #17 does body searches on patients' skin and clothing when they are admitted. Interview revealed if a patient has shoes with laces, RN #17 asks if the laces can be removed and if not, the patient is given facility provided slide on slippers while the shoes with the laces are locked with the patient's belongings.

Interview on 12/10/2022 at 1247 with MHT #35 revealed he remembered Patient #23. Interview revealed the nursing staff look at the patients' skin and the MHTs look at clothing, jewelry, or anything the patient may use to harm themselves or others with. Interview revealed when Patient #23 came from another facility, he was wearing scrubs and socks. Interview revealed Patient #23 did not have on shoes. Interview revealed when someone brings a patient belongings, they are to be checked in on another inventory sheet.

3. Observation in (Named building) on A unit on 02/10/2022 between 1000 through 1025 revealed Patient #24 ambulating in the hallway toward the telephone. Observation revealed Patient #24 was wearing shoes with shoestrings in them.

Review on 02/10/2022 of the open medical record for Patient #24 revealed a 60-year-old female admitted with a diagnosis of CAH (command auditory hallucinations) with suicidal ideation. Review of the Patient's Possession List dated 01/26/2022 listed shoes as an item the patient was wearing. Review of the "What are you giving the patient to keep ..." did not have shoes marked as an item Patient #24 was given to have on the unit.

Interview on 02/10/2022 at 1010 with RN #36 identified Patient #24 and her date of admission was 01/25/2022. Interview revealed Patient #24 has shoelaces in her shoes. Interview revealed Patient #24 should not have shoelaces due to the safety issue. Interview revealed RN #36 notified Patient #24 she would need to either take the shoestrings out of her shoes or put her shoes in the patient belongings and wear facility provided slide on slippers.

Based on review of policy, medical record review and staff and physician interview, the facility staff failed to obtain a physician's order for use of seclusion in 2 of 5 restraint/ seclusion records reviewed (Patient #13, #12).

The findings include:

Review of the facility policy titled "Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion" revised July 2020 revealed "...Procedure...3.1 Restraint or seclusion shall be used in emergency situations only and requires an order from a physician...3.1.2 In the absence of a physician/authorized LIP (licensed independent practitioner), the registered nurse may authorized [sic] the initiation of restraint or seclusion in an emergency 3.1.3 The physician/LIP must be contacted for an order either during the emergency initiation of the restraint/seclusion or immediately (within a few minutes) after the restraint/seclusion has been initiated..."

1. Review of a closed medical record on 02/08/2022 revealed Patient #13 was a 29-year-old female admitted to the hospital on 10/01/2021 at 1333 with paranoia, delusions and non-compliance with psychiatric medications. Medical record review revealed Patient #13 had a history of Schizophrenia. Review of the 10/01/2021 Patient Observation sheet revealed nursing staff documented Patient #13 was in the unit's "Quiet Room" from 1545 to 1715. Review of a "RN Admission Note" dated 10/01/2021 at 2300 revealed "Pt. very angry, loud, aggressive, threatening to staff...Pt jumped onto nurses' desk and jumped onto staff. Code White (psychiatric emergency response) was called, Dr. notified, Geodon and Benadryl (medications for agitation) administered. Pt taken to Seclusion...MHT stayed in observation. Pt took approximately 1 hour nap, woke up and was brought out of seclusion..." Medical record review failed to reveal evidence of a physician's order for seclusion. Medical record revealed Patient #13 discharged home 10/12/2021.

Interview on 02/09/2022 at 1630 with Nurse Manager #1 revealed the quiet room was the seclusion room. Interview revealed the physician's order should be in the restraint/seclusion packet and a part of the patient's medical record.

Interview with the Director of Quality and Risk Management (DQRM) on 02/10/2022 at 0830 revealed there was no restraint/seclusion packet for Patient #13. Interview revealed there should be a physician's order for the seclusion episode on 10/01/2021.

Telephone interview on 02/09/2022 at 1320 with the attending Psychiatrist (CMO) revealed the facility policy states the staff should notify the provider before or immediately after putting a patient in seclusion to obtain an order. Interview revealed the CMO did not recall Patient #13 or the seclusion event.



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2. Review of a closed medical record revealed Patient #12 was a 18 year old male admitted on 12/27/2021 with anger issues towards his family and property damage towards his mother's vehicle. Review of the restraint documentation revealed Patient #12 was placed in seclusion on 12/31/2021 at 1110 and released at 1210, one hour. Review of the restraint documentation on 12/31/2021 failed to revealed a physician's order for the seclusion.

Interview on 02/10/2022 at 0845 with CNO revealed there was no order for the seclusion on Patient #12. Interview revealed Patient #12 should have an order for the seclusion.

Interview on 02/09/2022 at 1608 with the Director of Quality and Risk Management (DQRM) revealed there was no restraint order for Patient #12. Interview revealed there should be a physician's order for the seclusion episode on 12/31/2021 at 1110.

Based on review of policy, medical record review and staff interview, the facility staff failed to assess a patient within one hour after the initiation of seclusion or restraint in 2 of 5 restraint or seclusion records reviewed (Patient #13, #12).

The findings include:

Review of the facility's policy titled "Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion" revised July 2020 revealed "...5.0 Face to Face Evaluation by the Physician, LIP (licensed independent practitioner), or trained RN/PA: Within one hour of the initiation of restraint or seclusion, the patient shall be evaluated in person by a physician, authorized LIP...or trained RN/PA...The evaluation will be in the medical record..."

1. Review of a closed medical record on 02/08/2022 revealed Patient #13 was a 29-year-old female admitted to the hospital on 10/01/2021 at 1333 with paranoia, delusions and non-compliance with psychiatric medications. Medical record review revealed Patient #13 had a history of Schizophrenia. Review of the 10/01/2021 Patient Observation sheet revealed nursing staff documented Patient #13 was in the unit's "Quiet Room" from 1545 to 1715 (1 hour and 30 minutes). Review of a "RN Admission Note" dated 10/01/2021 at 2300 revealed "Pt. very angry, loud, aggressive, threatening to staff...Pt jumped onto nurses' desk and jumped onto staff. Code White was called, Dr. notified, Geodon and Benadryl (medications for agitation) administered. Pt taken to Seclusion...MHT stayed in observation. Pt took approximately 1 hour nap, woke up and was brought out of seclusion..." Medical record review failed to reveal evidence of an assessment by a physician or RN. Medical record revealed Patient #13 discharged home 10/12/2021.

Interview on 02/09/2022 at 1630 with Nurse Manager #1 revealed the quiet room was the seclusion room. Interview revealed the face to face assessment of the patient's condition should be in the restraint/seclusion packet and a part of the patient's medical record.

Interview with the Director of Quality and Risk Management (DQRM) on 02/10/2022 at 0830 revealed there was no restraint/seclusion packet for Patient #13. Interview revealed there should documentation of the face to face assessment of the patient's condition for the seclusion episode on 10/01/2021.



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2. Review of a closed medical record revealed Patient #12 was a 18 year old male admitted on 12/27/2021 for anger issues towards his family and property damage towards his mother's vehicle. Review of restraint documentation revealed Patient #12 was placed in seclusion on 12/31/2021 at 1110 and released at 1210, one hour. Review of restraint documentation from 12/31/2021 revealed no documentation of a face to face assessment after the release of Patient #12. Review revealed Patient #12 was discharged home on 01/04/2022.

Interview for assigned Registered Nurse was requested. Interview was not obtained due to Registered Nurse was not available.

Interview on 02/09/2022 at 1608 with DQRM revealed the documentation of the face to face assessment of the patient after the seclusion episode on 12/31/2021 was missing.

Interview on 02/10/2022 at 0845 with CNO revealed the documentation for the face to face assessment after the seclusion episode on 12/31/2021 was missing. Interview revealed the facility policy was not followed.

Based on review of the facility's Restraint Policy, Philosophy and Practice Statement, and staff interviews, the hospital staff failed to measure, analyze and track quality indicators related to restraints and seclusion.

The findings include:

Review on 02/11/2022 of the policy titled "Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion" with original date of 9/15/2000, revealed "...15.0 Performance Improvement...Performance improvement data is collected on the use of restraint/seclusion in order to monitor and improve its performance of a process that involves risks and may result in sentinel events...."

Interview on 02/11/2022 at 1130 with CNO revealed no data was available for the accuracy of restraint and seclusion use. Interview revealed "Don't know why restraints had not been auditing quality of restraints packets." Interview revealed the facility should audit all restraints to ensure all components are present such as physician and face to face orders.

Interview on 02/09/2022 at 1608 with DRQM revealed the use of restraints and seclusion are monitored and reported each month. Interview revealed restraints and seclusion are not tracked for completeness. Interview revealed there was no data available for completeness of the restraints requirements.

Based on policy review, medical record review and staff interviews, nursing staff failed to supervise care by failing to perform two nurse verification of insulin prior to administration, failing to accurately document the time of insulin administration, and failing to verify new blood pressures prior to administering anti-hypertensive medications for 1 of 25 medical records reviewed (#18)

The findings include:

Review of policy NU.255.00, Medication Management and Administration, original date 02/01/2019, revealed "...PURPOSE: ...Medications are administered pursuant to a prescibers order....PROCEDURE...4. High risk medication (i.e. insulin) require a second RN witness)...5. Some medications require assessment and verification of patient condition prior to, or as a result of dosing....Examples are: Determining blood glucose levels to decide the appropriate sliding scale dose Determining blood pressure prior to administering antihypertensive medication. ..."

Medical record review, on 02/10-11/2022, revealed Patient #18 was admitted on 11/13/2021 with diagnoses that included diabetes and hypertension. Review of the Medication Administration Record (MAR) revealed Patient #18 was ordered sliding scale insulin before meals and at bedtime. The MAR indicated the dose was 4 units for a blood glucose of 251-300, 6 units for a blood glucose of 301-350, and 8 units for a blood glucose of 351-400. MAR review revealed on 11/16/2021 at 1132, 4 units of Novolog insulin was recorded as given for a blood glucose of 258 and at 1135 (3 minutes later) an 8 unit dose of Novolog was recorded as administered for a blood glucose of 361. At 2100 on 11/16/2021 the patient was noted to receive 4 units of Novolog insulin for a blood glucose of 324 and another 4 units was documented at 2327 also for a blood glucose of 324. MAR review revealed the sliding scale orders were not administered per the parameters ordered for dosage and timing or the medication administration was documented incorrectly. Review of Blood Pressures on the "Observations" form, revealed a blood pressure of 147/79 was documented on the Observation sheet six times in a row, on 11/16/2021 at 1128, 1644, and 2015 and 11/17/2021 at 1012, 1422, and 2058. No other blood pressures were recorded on the form during those hours. Review revealed an anti-hypertensive medication Losartan was administered at 1013 on 11/17/2021 and Carvedilol (Coreg) was administered at 2059.

Interview with RN #20, a supervisor, on 02/11/2022 at 1047 revealed that two nurses were required to "co-sign" insulin and when only one nurse was on the unit that nurse might go ahead and administer the medication but could not document it without the second nurse verification. Interview revealed RN #20 believed the nurse may have just forgotten to change the administration times on the MAR. RN #20 stated that sometimes nurses would stop the supervisor later on rounds to sign the verification when there was only one nurse working on a unit. Interview revealed RN #20 did not know why there would be so many blood pressure values exactly the same.

Interview with the CNO, on 02/11/2022 at 1140, revealed the CNO was not aware that the two nurse verification was not always occurring real time. Interview revealed it was not acceptable. Follow-up interview, on 02/14/2022, confirmed the insulin doses on 11/16/2021 were were given or documented incorrectly. Further interview revealed blood pressures should be checked prior to administering BP medication

Interview with RN #10, on 02/14/2022 at 1225, revealed Techs check the vital signs, record them on a piece of paper, and RNs enter them into the computer. Interview revealed staff members had the ability to click "use last value" for the blood pressure. Interview revealed blood pressures should be taken before giving blood pressure medication.

Telephone interview with RN #26 on 02/11/2022 at 1240 revealed the RN administered medications to Patient #18. Interview revealed insulin required a two nurse verification of the correct dosage. Interview revealed that often there was only one nurse on the unit in the evening and so no one was available to verify the dosage. Interview revealed RN #26 would give the insulin and then get the verification signed later when someone was available. The nurse stated "that's what a lot of people do". Interview revealed the nurse had called supervisors in the past but they had not been able to come timely. RN #26 indicated supervisors covered multiple units and calling them was not a workable solution. Interview revealed the 2nd nurse verification was signed when another nurse came on the unit and that second nurse signed the verification based on what they were told. Further interview revealed as far a vital signs there was a button in the documentation system that said "use last value". Interview revealed RN#26 did not have access to the computer during the interview and could not recall specific details about dosages or lab or vital sign values. Further interview revealed the nurse did not recall for certain but may have clicked "use last value" before giving a BP medication to Patient #18.

Based on policy review, medical record review, staff and physician interview, the nursing staff failed to administer medications to a patient as prescribed in 2 of 25 Medication Administration Records reviewed (Patients #18, 13).

The findings include:

Review of policy NU.255.00, Medication Management and Administration, original date 02/01/2019, revealed "...PURPOSE:...Medications are administered pursuant to a prescribers order....PROCEDURE...4. High risk medication (i.e. insulin) require a second RN witness)...5. Some medications require assessment and verification of patient condition prior to, or as a result of dosing....Examples are: Determining blood glucose levels to decide the appropriate sliding scale dose Determining blood pressure prior to administering antihypertensive medication. ..."

1. Medical record review, on 02/10-11/2022, revealed Patient #18 was admitted on 11/13/2021 with diagnoses that included diabetes and hypertension. Medication Administration Record (MAR) review revealed Patient #18 was ordered sliding scale Novolog insulin with the following parameters "...For Blood Glucose Values: ...251-300 Give 4 Units 301-350 Give 6 Units... ." Review of the MAR, timed at 2100 on 11/16/2021 revealed a blood glucose value of 324. Review revealed Patient #18 was administered 4 units of Novolog insulin. At 2327, per MAR review, a dose of 4 units of Novolog insulin was administered for a blood glucose of 324. Review revealed that based on the sliding scale, a blood glucose of 324 should have resulted in administration of 6 units. Review revealed the insulin was not administered according to the sliding scale parameters.

Interview with RN #20, a supervisor, on 02/11/2022 at 1047 revealed that two nurses were required to "co-sign" insulin and when only one nurse was on the unit the nurse would go ahead and administer the medication but could not document it without the second nurse verification. RN #20 stated that sometimes nurses would just stop the supervisor later on rounds to sign the verification when there was only one nurse working on a unit.

Telephone interview with RN #26 on 02/11/2022 at 1240 revealed the RN administered medications to Patient #18. Interview revealed insulin required a two nurse verification of the correct dosage. Interview revealed that often there was only one nurse on the unit in the evening and no one was available to verify the dosage. Interview revealed RN #26 would give the insulin then get the verification later and stated "that's what a lot of people do". Interview revealed RN #26 had called the supervisor in the past but the supervisor had not been able to come at that time. Interview revealed RN#26 was not able to see the computer during the interview and could not recall specific details about specific dosages. Interview revealed the 2nd nurse verification was done when a second nurse came on the unit which may not have been at the time the medication was given. RN #26 stated the second nurse then verified the dosage by what the nurse was told was adminstered.

Interview with the CNO, on 02/11/2022 at 1140, revealed the CNO was not aware the two nurse verification was not always occurring real time. Interview revealed that practice was not acceptable and did not follow policy. Follow-up interview with the CNO on 02/14/2022 confirmed the medication doses on 11/16/2021 at 2100 and 2327 were given incorrectly according to the sliding scale order.



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2. Review of a closed medical record on 02/08/2022 revealed Patient #13 was a 29-year-old female admitted to the hospital on 10/01/2021 with paranoia, delusions and non-compliance with psychiatric medications. Medical record review revealed Patient #13 had a history of Schizophrenia. Review of the Medication Administration Record (MAR) revealed a physician's order for temazepam (sleep medication) 30 milligrams at bedtime. Medical record review revealed documentation the medication was not administered on 10/02/2021, 10/04/2021, 10/05/2021, 10/10/2021 and 10/11/2021 due to "Drug not available." Medical record review failed to reveal evidence the attending physician was notified the medication was not administered as ordered. Medical record review revealed Patient #13 discharged home on 10/12/2021.

Telephone interview on 02/09/2022 at 1320 with the Chief Medical Officer (CMO) revealed the facility has not been out of temazepam. Interview revealed the CMO was not notified Patient #13 had not received temazepam as ordered. Interview revealed the medication was on the hospital's formulary and should have been administered.

Interview on 02/09/2022 at 1630 with the Nurse Manager revealed the hospital's pharmacy stocks five days of a patient's medications on the med cart. Interview revealed if the nurse was unable to find the medication, the nurse supervisor should have been contacted for assistance. Interview revealed the temazepam should have been administered as ordered by the physician. Interview revealed the attending physician should have been notified the medication was not administered as ordered. Interview revealed the staff nurses did not follow the facility's policy for medication administration.

Based on policy review, medical record reviews and staff interview, the facility staff failed to ensure a Master Treatment Plan was completed within 72 hours of admission for 2 of 30 sampled patients. (Patients #13, #20, #29 ).

The findings include:

Review of the facility policy titled "INTERDISCIPLINARY PATIENT-CENTERED CARE PLANNING" revised July 2020 revealed "...Procedure: Developing the Treatment Plan...4. Within 72 hours of admission, the multi-disciplinary team shall meet to develop the treatment plan..."

1. Review of a closed medical record on 02/08/2022 revealed Patient #13 was a 29-year-old female admitted to the hospital on 10/01/2021 at 1333 with paranoia, delusions and non-compliance with psychiatric medications. Medical record review revealed Patient #13 had a history of Schizophrenia. Medical record review revealed a Master Treatment Plan dated 10/12/2021 (11 days after admission). Medical record review revealed Patient #13 discharged home 10/12/2021.

An interview with Therapist #2 was requested who was unavailable for interview.

Interview on 02/09/2022 at 1535 with the Director of Clinical Services revealed the patient's Master Treatment Plan should be complete within 72 hours (3 days) of admission to the facility. Interview revealed the clinical staff was responsible for creating the the Master Treatment Plan and should be signed by the provider, therapist and nurse. Interview revealed Therapist #2 did not follow the facility's treatment plan policy.



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2. Review of an open medical record on 02/09/2022 revealed Patient #20 was a 14-year-old female admitted involuntarily on 02/05/2022 after an intentional drug overdose. Medical record review revealed Patient #20's Psychiatric Evaluation and History and Physical included ADHD (attention deficit hyperactivity disorder) and ODD (oppositional defiance disorder). Medical record review revealed a Master Treatment Plan (MTP) included treatment for Assaultive/Aggressive behaviors and was signed by the Unit Clinician on 02/07/2022 (2 days) and nursing staff on 02/10/2022 (5 days). Review revealed no documentation of physician involvement on the MTP. Medical record review revealed Patient #20 remained admitted to the facility on 02/14/2022 (9 days).

Interview on 02/09/2022 at 1130 with the Director of Clinical Services revealed the patient's Master Treatment Plan should be complete within 72 hours (3 days) of admission to the facility and the plan was not consistent with facility policy.

3. Review of an open medical record on 02/14/2022 revealed Patient #29 was a 64-year-old male admitted voluntarily on 02/04/2022 with suicidal ideation, depression and cocaine and alcohol abuse. Medical record review revealed Patient #29's Psychiatric Evaluation and History and Physical also included, diabetes, and Tourette's syndrome. Medical record review revealed a Master Treatment Plan (MTP) included treatment for two problems: 1. Substance Use and 2. Depression, was signed by the Unit Clinician on 02/07/2022 (3 days) and the Recreational Therapist on 02/08/2022 (4 days). Review revealed no documentation of physician or nursing involvement on MTP on 02/14/2022 (10 days) and Patient #29 remained admitted to the facility.

Interview on 02/09/2022 at 1130 with the Director of Clinical Services revealed the patient's Master Treatment Plan should be complete within 72 hours (3 days) of admission to the facility. Interview again on 02/14/2022 at 1015 revealed Patient #29's MTP did not follow the facility's treatment plan policy.

Based on policy and procedure review, medical record reviews and staff interviews, the facility staff failed to ensure short term goals were complete on the initial nursing treatment plan within the eight (8) hours of admission for 3 of 30 sampled patients (Patients #16, #23, and #15).

The findings include:

Review of the facility policy "Interdisciplinary Patient Centered Care Planning" with an origination date of 09/15/2020 revealed "... Each patient's written Treatment Plan must include: *Substantiated diagnosis(es) *Identification of problems to be treated and the specific behavioral manifestations of those problems in the patient *Short-term and long term goals for each active problem, developed with the patient input *The specific treatment modalities with individualized patient focus *The responsibilities of each member of the treatment team; Procedure: Developing the Treatment Plan: 1. The Nurse completing the Nursing Assessment or designee shall develop the Initial Treatment within eight (8) hours of admission ... 2. Each discipline completing their individual assessments will begin to identify the patient's problems to be treated and the focus of their treatment interventions which will be included in the MTP (master treatment plan) ..."

1. Open medical record review on 02/09/2022 revealed Patient #16, a 64-year old female admitted to the facility on 02/01/2022 at 2325 for diagnoses of Suicidal Ideation with a plan to cut herself with a razor and auditory hallucinations. Record review of the Initial Nursing Treatment Plan dated 02/01/2022 at 0016 revealed the Problem/Short-term Goals was checked "Patient will demonstrate use of the following coping skill(s) when having thoughts of harming self: (blank)." The short term goal was not completely filled out in that it did not identify the coping skill(s) the patient should use.

Interview on 02/10/2022 at 1520 with Chief Nursing Officer (CNO) revealed "Danger to Self and Others" was an identified problem area and there should have been a short term goal completed for this problem area. Interview revealed coping skills should have been listed. Interview revealed the staff are supposed to be doing night time medical record audits to identify when things are not completed.

2. Open medical record review on 02/10/2022 revealed for Patient #23 revealed a 63-year old male admitted under involuntary commitment (IVC) papers for suicidal ideation and major depression disorder. Record review of the Initial Nursing Treatment Plan dated 02/08/2022 not timed revealed the Problem/Short-term Goals was checked "Patient will demonstrate use of the following coping skill(s) when having thoughts of harming self: (blank)." The short term goal was not completely filled out in that it did not identify the coping skill(s) the patient should use.

Interview on 02/10/2022 at 1520 with Chief Nursing Officer (CNO) revealed the "Danger to Self and Others" was an identified problem area and there should have been a short term goal completed for this problem area. Interview revealed coping skills should have been listed. Interview revealed the staff are supposed to be doing night time medical record audits to identify when things are not completed.

3. Open medical record review on 02/10/2022 revealed for Patient #15 revealed a 20-year old female admitted on 02/03/2022 at 1132 with a diagnosis of suicidal ideation with a plan. Record review of the Initial Nursing Treatment Plan dated 02/03/2022 at 1915 revealed the Problem/Short-term Goals was checked "Patient will demonstrate use of the following coping skill(s) when having thoughts of harming self: (blank)." The short term goal was not completely filled out in that it did not identify the coping skill(s) the patient should use.

Interview on 02/10/2022 at 1520 with Chief Nursing Officer (CNO) revealed the "Danger to Self and Others" was an identified problem area and there should have been a short term goal completed for this problem area. Interview revealed coping skills should have been listed. Interview revealed the staff are supposed to be doing night time medical record audits to identify when things are not completed.

Based on policy review, medical record reviews and staff interview, the facility staff failed to ensure a Master Treatment Plan that reflected medical treatment therapies and patient response to interventions for 4 of 30 sampled patients (Patient #20, Patient #29, Patient #21 and Patient #22).

Findings include:

Review on 02/08/2022 of the policy "Interdisciplinary Patient Centered Care Planning" dated 09/05/2020 revealed, "...It is the policy of (Named) Behavioral Health Services to provide therapeutic services based upon a patient-centered, individualized treatment plan. The treatment team led by the attending psychiatrist works with the patient and family/representative to collaboratively identify the patient's assessed needs to be addressed during treatment and develop appropriate goals and interventions. All therapeutic services that are beyond routine tasks are included in the plan and the treatment plans are routinely reviewed to assess the patient's progress and determine if any modifications are needed..."

1. Review of an open medical record on 02/09/2022 revealed Patient #20 was a 14-year-old female admitted involuntarily on 02/05/2022 after an intentional drug overdose. Medical record review revealed Patient #20's Psychiatric Evaluation and History and Physical included ADHD, ODD and "possibility of UTI-ordered UA and Macrobid." Medical record review revealed a Master Treatment Plan (MTP) included treatment for Assaultive/Aggressive behaviors and was signed by the Unit Clinician on 02/07/2022 and nursing staff on 02/10/2022 . Review revealed treatment for a urinary tract infection but no inclusion of Patient #20's urinary tract infection in the MTP. Review revealed a physician order for antibiotic treatment of a urinary tract infection but revealed no documentation of the urinary tract infection on the MTP. Review of the MTP revealed no documented of physician involvement on the MTP and Patient #20 remained admitted to the facility on 02/14/2022.

Interview on 02/09/2022 at 1130 with the Director of Clinical Services revealed the patient's Master Treatment Plan should be completed within 72 hours (3 days) of admission to the facility and include all active patient problems. Interview revealed the plan was not consistent with facility policy.

2. Review of an open medical record on 02/14/2022 revealed Patient #29 was a 64-year-old male admitted voluntarily on 02/04/2022 with suicidal ideation, depression and cocaine and alcohol abuse. Medical record review revealed Patient #29's Psychiatric Evaluation and History and Physical also included, diabetes, and Tourette's syndrome. Medical record review revealed a Master Treatment Plan (MTP) included treatment for two problems: 1. Substance Use and 2. Depression, was signed by the Unit Clinician on 02/07/2022 and the Recreational Therapist on 02/08/2022. Review revealed no assessment of Patient #29's medical problems in the MTP. Review also revealed no documentation of physician or nursing involvement on the plan. Medical record review revealed Patient #29 remained admitted to the facility on 02/14/2022.

Interview on 02/09/2022 at 1130 with the Director of Clinical Services revealed the patient's Master Treatment Plan should be complete within 72 hours (3 days) of admission to the facility and include all active patient problems. Interview again on 02/14/2022 at 1015 revealed Patient #29's MTP did not follow the facility's treatment plan policy.



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3. Review of a closed medical record on 02/20/2022 revealed Patient #21 was a 13 year old female admitted on 01/21/2022 with worsening depressive symptoms. Review revealed Patient #21's COVID-19 test results were positive on 01/24/2022. Review revealed a Master Treatment Plan dated 01/24/2022 was incomplete. Review revealed a failure to include documentation of the medical diagnosis of COVID-19 on the treatment plan. Review revealed Patient #21 was discharged on 01/28/2022.

Interview on 02/11/2022 at 1250 with Director of Clinical Services revealed no written documentation of COVID-19 on the treatment plan. Interview revealed the treatment plan should have included the medical diagnosis of COVID-19.

4. Review of a closed medical record on 02/20/2022 revealed Patient #22 was a 15 year old female admitted on 01/21/2022 with worsening symptoms of depression and had written a suicide note wanting to kill herself. Review of the rapid COVID-19 test revealed positive test results on 01/24/2022 at 2100. Review of the Master Treatment Plan dated 01/24/2022 through 01/27/2022 failed to include documentation of the COVID-19 diagnosis. Review revealed Patient #22 was discharged on 01/28/2022,

Interview on 02/11/2022 at 1250 with the Director of Clinical Services revealed no written documentation of COVID-19 on the treatment plan. Interview revealed the treatment plan should have included the medical diagnosis of COVID.

NC00185689; NC00183402; NC00185443; NC00183589; NC00183600; NC00183439; NC0018?618; NC00183430; NC00185023; NC00184308; NC00183774