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Based on record reviews and interview, the hospital failed to ensure two patients' complaints (R2, R3) regarding patient-to-patient sexually inappropriate behavior exhibited by Random Patient R1 were handled as a grievance for 2 of 3 complaints reviewed. There was no documented evidence that the occurrences were investigated (no documented interviews of staff), and there was no documented evidence that Patients R2 and R3 were sent a resolution letter at the conclusion of the investigation.
Findings:

Review of the hospital policy titled "Patient Complaints and Grievances," contained in the policy and procedure manual presented by S2Director of Nursing (DON) as the hospital's current policies and procedures, revealed that a patient grievance is defined as a formal, written, or verbal grievance that is filed by a patient when the issue cannot be resolved promptly. The Charge Nurse is responsible for notifying the Director of Quality Improvement (QI) who will make personal contact with the patient within 2 working days of receipt of the grievance. If the Director of QI and the patient come to a resolution of the expressed problem, no further action will be necessary, and a written response will be provided to the patient within 3 working days of the initial meeting of the patient and the Director of QI. If the problem or concern is not resolved at this stage, the Director of QI is responsible for facilitating the Grievance Process as follows:
1) The Director of QI will meet with the Grievance Committee to present all known information regarding the patient's grievance within 10 working days of the report.
2) The Grievance Committee will review and further investigate the substance of the grievance.
3) Within 5 working days of the Grievance Committee Meeting, a written response will be provided to the patient or his/her legal representative giving notice of the determination regarding the committee's decision.
4) Grievances about situations that endanger the patient, such as neglect or abuse, shall be reported immediately to the DON and to the Total Quality Improvement Coordinator.

Review of the "June 2013 Grievances/Complaints" report revealed the following 2 complaints that were handled as a complaint rather than a grievance:
Random Patient R3
Random Patient R3 reported on 06/05/13 at 1:00 a.m. that Random Patient R1 "rolled over to her while she was on the sofa and kissed her without her consent." The variance report was received and reviewed on 06/06/13 at 2:40 p.m. Further review revealed S2DON met with Random Patient R3 on 06/07/13 (2 days after the patient reported the complaint/grievance), and she (Random Patient R3) was satisfied with the staff's interventions and response at the time of the occurrence.

Review of the risk management review of the "Confidential Hospital Occurrence Report" documented by S15Dietary Manager, who is also a nursing supervisor, revealed that upon review of the camera Random Patient R1 did lean over and appeared to kiss Random Patient R3. Follow-up action revealed that Random Patient R1 was placed on 1:1 observation on 06/05/14 at 8:00 a.m. There was a written statement of what Random Patient R3 reported with no documented evidence of which staff member wrote her statement. There was no documented evidence that the staff members who were present were interviewed to determine what was observed at the time of the occurrence. There was no documented evidence that a resolution letter was sent to Random Patient R3.

Random Patient R2
Random Patient R2 reported on 06/05/13 at 10:30 a.m. that a couple of days ago prior to bedtime, Random Patient R1 reached up and attempted to kiss her and rub on her. The variance report was received and reviewed on 06/07/13.

Review of the risk management review of the "Confidential Hospital Occurrence Report" documented by S15Dietary Manager, who is also a nursing supervisor, revealed that Random Patient R1 was placed on 1:1 observation and boundary limitations with female peers. The recommendation was to refer for further follow-up. There was no documented evidence that staff members who had worked during the time of the allegation had been interviewed to determine if anyone had witnessed the behavior. There was no documented evidence that a resolution letter was sent to Random Patient R2.

In an interview on 05/01/14 at 3:50 p.m., S2DON indicated the complaints received from Random Patients R2 and R3 were handled by the staff nurse. She confirmed that she did not have any documented investigation of the allegations, did not handle the complaints as grievances, and did not send resolution letters to the 2 patients.

30984

Based on observations and interviews, the hospital failed to ensure that patients received care in a safe setting as evidenced by failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality for acute care psychiatric patients.
Findings:

During the entrance conference on 4/29/14 at 10:45 a.m., S2DON said the hospital was a 9 room, 18 bed unit. She explained one of the inpatient rooms was not in use at the time of the survey due to renovations (Room #1).

During the initial hospital tour on 4/29/14 at 11:00 a.m., the following observations were made in patient rooms:
a. Lever style door handles (not anti-ligature) on all doors throughout the unit;
b. Exposed plumbing/pipes in bathrooms;
c. Interior bathroom door hinges separated widely enough to facilitate potential ligature risk;
d. Crank beds with cranks attached;
e. Siderails on all patient beds (both sides);
f. Slatted fold-up shower seats (in all rooms with showers) with pipe hardware securing it to the wall;
g. Flanged handles on the bathroom sinks in patient rooms;
h. Drawer pulls (non-flush) on chest of drawers, facilitating a potential ligature anchor in patient rooms;
i. Patient room ceilings non-monolithic and not secured by clamps;
j. Screws, not tamper resistant, in doorframes;
k. Zippered covers on mattresses which could be unzipped and removed

Other observations made during the tour were as follows:
Plastic trash can liners were noted in the trash cans in the commons area and in the unlocked, unattended Activity Room;
The Activity Room was unlocked and unattended with phone cords, phone wires, and plastic grocery bags noted in the room.
A gait belt was noted in the first drawer of the chest of drawers adjacent to the A bed in Room 8. Review of the current census revealed Patient #5 was assigned to Room 8, bed A. The patient's diagnoses included Intermittent Explosive Disorder and Major Depression. These observations were confirmed by S2DON who was present for the observations.

In an interview on 4/29/14 at 11:40 a.m. with S2DON, she said patients were allowed to go to their rooms unattended if they were not on 1:1 or visual contact. She also said the patients were allowed to close their doors.

In an interview on 4/29/14 at 11:45 a.m. with S6Maintenance, he said he could see how a sheet could be thrown over the bathroom door or tied in the space between the bathroom door hinges to provide a way for someone to hang themselves. He also confirmed the mattress covers unzipped all the way and could be removed.

Based on record review and staff interview, the hospital failed to ensure the patient's plan of care was updated/modified when restraints were used for violent behavior for 1 of 1 (#15) sampled patients reviewed for the use of restraints out of a total sample of 29 (#1-#29). Findings:

Review of the hospital's policy titled Restriction of Activity: Restraint/Seclusion, Policy number NU.452, revised date of 08/07/13, revealed in part the following: .... III. Procedure: .... W. The use of restraint or seclusion must be implemented in accordance with a written modification to the patient's plan of care; and implemented in accordance with safe and appropriate restraint and seclusion techniques....

Patient #15
Review of the patient's clinical record revealed the patient was a 55 year old male admitted to the hospital on 04/16/14 under a PEC (Physician Emergency Certificate) for attempted suicide by hanging. A CEC (Coroner Emergency Certificate) dated 04/16/14 indicated the patient was dangerous to self and unwilling to seek voluntary admission.

Review of the record revealed the patient became disruptive and aggressive at 11:30 a.m. on 04/17/14 and was placed in 5 point restraints (Wristlets, Anklets, and Waist belt) and seclusion at 12:30 p.m. on 04/17/14. The record revealed the patient attempted to break the window and jump out of the window. The record revealed the patient was threatening physical harm to the staff and less restrictive interventions were unsuccessful. Review of the Restraint/Seclusion orders revealed the patient was in 5 point restraints and seclusion from 12:30 p.m. until 4:30 p.m.

Review of the patient's treatment plan revealed no documented evidence that the treatment plan was updated with the restraint/seclusion intervention on 04/17/14.

In an interview on 05/01/14 at 10:20 a.m., S2DON (Director of Nursing) stated she was present on the unit when Patient #15 was placed in restraints/seclusion on 04/17/14. S2DON stated she instructed S28RN on what she had to complete and provided a packet of forms. S2DON reviewed the patient's record and verified the treatment plan was not updated as required with the use of restraint and seclusion on 04/17/14. S2DON stated S28RN was on leave.

Based on record review and staff interview, the hospital failed to ensure the condition of the patient who was restrained was monitored in accordance with the hospital's policy for for 1 of 1 (#15) sampled patients reviewed for the use of restraints out of a total sample of 29 (#1-#29). Findings:

Review of the hospital's policy titled Restriction of Activity: Restraint/Seclusion, Policy number NU.452, revised date of 08/07/13, revealed in part the following: .... III. Procedure: .... Q. The RN will assess the patient every hour. An RN assessment will be documented on the Seclusion/Restraint Flow Sheet hourly. There will also be an entry in the form of a progress note updating patient's status at least every 2 hours while patient remains in seclusion and/or restraints. Assess for general condition, cardio/pulmonary status, skin integrity, physical complaints, signs and symptoms of injury, mental status, behavior, and neurological status. Monitor vital signs unless it is contraindicated by the patient's behavior....Seclusion/Restraint Debriefing: Following the initiation of each episode of seclusion/restraint, all staff directly involved on the scene, will be offered the opportunity to participate in a debriefing session, to be set up by the Charge Nurse....

Patient #15
Review of the patient's clinical record revealed the patient was a 55 year old male admitted to the hospital on 04/16/14 under a PEC (Physician Emergency Certificate) for attempted suicide by hanging. A CEC (Coroner Emergency Certificate) dated 04/16/14 indicated the patient was dangerous to self and unwilling to seek voluntary admission.

Review of the record revealed the patient became disruptive and aggressive at 11:30 a.m. on 04/17/14 and was placed in 5 point restraints (Wristlets, Anklets, and Waist belt) and seclusion at 12:30 p.m. on 04/17/14. The record revealed the patient attempted to break the window and jump out of the window. The record revealed the patient was threatening physical harm to the staff and less restrictive interventions were unsuccessful. Review of the Restraint/Seclusion orders revealed the patient was in 5 point restraints and seclusion from 12:30 p.m. until 4:30 p.m.

Review of the patient's record revealed the only documentation of hourly monitoring was documented by S28RN at 2:15 p.m., 1 hour and 45 minutes after the patient was placed in restraints and seclusion. There was no other documentation of monitoring. Further review of the Seclusion/Restraint flow sheet revealed the debriefing form was incomplete and failed to include the staff attending the debriefing.

In an interview on 05/01/14 at 10:20 a.m., S2DON (Director of Nursing) stated she was present on the unit when Patient #15 was placed in restraints/seclusion on 04/17/14. S2DON stated she instructed S28RN on what she had to complete and provided a packet of forms. S2DON reviewed the patient's record and verified the hourly assessment of the patient had not been documented by S28RN and stated the debriefing form was incomplete. S2DON verified the hospital's policy for monitoring the patient had not been followed. S2DON stated S28RN was on leave.

Based on record review and staff interview, the hospital failed to ensure the patient was evaluated face-to-face within 1 hour after the initiation of restraints for 1 of 1 (#15) sampled patients reviewed for restraints out of a total sample of 29 (#1-#29). Findings:

Review of the hospital's policy titled Restriction of Activity: Restraint/Seclusion, Policy number NU.452, revised date of 08/07/13, revealed in part the following: .... III. Procedure: .... H. When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1 hour after the initiation of the intervention by a Physician or Psychologist, or a Registered Nurse who has completed and deemed competent in Restraint and Seclusion intervention and completed Crisis Prevention Intervention Training. The face-to-face evaluation shall address the patient's immediate situation; the patient's reaction to the intervention; the patient's medical and behavioral condition; and the need to continue or terminate the restraint or seclusion. I. If the face-to-face evaluation is conducted by a trained registered nurse, the trained registered nurse must consult the attending physician or psychologist who is responsible for the care of the patient as soon as possible after the completion of the 1-hour face-to-face evaluation....

Patient #15
Review of the patient's clinical record revealed the patient was a 55 year old male admitted to the hospital on 04/16/14 under a PEC (Physician Emergency Certificate) for attempted suicide by hanging. A CEC (Coroner Emergency Certificate) dated 04/16/14 indicated the patient was dangerous to self and unwilling to seek voluntary admission.

Review of the record revealed the patient became disruptive and aggressive at 11:30 a.m. on 04/17/14 and was placed in 5 point restraints (Wristlets, Anklets, and Waist belt) and seclusion at 12:30 p.m. on 04/17/14. The record revealed the patient attempted to break the window and jump out of the window. The record revealed the patient was threatening physical harm to the staff and less restrictive interventions were unsuccessful. Review of the Restraint/Seclusion orders revealed the patient was in 5 point restraints and seclusion from 12:30 p.m. until 4:30 p.m.

Review of the patient's record revealed the 1-hour face-to-face evaluation of the patient was documented by S28RN at 2:15 p.m., 1 hour and 45 minutes after the patient was placed in restraints and seclusion.

In an interview on 05/01/14 at 10:20 a.m., S2DON (Director of Nursing) stated she was present on the unit when Patient #15 was placed in restraints/seclusion on 04/17/14. S2DON stated she instructed S28RN on what she had to complete and provided a packet of forms. S2DON reviewed the patient's record and verified the 1-hour face-to-face assessment was not conducted within 1 hour of the patient being placed in restraints and seclusion. S2DON stated S28RN was on leave.

Based on record review and staff interview, the hospital failed to meet the requirements for the Condition of Participation for Quality Assurance/Performance Improvement as evidenced by:

A) The hospital failed to ensure the QAPI program was an ongoing program that showed measurable improvement in indicators as evidenced by failing to analyze the data collected to improve performance and processes of care and identify opportunities for improvement. The QAPI program failed to improve performance in quality indicators of medical staff credentialing, delinquent medical records, and food temperatures (see findings in A-0273).

B) The hospital failed to set priorities for high-risk, high volume and problem-prone areas as evidenced by:
1) failing to monitor the hospital process for compliance with the Pharmacist review of the patient's medication profile prior to the first dose of a new medication, and;
2) failing to monitor the hospital process for treatment planning (see findings in A-0283).

C) The governing body failed to ensure that the hospital's Performance Improvement Program reflected the hospital's organization and services as evidenced by not having all hospital departments and services including those services furnished under contract involved in the Performance Improvement Program (see findings in A-0308).

Based on review of QAPI (Quality Assessment Performance Improvement) records and staff interview, the hospital failed to ensure the QAPI program was an ongoing program that showed measurable improvement in indicators as evidenced by failing to analyze the data collected to improve performance and processes of care and identify opportunities for improvement. The QAPI program failed to improve performance in quality indicators of medical staff credentialing, delinquent medical records, and food temperatures. Findings:

Medical Staff Credentialing:
Review of the 4th Quarter 2013 Quality Improvement report revealed S5Human Resource Director was maintaining and updating physician and nurse practitioner credentialing files. Review of the credentialing report for the first quarter of 2014 revealed no identified problems or corrective actions.

Review of S3Medical Director's credentialing file revealed S3Medical Director reviewed and signed his own request for privileges. Review of his "Medical Privilege Approval and Staff Initial Appointment Form" revealed the Medical Executive Committee signature was that of a non-physician. There was no documented evidence that a physician other than himself reviewed S3Medical Director's request for privileges. Further review of the credentialing file revealed that 3 reference letters were mailed on 04/08/14, and a response had not been received from any of the 3 peers prior to S3Medical Director's appointment being approved by the Governing Body as required by the Medical Staff By-laws.

In an interview on 05/01/14 at 11:05 a.m., S5Human Resources Director indicated she was the person responsible for the credentialing process. She confirmed that S3Medical Director signed his own request for privileges, and no peer references were received prior to the Governing Body approving S3Medical Director's appointment.

Review of the credentialing file for S10NP revealed the practitioner's Governing Body appointment to the medical staff was dated 03/08/12 (reappointment due by 03/08/14). Review of the credentialing file 05/01/14 revealed no documented evidence of a Governing Body re-appointment to the medical staff since 03/08/12. There was no current application, no National Data Bank query, no request for privileges, no professional references, no CME (Continuing Medical Education), and no recommendation for appointment by the medical staff.

Review of the clinical record for Patient #1 revealed the psychiatric evaluation was documented by S10NP on 4/22/14. Review of the clinical record for Patient #7 revealed the psychiatric evaluation was documented by S10NP on 04/24/14.

In an interview on 05/01/14 at 1:45 p.m., S5Human Resource Director verified she was responsible for credentialing. S5Human Resource Director reviewed the credentialing file for S10NP and verified the last appointment was 03/08/12. S5Human Resource Director stated she knew S10NP's licenses were current and verified she was aware that re-appointment was required every 2 years. She verified there was no National Data Bank query, no application for re-appointment, and no professional references. S5Human Resource Director verified S10NP was currently providing care and treatment to patients in the hospital. S5Human Resource Director was unable to explain why the re-appointment process was not conducted for S10NP.

Review of the credentialing file for S9Physician revealed the physician was re-appointed to the medical staff by the governing body on 08/02/13. Review of the credentialing file revealed no documented evidence of any referral letters or continuing education for the re-application dated 7/30/13.

In an interview on 05/01/14 at 1:45 p.m., S5Human Resource Director verified the re-appointment application dated 7/30/13 did not include professional referral letters.

In an interview on 05/01/14 at 4:15 p.m., S2DON (Director of Nursing) verified she was responsible for the QAPI program. S2DON verified S5Human Resource Director reported medical staff credentialing to the QAPI committee. S2DON stated she was not aware that S10NP had not been reappointed to the medical staff and confirmed S10NP was currently providing care to the hospital's patients. S2DON also verified she was not aware of the above issues identified in the credential files. S2DON provided the medical staff credential report from the first quarter of 2014 and verified the above issues were not identified and no corrective action had been taken.


Delinquent Medical Records:
Review of the 4th Quarter 2013 Quality Improvement report revealed the following:
Physician Progress Notes Timed - 90% compliance
Physician times all physician orders - 97% compliance
Timing of Psychiatric Evaluation - 90% compliance
Timing of History & Physical - 73% compliance
Physician times verbal and phone orders - 17% compliance.
Further review of the report revealed the action plan was to notify each physician with identified chart deficiencies and establish a date and time for corrective action. The Health Information Management (HIM) department manager would forward a memo to the Medical Director addressing the results of chart audits and physician in non-compliance. The action plan also indicated the HIM director would forward written communication to employees with identified deficiencies and copy to respective manager.

Review of the delinquent medical record list provided to the survey team by S17Medical Records revealed the following:

S9 Physician:
8 medical records greater than 30 days delinquent
14 medical records greater than 60 days delinquent
16 medical records greater than 90 days delinquent

S10NP:
3 medical records greater than 90 days delinquent (dating back to 11/2013 and 12/2013)
1 medical record greater than 60 days delinquent
1 medical record greater than 30 days delinquent

Further review of the delinquent medical record list revealed multiple staff members from multiple disciplines also had delinquent medical record entries. The following deficient records were noted from other disciplines:
32 medical records greater than 30 days delinquent
23 medical records greater than 60 days delinquent
41 medical records greater than 90 days delinquent (dating back to 1/2013)

In an interview on 5/1/14 at 9:01 a.m. with S17Medical Records she explained medical records were not considered completed until all entries were signed, dated and timed. She explained medical records that had not been completed within 30 days after patient discharge were considered delinquent. S17Medical Records said she kept a list of delinquent medical records with the patients' admission and discharge dates to enable them to track the number of days the chart was deficient. She said the list was arranged by discipline (Doctors, Nurses, Techs, Dietary, ect..). S17Medical Records also said she printed the list weekly and gave a copy to the nursing staff and S2DON. She explained the list was used by the nursing staff to identify incomplete medical records requiring physician signatures. S17Medical Records said she had not sent out any letters related to delinquent medical records because S2DON was responsible for sending out the letters.

In an interview on 5/1/14 at 9:30 a.m. with S2DON she explained tracking of delinquent medical records was conducted by utilizing 24 hour chart audits. She said color coded tabs were used to mark incomplete entries. She explained any patient records with remaining incomplete entries were placed on the delinquent record list compiled by S17Medical Records. S2DON said she received a copy of the list and any doctor or advanced practitioner with medical records delinquent in excess of 30 days should have received a letter indicating possible disciplinary action and a deadline for completion of the deficient record. She said if the employee with deficient records was a nurse she would have handled disciplinary action including possible suspension. S2DON explained doctors or advanced practice nurses with deficient records would have been disciplined by Administration and the Medical Director. S2DON said no letters related to delinquent charts had been sent out because they didn't have any medical records that were in excess of 30 days delinquent. She was read entries from the list prepared by S17Medical Records for the survey team and acknowledged there were medical records in excess of 90 days delinquent on the list. She agreed no medical record should have been 90 days delinquent. She confirmed a letter should have been sent and disciplinary action should have been taken through the Medical Executive Committee as set forth in the Medical Staff Rules and Regulations.

In an interview on 05/01/14 at 4:15 p.m., S2DON verified she was responsible for the hospital's QAPI program. When asked what had been done to address the incomplete medical records, she stated an audit was done on the unit, a 24 hour chart check was done by the staff, and medical records compiles a deficiency list. S2DON verified she was unaware of the above numbers of delinquent medical records and stated, "I thought it was looking better." S2DON verified there was no corrective action plan identified for delinquent medical records.


Food Temperatures:
Review of the 4th Quarter 2013 Quality Improvement report revealed the following:
Nursing staff complete food temperature logs three times weekly - 100% compliance
Hot foods maintained at 120 degrees or greater - 96% compliance
Cold foods maintained at 50 degrees or colder; milk at 41 degrees or colder - 59% compliance.
Further review of the report revealed the action plan was to continue monitoring for an additional quarter.

Review of the hospital's food temperature log revealed the following temperature guideline reference: Food temperatures shall be maintained at 120 degrees F (Fahrenheit) or above for hot foods and 50 degrees or below for cold items, except milk which shall be at 41 degrees F.

Further review of the hospital's food temperature logs from 3/31/14 through 4/30/14 revealed only lunch and dinner meal service temperatures had been evaluated. Breakfast meal service temperatures had not been evaluated during that time period.

On 4/29/14 at 11:30 a.m., an observation was made of the lunch meal service. The patients' food trays were served directly from the enclosed metal cart used to transport the food from the kitchen (located in an adjacent hospital).

In an interview on 5/1/14 at 9:30 a.m. with S2DON, she explained the clinical assistants checked and recorded food temperatures in a log three times a week on Monday, Wednesday and Friday. She confirmed food temperatures were not checked for each meal daily. She said a random tray from one meal service was selected for temperature evaluation on the days when food temperatures were spot checked.
In an interview on 5/1/14 at 10:45 a.m. with S7RD (Registered Dietician) she explained the monitoring of food temperatures and the process of food delivery from the kitchen of the adjacent contracted hospital. She said measurement of food temperatures was performed in the contracted hospital's kitchen where the food was prepared and plated. She said the food was placed on heated plates, covered, and placed in a metal cart. S7RD then explained the food cart was transported from the kitchen, through the Emergency Room, out of the ambulance bay exit to the outside, then into the hospital, up the elevator and onto the unit where it was served. S7RD said the turnaround time for delivery of food from the contracted kitchen in the adjacent building was about 15 minutes. S7RD confirmed the meal temperatures were not retested daily upon arrival to the unit where the meal was to be served because that would have been "unrealistic" and "overkill" since the food temperatures had been evaluated when the food had been plated in the contracted hospital's kitchen.

In an interview on 5/1/14 at 1:57 p.m., S15Dietary (Manager) said food temperatures were evaluated three times a week on Monday, Wednesday, and Friday, and the temperatures were logged in a log book. She explained staff checked the temperatures on one randomly selected tray during one meal service on the days that meal temperatures were evaluated. She explained it was usually a meal service when the staff felt they had time to perform the temperature checks. S15Dietary verified she could not ensure that every meal was served within regulatory temperature ranges because the staff only performed spot checks of random meals/trays on the unit three times a week.

In an interview on 05/01/14 at 4:15 p.m., S2DON verified the only corrective action plan to address the results of the monitoring of the food temperatures was to continue to monitor.

Based on record review and interview the hospital failed to set priorities for high-risk, high volume and problem-prone areas as evidenced by:
1) failing to monitor the hospital process for compliance with the Pharmacist review of the patient's medication profile prior to the first dose of a new medication, and;
2) failing to monitor the hospital process for treatment planning.

Findings:

1) failing to monitor the hospital process for compliance with the Pharmacist review of the patient's medication profile prior to the first dose of a new medication:

Review of the policy entitled First Dose Procedure revealed the following, in part:
I. Policy: It is the policy of this hospital that a pharmacist reviews all medication orders (except in emergency situations) for appropriateness before the first dose is administered.

In an interview on 4/30/14 at 10:08 a.m. with S8Pharmacist, he said he was one of the pharmacists who helped with oversight of the pharmaceutical services which were provided through contractual agreement with the hospital. S8Pharmacist explained first dose review was performed during the day but a medication ordered during the night, like at 2:00 a.m., would have been given before the pharmacist had an opportunity to perform first dose review of the new medication.

In an interview on 4/30/14 at 10:55 am with S2DON, she said she was under the impression the pharmacy had been performing first dose review on new medication orders prior to administration. S2DON said no one had made her aware that the pharmacy had not been performing first dose review on all new medication orders.

In an interview on 5/1/14 at 8:40 a.m. with S19RN, she explained medication orders received on both day and night shifts were faxed to the pharmacy. She said the new medications should have been reviewed by the pharmacist prior to administration of the first dose. S19RN explained first dose review had not always been performed prior to administration of the first dose when the medication had been ordered after hours.


2) failing to monitor the hospital process for treatment planning;

Review of the hospital's policy for treatment plans provided by S2DON as the current policy revealed a comprehensive individualized written treatment plan shall be developed pursuant to the staffing process and comprehensive medical, psychiatric, psychosocial, and nursing, activity/leisure, dietary, and other evaluations as indicated, in accordance with applicable law and regulations. Further review of the policy revealed the initial psychiatric evaluation shall include an inventory of the patient's assets in descriptive, not interpretive, fashion.


Patient #4
Review of Patient #4's medical record revealed she was an 82 year old female admitted on 04/17/14 with diagnoses of Bipolar Disorder Type I, most recent episode Manic with Psychotic Features, Hypertension, Emphysema, Parkinsonian Symptoms, COPD (Chronic Obstructive Pulmonary Disease), Diabetes Mellitus Type II, and Osteomalacia.

Review of Patient #4's "Master Treatment Plan Cover Sheet" dated 04/17/14 revealed her identified problems were Psychosis with Behavioral Disturbance, Decreased Cardiac Output, Imbalanced Nutrition, Risk for Injury/Falls, and Non-compliance with Medications. Review of her treatment plan for "Psychosis With Behavioral Disturbance" revealed a generic printed treatment plan that included check boxes for a long-term goal (one listed and checked), 11 short-term objectives to choose from with all choices checked, and interventions to choose from for the nurse, physician, social services, and activity therapist. There was no documented evidence the treatment plan had been individualized with treatment goals and interventions specific to Patient #4's problems, strengths, and disabilities. Review of her treatment plan for "Decreased Cardiac Output," "Impaired Nutrition,", "Risk For Injury/Falls" and "Non-Compliance With Medications" revealed all plans were a generic printed treatment plan that had not been individualized with treatment goals and interventions specific to Patient #4's problems, strengths, and disabilities.

Review of the "Master Treatment Plan Cover Sheet" revealed a generic printed form that included a list of "liabilities and special needs" and "strengths/assets" with a box to be checked if it was selected for the patient. Review of the psychiatric evaluation for Patients #4 revealed no documented evidence that the patient's disabilities were identified.

Review of Patient #4's treatment plan for "Psychosis With Behavioral Disturbance" revealed the long-term goal was stated as "patient's thought processes and behavior will be more organized and appropriate by discharge." There was no documented evidence that the goal was stated as an expected behavioral outcome for the patient and was written as an observable, measurable patient behavior to be achieved. Further review revealed some of the short-term goals that were not written as observable and measurable behaviors were as follows: patient will establish meaningful communication and trust with others within 3 days; patient will demonstrate no or reduced physical aggression; patient will be medication compliant. Review of the treatment plan for "Decreased Cardiac Output" revealed the long-term goal was to demonstrate "adequate cardiac output as evidenced by blood pressure and pulse rate and rhythm within normal parameters for client..." There was no documented evidence of what the patient's normal parameters were to determine when the goal was met.


Patient #5
Review of Patient #5's medical record revealed he was a 77 year old male admitted on 04/02/14 with diagnoses of Impulse Control Disorder, Dementia Alzheimer's Type with Behavioral Disturbance, Hypertension, Non-Insulin Dependent Diabetes Mellitus, Hypercholesterolemia, Degenerative Joint Disease, and Coronary Artery Disease.

Review of Patient #5's "Master Treatment Plan Cover Sheet" dated 04/02/14 revealed his identified problems were Poor Impulse Control, Dementia with Psychosis/Behavioral Disturbance, Decreased Cardiac Output, Imbalanced Nutrition, and Risk for Injury/Falls. Review of each treatment plan for the identified problem revealed that it was a generic printed treatment plan that had not been individualized with treatment goals and interventions specific to Patient #5's problems, strengths, and disabilities. His treatment plan for "Psychosis With Behavioral Disturbance," "Decreased Cardiac Output," "Impaired Nutrition," and "Risk For Injury/Falls" was the same as that of Patient #4 with no changes other than the ordered diet being written.

Review of Patient #5's group therapy progress notes revealed he consistently did not attend or participate in therapy. There was no documented evidence that his treatment plan was revised to address his non-compliance with therapy and to develop alternative interventions to meet his needs.

Review of the "Master Treatment Plan Cover Sheet" revealed a generic printed form that included a list of "liabilities and special needs" and "strengths/assets" with a box to be checked if it was selected for the patient. Review of the psychiatric evaluations for Patient #5 revealed no documented evidence that the patient's disabilities were identified.

Review of Patient #5's treatment plan for "Poor Impulse Control" revealed the long-term goal was stated as "patient will exhibit medication compliance and improved self-control." There was no documented evidence that the goal was stated as an expected behavioral outcome for the patient and was written as an observable, measurable patient behavior to be achieved. His short-term goals for "Psychosis With Behavioral Disturbance" and "Decreased Cardiac Output" were stated and written the same as that of Patient #4 (listed above).


Patient #6
Review of Patient #6's medical record revealed she was an 82 year old female admitted on 04/22/14 with diagnoses of Dementia with Behavioral Disturbance complicated by Major Depressive Disorder, Hypertension, Parkinson's Disease, COPD, Seizure Disorder, and frequent Urinary Tract Infections.

Review of Patient #6's "Master Treatment Plan Cover Sheet" dated 04/22/14 revealed her identified problems were Psychosis/Behavioral Disturbance, Other Directed Violence, Risk for Injury/Falls, Infection, Decreased Cardiac Output, and Impaired Skin Integrity. Review of each treatment plan for the identified problem revealed that it was a generic printed treatment plan that had not been individualized with treatment goals and interventions specific to Patient #6's problems, strengths, and disabilities. Her treatment plan for "Psychosis With Behavioral Disturbance," "Decreased Cardiac Output," and "Risk For Injury/Falls" was the same as that of Patient #4 and Patient #5.

Review of the "Master Treatment Plan Cover Sheet" revealed a generic printed form that included a list of "liabilities and special needs" and "strengths/assets" with a box to be checked if it was selected for the patient. Review of the psychiatric evaluations for Patients #6 revealed no documented evidence that the patient's disabilities were identified.

In an interview on 05/01/14 at 3:50 p.m., S2DON confirmed that the patients' treatment plans were generic and were not individualized for each patient. She indicated that Patient #5 should have had an alternate intervention implemented when he did not attend or participate in group therapy. S2DON confirmed that the patients' treatment plans were not individualized for each patient related to their strengths and disabilities. S2DON confirmed that the patient goals were not stated as expected behavioral outcomes for the patient and written as observable, measurable patient behaviors to be achieved.

In an interview on 05/01/14 at 4:15 p.m., S2DON verified she was responsible for the QAPI program. S2DON verified the QAPI program was not monitoring the first dose medication review by the pharmacist. She stated the nurses had a protocol to follow to ensure the first dose review was done, but verified there was no monitoring to ensure the protocol was followed. S2DON verified there was no QAPI monitoring done on patient treatment plans and the QAPI process had not identified any problems with treatment plans.

Based on record reviews and interview, the governing body failed to ensure that the hospital's Performance Improvement Program reflected the hospital's organization and services as evidenced by not having all hospital departments and services including those services furnished under contract involved in the Performance Improvement Program.
Findings:

Review of the performance improvement quality indicators and the quarterly QAPI reports for the last 3 quarters revealed no documented evidence that respiratory services, laboratory services, radiology services, laundry/linen services and biohazard waste disposal services were included in the QAPI program.

Review of the hospital contracts, policies and procedures, medical staff appointments and credentialing files, and current personnel records revealed the hospital did not have policies and procedures to address all areas of respiratory therapy and the hospital did not have a Respiratory Therapist on staff/contract. In an interview on 05/01/14 at 10:10 a.m., S2DON (Director of Nursing) verified the hospital did not have a respiratory therapist/s on staff or contracted. S2DON stated the nursing staff administered oxygen and respiratory treatments to patients and stated the nurses were checked off in respiratory treatments by S15RN/Dietary Manager. S2DON verified S15RN/Dietary Manager had not received training or competency evaluation in respiratory treatments, and stated she had, "just nursing experience." S2DON verified the only policies regarding respiratory services were for oxygen administration, incentive spirometry, pulse oximetry and aerosol therapy. S2DON verified the hospital did not have a policy that defined the education/training/experience of personnel authorized to perform each type of respiratory care service. S2DON verified the hospital did not have a policy on the amount of supervision required for personnel to perform the procedures, or the type of personnel qualified to provide the direct supervision. S2DON further indicated the laboratory services were not monitored by the hospital's Quality Assurance and Performance Improvement committee.

Review of the hospital contracts, policies and procedures, medical staff appointments and credentialing files, and current personnel records revealed the hospital did not have radiologist who was a member of the medical staff and supervised the radiology services and interpreted the radiological tests on either a full-time, part-time, or consulting basis and the hospital failed to develop policies and procedures that addressed proper safety precautions against radiation hazards. In an interview on 04/30/14 at 10:30 a.m., S2DON indicated the hospital did not have a credentialed and privileged Radiologist on its medical staff to supervise radiology services, and she was not aware that the hospital needed a director of radiology since the services were contracted services. S2DON also indicated the radiologists for Company A and Company B interpreting radiologic tests were not credentialed and privileged by the hospital's Medical Staff and Governing Body. S2DON also indicated there was no monitoring of the services provided by Company A and Company B by the hospital's Quality Assurance and Performance Improvement committee.

Review of the hospital contracts, policies and procedures, medical staff appointments and credentialing files, and current personnel records revealed the hospital did not have a pathologist who was a member of the medical staff to supervise the laboratory services on either a full-time, part-time, or consulting basis. In an interview on 04/30/14 at 5:15 p.m., S2DON indicated there was no director of laboratory services at the hospital, and that she was not aware that the hospital needed a director over laboratory services since the services were contracted services. S2DON also indicated the pathologists interpreting tests for Company A and Company C were not privileged and credentialed by the hospital. S2DON confirmed the hospital did not have a policy that addressed procedures for the safety of patients and personnel during x-ray tests. S2DON further indicated the laboratory services were not monitored by the hospital's Quality Assurance and Performance Improvement committee.

In an interview on 05/01/14 at 4:15 p.m., S2DON verified she was responsible for the QAPI program. S2DON verified the hospital's contracted services of respiratory services, laboratory services, radiology services, laundry/linen services and biohazard waste disposal services were not included in the QAPI program and there were no quality indicators being monitored for these patient care services.

Based on record review and interviews, the hospital failed to meet the Condition of Participation for Medical Staff as evidenced by:

A. The hospital failed to ensure that the medical staff examined the credentials of candidates for medical staff membership and made recommendations to the governing body for appointment/reappointment for 3 of 3 (S3Medical Director, S9Physician, S10NP) practitioner credentialing files reviewed from a total of 5 credentialed practitioners (S3Medical Director, S9Physician, S10NP, S22Physician, S23NP). This was evidenced by:
1) S3Medical Director reviewed his own credentialing file and request for privileges and recommended his appointment to the medical staff, and there was no documented evidence that the 3 peer references had been received for S3Medical Director prior to his appointment as required by the Medical Staff By-laws;
2) Failing to ensure the reappointment of current practitioners which resulted in S10NP (Nurse Practitioner) providing care and treatment to patients in the hospital without delineation of privileges and written approval for reappointment to the medical staff. and;
3) Failing to ensure credentialing files contained all supporting documents for examination by failing to obtain peer references for S9Physician (see findings in A0341).

B. The hospital failed to ensure the medical staff conducted periodic appraisals of its members for 2 of 2 (S9Physician, S10NP) credentialing files reviewed for medical staff appraisals out of 5 current credentialed practitioners (S3Medical Director, S9Physician, S10NP, S22Physican, S23NP) (see findings in A0340).


C. The hospital failed to ensure the medical staff enforced the by-laws and the rules and regulations adopted by the medical staff as evidenced by failing to ensure that an effective system was in place for addressing delinquent medical records (greater than 30 days delinquent) and its failure to discipline a physician (S9Physician) and an Advanced Practice Nurse (S10NP) who had delinquent medical records greater than 90 days after patients' discharge (see findings in A0353).

Based on record review and staff interview, the hospital failed to ensure the medical staff conducted periodic appraisals of its members for 2 of 2 (S9Physician, S10NP) credentialing files reviewed for medical staff appraisals out of 5 current credentialed practitioners (S3Medical Director, S9Physician, S10NP, S22Physican, S23NP). Findings:

Review of the Governing Body By-Laws dated 02/07/14 revealed in part the following, Article VI Medical Staff, Item No. 6.03 Medical Care and Its Evaluation: The Governing Board shall, in the exercise of its discretion, delegate to the Medical Staff the responsibility of monitoring and evaluating the appropriateness of professional care rendered to the Hospital's patients. The Medical Staff shall conduct a continuing review and appraisal of the quality of professional care rendered in the Hospital, and shall report such activities and their results to the Board.
Item No. 6.09 Term of Appointment. All initial appointments, including privileges granted, shall be for a period not to exceed one provisional year. All subsequent reappointments shall be for a period not to exceed two years except for initial appointments made directly by the Governing Board. Appointments shall be granted by the Board after the recommendation of the Medical Staff is considered. The following information is considered by the Medical Staff and the Governing Board for appointments, reappointments and the delineation of staff privileges: education, training, experience, current competence, references, peer appraisal, continuing education, health status, moral and ethical qualifications and any other information relevant to the granting of such privileges.

S10NP
Review of the credentialing file for S10NP revealed the practitioner's Governing Body appointment to the medical staff was dated 03/08/12 (reappointment due by 03/08/14). Review of the credentialing file revealed no documented evidence of an appraisal by the medical staff.


S9Physician
Review of the credentialing file for S9Physician revealed the physician was re-appointed to the medical staff by the governing body on 08/02/13. Review of the credentialing file revealed no documented evidence of an appraisal by the medical staff.

In an interview on 05/01/14 at 1:45 p.m., S5Human Resource Director verified she was responsible for credentialing. S5Human Resource Director reviewed the credentialing file for S10NP and S9Physician and verified there was no appraisal by the medical staff for either practitioner. S5Human Resource Director stated she was not aware that medical staff appraisals were required.

25065

Based on record reviews and interviews, the hospital failed to ensure that the medical staff examined the credentials of candidates for medical staff membership and made recommendations to the governing body for appointment/reappointment for 3 of 3 (S3Medical Director, S9Physician, S10NP) practitioner credentialing files reviewed from a total of 5 credentialed practitioners (S3Medical Director, S9Physician, S10NP, S22Physican, S23NP). This was evidenced by:
1) S3Medical Director reviewed his own credentialing file and request for privileges and recommended his appointment to the medical staff, and there was no documented evidence that the 3 peer references had been received for S3Medical Director prior to his appointment as required by the Medical Staff By-laws;
2) Failing to ensure the reappointment of current practitioners which resulted in S10NP (Nurse Practitioner) providing care and treatment to patients in the hospital without delineation of privileges and written approval for reappointment to the medical staff. and;
3) Failing to ensure credentialing files contained all supporting documents for examination by failing to obtain peer references for S9Physician.

Findings:

1) S3Medical Director

Review of the hospital's Medical Staff By-laws revealed the Governing Body shall act on appointments, reappointments, or revocation of appointments only after there has been a recommendation from the Medical Staff. The application shall require detailed information concerning the applicant's professional qualifications and shall include the name of at least 3 persons who have had extensive experience in observing and working with the applicant and who can provide adequate references pertaining to the applicant's professional current competence and ethical character. After collecting the completed application, three references, and other materials deemed pertinent, the Administrator will transmit the application and supporting materials to the Medical Staff Committee who will provide their recommendations regarding staff membership and clinical privileges granted. Once the Executive Committee has made a favorable recommendation, the Administrator will forward the supporting documentation to the Governing Body.

Review of S3Medical Director's credentialing file revealed a special meeting of the Governing Board was conducted on 04/11/14 to review his credentialing packet, and the Governing Board approved S3Medical Director's appointment effective 04/14/14. Review of S3Medical Director's "Clinical Privilege Sheet" revealed he requested and was approved for privileges to provide General Medical Care, Psychiatric Diagnosis and Treatment, Psychotherapy, Consultation, Special Procedures (use of restraint and seclusion), Prescribing of Psychotropic Medications, and Detoxing Opiates with Suboxone. Further review revealed S3Medical Director reviewed and signed his own request for privileges. Review of his "Medical Privilege Approval and Staff Initial Appointment Form" revealed the Medical Executive Committee signature was that of a non-physician. There was no documented evidence that a physician other than himself reviewed S3Medical Director's request for privileges. Further review of the credentialing file revealed that 3 reference letters were mailed on 04/08/14, and a response had not been received from any of the 3 peers prior to S3Medical Director's appointment being approved by the Governing Body as required by the Medical Staff By-laws.

In an interview on 05/01/14 at 11:05 a.m., S5Human Resources Director indicated she was the person responsible for the credentialing process. She confirmed that S3Medical Director signed his own request for privileges, and no peer references were received prior to the Governing Body approving S3Medical Director's appointment.

In an interview on 05/01/14 at 12:35 p.m., S3Medical Director confirmed that he had signed his own request for privileges as the Medical Director.


2) S10NP

Review of the hospital's Medical Staff By-laws revealed the Governing Body shall act on appointments, reappointments, or revocation of appointments only after there has been a recommendation from the Medical Staff. Review of the By-Laws revealed all reappointments were for a period of 2 years. Review of the By-Laws revealed at least 90 days prior to the expiration date of the current appointment, the appointee must furnish in writing a complete application, documentation of CME (Continuing Medical Education), request for clinical privileges, National Data Bank report, and professional references from internal/external sources.

Review of the credentialing file for S10NP revealed the practitioner's Governing Body appointment to the medical staff was dated 03/08/12 (reappointment due by 03/08/14). Review of the credentialing file revealed no documented evidence of a Governing Body re-appointment to the medical staff since 03/08/12. There was no current application, no National Data Bank query, no request for privileges, no professional references, no CME, and no recommendation for re-appointment by the medical staff.

Review of the clinical record for Patient #1 revealed the psychiatric evaluation was documented by S10NP on 4/22/14. Review of the clinical record for Patient #7 revealed the psychiatric evaluation was documented by S10NP on 04/24/14.

In an interview on 05/01/14 at 1:45 p.m., S5Human Resource Director verified she was responsible for credentialing. S5Human Resource Director reviewed the credentialing file for S10NP and verified the last appointment was 03/08/12. S5Human Resource Director stated she knew S10NP's licenses were current and verified she was aware that re-appointment was required every 2 years. She verified there was no National Data Bank query, no application for re-appointment, and no professional references. S5Human Resource Director verified S10NP was currently providing care and treatment to patients in the hospital. S5Human Resource Director was unable to explain why the re-appointment process was not conducted for S10NP.


3) S9Physician
Review of the credentialing file for S9Physician revealed the physician was re-appointed to the medical staff by the governing body on 08/02/13. Review of the credentialing file revealed no documented evidence of any referral letters for the re-application dated 7/30/13.

In an interview on 05/01/14 at 1:45 p.m., S5Human Resource Director verified the re-appointment application dated 7/30/13 did not include professional referral letters and did not contain documentation of the physician's CME. S5Human Resource Director stated she did not know these were required on re-application.

Based on interview and record review the hospital failed to ensure the medical staff enforced the by-laws and the rules and regulations adopted by the medical staff as evidenced by failing to ensure that an effective system was in place for addressing delinquent medical records (greater than 30 days delinquent) and its failure to discipline a physician (S9Physician) and an Advanced Practice Nurse (S10NP) who had delinquent medical records greater than 90 days after patients' discharge.
Findings:

Review of the "Medical Staff Rules & (and) Regulations" revealed that all entries in the patient's medical record shall be legible and complete, and shall be authenticated, dated, and timed promptly by the person who is responsible for ordering, providing, or evaluating the service furnished. Further review revealed that a medical record shall not be permanently filed until it is completed by the responsible practitioner or is ordered filed by the Medical Records Committee. Medical records shall be considered delinquent 30 days after discharge. A temporary suspension in the form of withdrawal of a practitioner's admitting privileges, effective until medical records are completed shall be imposed automatically after a warning of delinquency has been given.

Review of the Health Information Management (HIM) policy entitled Chart Analysis revealed the following, in part:
I. Policy:
Qualitative and quantitative analysis will be performed on all discharged patients' medical records to check for both completeness and consistency. Concurrent review of open charts will be performed by Health Information Management staff every 2 weeks at the time of coding for billing.
II. Purpose:
To provide thorough, accurate and complete medical record.
III. Procedure
A. All medical records of discharged patients will be picked up by HIM department personnel the next business day after discharge.
C. The charts are reviewed for deficiencies and missing items are tagged for appropriate staff. The deficiencies are then entered on the deficiency list. Deficient charts are maintained in the HIM Department for completion of deficiencies.
A colored indicator tag is used whenever a signature is needed. Use different colored tag for each service that needs to complete the record.
D. The chart is checked for the following items:
4. History and Physical:
ALL records must have a History and Physical completed and signed by a physician within 24 hours of admission.
d. Contains date, full signature and credentials of physician.
6. Physician orders:
Physician orders must be dated, signed, and timed by the responsible physician. All verbal orders must be signed and dated within 48 hours of the order.

Review of the HIM policy entitled delinquent records revealed the following, in part:
I. Policy:
The patient's medical record will be considered complete when the required contents are assembled and authenticated, including recording of final diagnosis, dictation of discharge summary and the insertion of any reports, but not longer than 30 days from discharge. If a record is not completed by the physician within 90 days of discharge, it may result in suspension of the physician's admitting or consulting privileges until the records are completed.
III. Procedure:
HIM Personnel:
A. A deficiency list is generated weekly for physicians and staff.
B. Medical records that are not completed by the physician 90 days following discharge may result in suspension of the physician's admitting or consulting privileges.
D. HIM department will prepare a delinquent record list weekly.
E. Deficiency lists and/or reminder letters will be sent weekly to physicians with incomplete charts, encouraging them to complete these charts before they become delinquent.
F. If the records are not complete after the 90 days, a letter will be sent by certified mail to the doctor notifying him/her that their admitting privileges may be suspended unless the records are completed before 90 days post discharge.
G. The suspension list is distributed by the HIM Department to Administration, Admitting, Medical Director, and Nursing Service.
I. HIM is responsible for notifying Administration, Admitting, the Medical Staff Office and Nursing Service as soon as the physician on the suspension list has completed his/her records.

Review of the delinquent medical record list provided to the survey team by S17MedicalRecords revealed the following:

S9 Physician:
8 medical records greater than 30 days delinquent
14 medical records greater than 60 days delinquent
16 medical records greater than 90 days delinquent

S10NP:
3 medical records greater than 90 days delinquent (dating back to 11/2013 and 12/2013)
1 medical record greater than 60 days delinquent
1 medical record greater than 30 days delinquent

Further review of the delinquent medical record list revealed multiple staff members from multiple disciplines also had delinquent medical record entries. The following deficient records were noted from other disciplines:
32 medical records greater than 30 days delinquent
23 medical records greater than 60 days delinquent
41 medical records greater than 90 days delinquent (dating back to 1/2013)

In an interview on 5/1/14 at 9:01 a.m.with S17Medical Records, she explained medical records were not considered completed until all entries were signed, dated and timed. She explained medical records that had not been completed within 30 days after patient discharge were considered delinquent. S17Medical Records said she kept a list of delinquent medical records with the patients' admission and discharge dates to enable them to track the number of days the chart was deficient. She said the list was arranged by discipline (Doctors, Nurses, Techs, Dietary, etcetera.). S17Medical Records also said she printed the list weekly and gave a copy to the nursing staff and S2DON. She explained the list was used by the nursing staff to identify incomplete medical records requiring physician signatures. S17Medical Records said she had not sent out any letters related to delinquent medical records because S2DON was responsible for sending out the letters.

In an interview on 5/1/14 at 9:30 a.m. with S2DON, she explained tracking of delinquent medical records was conducted by utilizing 24 hour chart audits. She said color coded tabs were used to mark incomplete entries. She explained any patient records with remaining incomplete entries were placed on the delinquent record list compiled by
S17Medical Records. S2DON said she received a copy of the list and any doctor or advanced practitioner with medical records delinquent in excess of 30 days should have received a letter indicating possible disciplinary action and a deadline for completion of the deficient record. She said if the employee with deficient records was a nurse, she would have handled disciplinary action including possible suspension. S2DON explained doctors or advanced practice nurses with deficient records would have been disciplined by Administration and the Medical Director. S2DON said no letters related to delinquent charts had been sent out because they didn't have any medical records that were in excess of 30 days delinquent. She was read entries from the list prepared by S17Medical Records for the survey team and acknowledged there were medical records in excess of 90 days delinquent on the list. She agreed no medical record should have been 90 days delinquent. She confirmed a letter should have been sent, and disciplinary action should have been taken through the Medical Executive Committee as set forth in the Medical Staff Rules and Regulations.

In an interview on 5/1/14 at 12:39 p.m. with S2MedicalDirector he said according to the Medical Staff Rules and Regulations he would have contacted a physician if the physician had some records that were out of compliance. S2MedicalDirector also said he assumed there would have been some sort of disciplinary action that needed to be taken. S2MedicalDirector explained he had only been Medical Director for two weeks and he had not been made aware of any medical records being out of compliance. S2MedicalDirector agreed that action needed to be taken when medical records were deficient. He also agreed medical records should not have been in excess of 90 days delinquent without actions being taken.

In an interview on 5/1/14 at 4:36 p.m. with S2DON, she said to be honest she had someone in medical records previously and it had been a mess. She said she had not been aware she had that many deficient charts. S2DON confirmed she did not have an action plan in place at this time to address the medical record issues.

Based on record reviews and interviews, the hospital failed to ensure the registered nurse (RN) supervised and evaluated the nursing care of each patient as evidenced by failure to implement physician's orders for 2 of 8 active inpatient records (#5, #6) reviewed from a total of 29 sampled patients as listed below:

1) Failing to supervise the Clinical Associate (CA) to ensure a patient's physician-ordered one-to-one (1:1) observation of a patient was maintained. (#5).
2) Failing to implement the hypoglycemic protocol for a capillary blood glucose (CBG) less than 70mg/dl (milligrams per deciliter) (#5);
3) Failing to assess a patient's oxygen saturation to determine if oxygen was needed per physician's orders (#6); and
4) Failing to obtain an EKG (electrocardiogram) (#5);

Findings:

1) Failing to supervise the Clinical Associate (CA) to ensure a patient's physician-ordered one-to-one (1:1) observation of a patient was maintained.

Review of Patient #5's medical record revealed he was a 77 year old male admitted on 04/02/14 with diagnoses of Impulse Control Disorder, Dementia Alzheimer's Type with Behavioral Disturbance, Hypertension, Non-Insulin Dependent Diabetes Mellitus, Hypercholesterolemia, Degenerative Joint Disease, and Coronary Artery Disease.

Review of Patient #5's "Physician's Orders" revealed the following orders:
04/03/14 at 8:07 a.m. - provide 1:1 for safety precautions;
04/03/14 at 2:00 p.m. - continue 1:1 for safety secondary to impulsive aggressive behavior;
04/04/14 at 5:02 p.m. - continue 1:1;
04/07/14 at 2:50 p.m. - discontinue 1:1 at bedtime
04/08/14 at 12:30 p.m. - continue 1:1 during the day; alright 1:1 at bedtime (patient now sleeping well);
04/11/14 at 9:00 p.m. - continue 1:1 during the day;
04/13/14 at 5:45 p.m. - continue 1:1 during the day;
04/15/14 at 10:10 p.m. - continue 1:1 during the day.

Review of Patient #5's "Nursing Progress Note" dated 04/15/14 at 7:45 p.m. revealed the following documentation by S12RN:
"Patient up restless in dayroom. Urinated in garbage can in dayroom and continued to play (with) his penis. Patient assisted by male tech and redressed. Patient assisted back to seated position on sofa. Patient took blanket and wrapped his face and head in a "turbin style" around his head and neck. Blanket removed (with) patient assistance. Patient took off gait belt and wrapped gait belt around his neck. Gait belt removed (with) patient cooperation. S10NP on unit. Notified of above behaviors. Will maintain 1:1 status while awake. No new orders noted."

Review of Patient #5's "7P-7A (7:00 p.m. to 7:00 a.m.) Hour Observation Log" dated 04/15/14 revealed Patient #5's observation was documented as 1:1 while awake due to impulsive behavior. Further review revealed the form was signed by S12RN and S13CA.

Review of the "Assignment Sheet," dated 04/15/14 for 7:00 p.m. to 7:00 a.m. and presented as the assignment sheet for the night shift for 04/15/14 by S2DON, revealed that S13CA was assigned 3 patients. There was no documented evidence on the assignment sheet of the type of observation that was ordered for each patient.

In an interview on 05/01/14 at 8:40 a.m., S12RN indicated that Patient #5 didn't tie the gait belt around his neck as a means to hurt himself. She did not indicate how she was able to determine that it was not an attempt to self-harm himself. She further indicated when he put the blanket and gait belt around his head and neck, the CA was sitting next to him and removed it. S12RN indicated that having a patient on 1:1 observation doesn't mean you will stop someone from walking. She further indicated that Patient #5 was standing at the window and turned to the garbage can, unzipped his pants, and began to urinate. S12RN indicated that the CA "couldn't grab his privates," so the CA tried to verbally get him to stop unzipping his pants. She further indicated that the CA tried to redirect Patient #5, but Patient #5 was quick. When asked about the physician order to observe Patient #5 every 15 minutes while asleep, and how she could tell when a patient was asleep and when he was awake, she answered, "I look at the patient and check respirations." She confirmed that there is no way to be sure 100% that the patient is asleep when he/she has his/her eyes closed.

In an interview on 05/01/14 at 9:25 a.m., S13CA indicated that he remembered the incident of Patient #5 urinating in the garbage can. He further indicated that he thought there was a staff member with another patient across the room when Patient #5 urinated in the trash can. S13CA indicated Patient #5 was assigned to him to be observed, but he wasn't aware that Patient #5 was ordered to be 1:1 while awake. He further indicated that he was assigned to observe 2 other patients at that time. He confirmed that he was not observing Patient #5 1:1 when Patient #5 urinated in the trash can.


2) Failing to implement the hypoglycemic protocol for a CBG less than 70mg/dl:
Review of Patient #5's medical record revealed he was a 77 year old male admitted on 04/02/14 with diagnoses of Impulse Control Disorder, Dementia Alzheimer's Type with Behavioral Disturbance, Hypertension, Non-Insulin Dependent Diabetes Mellitus, Hypercholesterolemia, Degenerative Joint Disease, and Coronary Artery Disease.

Review of Patient #5's "Physician Order Sheet: Diabetes/Hypoglycemia" dated 04/02/14 at 3:25 p.m. revealed CBG accuchecks were to be done before meals and at bedtime. Further review revealed the hypoglycemia protocol was as follows:
a) If CBG is less than 70mg/dl and the patient is responsive, administer 10 to 15 grams of carbohydrate, such as 4 ounces of orange, apple, or grape juice, 6 ounces non-diet soda, 1 cup milk, 4 saltine crackers with a teaspoon of peanut butter, 3 glucose tablets, or a tube of glucose gel;
b) Repeat treatment and recheck CBG every 15 minutes times 3 until the CBG is above 70 mg/dl;
c) Notify physician if CBG does not reach 60 mg/dl after 3 repeated treatments; d) Recheck CBG 1 hour after CBG reaches 70 mg/dl.

Review of Patient #5's "Diabetic Flow Sheet" revealed on 04/08/14 at 7:00 a.m. his CBG was 63 mg/dl, and his treatment consisted of 4 ounces of orange juice and breakfast. There was no documented evidence that Patient #5's CBG was rechecked until 11:00 a.m. It was not rechecked every 15 minutes times 3 until the CBG was above 70 mg/dl as ordered.

In an interview on 04/29/14 at 3:20 p.m., S20LPN (Licensed Practical Nurse) confirmed that the physician-ordered hypoglycemia protocol was not followed for Patient #5 on 04/08/14 when his CBG was 63 mg/dl.


3) Failing to assess a patient's oxygen saturation to determine if oxygen was needed per physician's orders:
Review of Patient #6's medical record revealed she was an 82 year old female admitted on 04/22/14 with diagnoses of Dementia with Behavioral Disturbance complicated by Major Depressive Disorder, Hypertension, Parkinson's Disease, COPD (Chronic Obstructive Pulmonary Disease), Seizure Disorder, and frequent Urinary Tract Infections.

Review of Patient #6's "Physician's Orders" revealed an order on 04/23/14 at 3:00 a.m. for oxygen per nasal cannula at 2 liters per minute as needed for an oxygen saturation less than 92% (per cent) or complaints of shortness of breath.

Review of Patient #6's "Nursing Progress Note" and "Integrated Progress Notes" from the time of admission on 04/22/14 at 10:30 p.m. through 04/30/13 at 8:00 a.m. revealed no documented evidence that Patient #6's oxygen saturation was assessed by a nurse to determine if she needed to have oxygen administered as ordered by the physician except on 04/24/14 at 8:45 p.m. (only documented assessment).

In an interview on 04/30/14 at 3:35 p.m., S21RN indicated he would not check a patient's oxygen saturation unless it was ordered to be assessed by the physician. When asked if an as needed order for oxygen based on an oxygen saturation of less than 92% would be considered a physician's order to assess the oxygen saturation level, he answered, "No." He indicated that the order would mean to check the oxygen saturation level only if the patient had a problem.

In an interview on 05/01/14 at 8:40 a.m., S12RN indicated it's a standard of practice to check a patient's oxygen saturation when the physician has ordered oxygen to be administered as needed for a oxygen saturation of less than 92%.

In an interview on 05/01/14 at 12:35 p.m., S3Medical Director indicated that he would expect the nurse to assess a patient's oxygen saturation level when the order for as needed oxygen based on the oxygen saturation level was given.


4) Failing to obtain an EKG:
Review of Patient #5's medical record revealed he was a 77 year old male admitted on 04/02/14 with diagnoses of Impulse Control Disorder, Dementia Alzheimer's Type with Behavioral Disturbance, Hypertension, Non-Insulin Dependent Diabetes Mellitus, Hypercholesterolemia, Degenerative Joint Disease, and Coronary Artery Disease.

Review of Patient #5's "Physician Admit Certification, Orders and Plan for Therapy" received by telephone from S10Nurse Practitioner (NP) on 04/02/14 (no time documented) revealed an order for an EKG. Review of Patient #5's entire medical record on 04/29/14 (27 days after admission) revealed no documented evidence that an EKG had been obtained as ordered.

In an interview on 04/29/14 at 2:55 p.m., S14RN confirmed Patient #5 did not have evidence in his medical record that an EKG had been done. She indicated that the chart audit performed by the nurses revealed that the assessment was checked as completed, and there was no notation that the EKG was not done. She further indicated if the EKG had not been done, the nurse should have documented such on the audit form.

Based on record reviews and interview, the hospital failed to ensure the effective implementation of the "Medical Staff Rules & Regulations" and the policies/procedures relative to the completion of delinquent medical records (records incomplete greater than 30 days after the patient was discharged from the hospital).
Findings:

Review of the "Medical Staff Rules & (and) Regulations" revealed that all entries in the patient's medical record shall be legible and complete, and shall be authenticated, dated, and timed promptly by the person who is responsible for ordering, providing, or evaluating the service furnished. Further review revealed that a medical record shall not be permanently filed until it is completed by the responsible practitioner or is ordered filed by the Medical Records Committee. Medical records shall be considered delinquent 30 days after discharge. A temporary suspension in the form of withdrawal of a practitioner's admitting privileges, effective until medical records are completed shall be imposed automatically after a warning of delinquency has been given.

Review of the Health Information Management (HIM) policy entitled Chart Analysis revealed the following, in part:
I. Policy:
Qualitative and quantitative analysis will be performed on all discharged patients' medical records to check for both completeness and consistency. Concurrent review of open charts will be performed by Health Information Management staff every 2 weeks at the time of coding for billing.
II. Purpose:
To provide thorough, accurate and complete medical record.
III. Procedure
A. All medical records of discharged patients will be picked up by HIM department personnel the next business day after discharge.
C. The charts are reviewed for deficiencies and missing items are tagged for appropriate staff. The deficiencies are then entered on the deficiency list. Deficient charts are maintained in the HIM Department for completion of deficiencies.
A colored indicator tag is used whenever a signature is needed. Use different colored tag for each service that needs to complete the record.
D. The chart is checked for the following items:
4. History and Physical:
ALL records must have a History and Physical completed and signed by a physician within 24 hours of admission.
d. Contains date, full signature and credentials of physician.
6. Physician orders:
Physician orders must be dated, signed, and timed by the responsible physician. All verbal orders must be signed and dated within 48 hours of the order.

Review of the HIM policy entitled delinquent records revealed the following, in part:
I. Policy:
The patient's medical record will be considered complete when the required contents are assembled and authenticated, including recording of final diagnosis, dictation of discharge summary and the insertion of any reports, but not longer than 30 days from discharge. If a record is not completed by the physician within 90 days of discharge, it may result in suspension of the physician's admitting or consulting privileges until the records are completed.
III. Procedure:
HIM Personnel:
A. A deficiency list is generated weekly for physicians and staff.
B. Medical records that are not completed by the physician 90 days following discharge may result in suspension of the physician's admitting or consulting privileges.
D. HIM department will prepare a delinquent record list weekly.
E. Deficiency lists and/or reminder letters will be sent weekly to physicians with incomplete charts, encouraging them to complete these charts before they become delinquent.
F. If the records are not complete after the 90 days, a letter will be sent by certified mail to the doctor notifying him/her that their admitting privileges may be suspended unless the records are completed before 90 days post discharge.
G. The suspension list is distributed by the HIM Department to Administration, Admitting, Medical Director, and Nursing Service.
I. HIM is responsible for notifying Administration, Admitting, the Medical Staff Office and Nursing Service as soon as the physician on the suspension list has completed his/her records.

Review of the delinquent medical record list provided to the survey team by S17MedicalRecords revealed the following:

S9 Physician:
8 medical records greater than 30 days delinquent
14 medical records greater than 60 days delinquent
16 medical records greater than 90 days delinquent

S10NP:
3 medical records greater than 90 days delinquent (dating back to 11/2013 and 12/2013)
1 medical record greater than 60 days delinquent
1 medical record greater than 30 days delinquent

Further review of the delinquent medical record list revealed multiple staff members from multiple disciplines also had delinquent medical record entries. The following deficient records were noted from other disciplines:
32 medical records greater than 30 days delinquent
23 medical records greater than 60 days delinquent
41 medical records greater than 90 days delinquent (dating back to 1/2013)

In an interview on 5/1/14 at 9:01 a.m.with S17Medical Records she explained medical records were not considered completed until all entries were signed, dated and timed. She explained medical records that had not been completed within 30 days after patient discharge were considered delinquent. S17Medical Records said she kept a list of delinquent medical records with the patients' admission and discharge dates to enable them to track the number of days the chart was deficient. She said the list was arranged by discipline (Doctors, Nurses, Techs, Dietary, etcetera.). S17Medical Records also said she printed the list weekly and gave a copy to the nursing staff and S2DON. She explained the list was used by the nursing staff to identify incomplete medical records requiring physician signatures. S17Medical Records said she had not sent out any letters related to delinquent medical records because S2DON was responsible for sending out the letters.

In an interview on 5/1/14 at 9:30 a.m. with S2DON, she explained tracking of delinquent medical records was conducted by utilizing 24 hour chart audits. She said color coded tabs were used to mark incomplete entries. She explained any patient records with remaining incomplete entries were placed on the delinquent record list compiled by
S17Medical Records. S2DON said she received a copy of the list and any doctor or advanced practitioner with medical records delinquent in excess of 30 days should have received a letter indicating possible disciplinary action and a deadline for completion of the deficient record. She said if the employee with deficient records was a nurse she would have handled disciplinary action including possible suspension. S2DON explained doctors or advanced practice nurses with deficient records would have been disciplined by Administration and the Medical Director. S2DON said no letters related to delinquent charts had been sent out because they didn't have any medical records that were in excess of 30 days delinquent. She was read entries from the list prepared by S17Medical Records for the survey team and acknowledged there were medical records in excess of 90 days delinquent on the list. She agreed no medical record should have been 90 days delinquent. She confirmed a letter should have been sent and disciplinary action should have been taken through the Medical Executive Committee as set forth in the Medical Staff Rules and Regulations.

In an interview on 5/1/14 at 12:39 p.m. with S2MedicalDirector he said according to the Medical Staff Rules and Regulations he would have contacted a physician if the physician had some records that were out of compliance. S2MedicalDirector also said he assumed there would have been some sort of disciplinary action that needed to be taken. S2MedicalDirector explained he had only been Medical Director for two weeks and he had not been made aware of any medical records being out of compliance. S2MedicalDirector agreed that action needed to be taken when medical records were deficient. He also agreed medical records should not have been in excess of 90 days delinquent without actions being taken.

In an interview on 5/1/14 at 4:36 p.m. with S2DON, she said to be honest she had someone in medical records previously and it had been a mess. She said she had not been aware she had that many deficient charts. S2DON confirmed she did not have an action plan in place at this time to address the medical record issues.


































































































































30984

30984

Based on record reviews and interview, the hospital failed to ensure that each medical record was completed promptly no later that 30 days after discharge as evidenced by:
1) having unsigned History and Physical (H&P) examinations for 3 (#14, #18, #22) of 21 closed medical records reviewed for completeness from a total sample of 29 (#1-#29) patients.
2) having incomplete physician order entries which were not signed, dated or timed and/or signed, but not dated and timed for 4 (#15, #16, #26, #28) of 21 closed medical records reviewed for completeness from a total sample of 29 patients (#1- #29).
Findings:

Review of the "Medical Staff Rules & (and) Regulations" revealed that all entries in the patient's medical record shall be legible and complete, and shall be authenticated, dated, and timed promptly by the person who is responsible for ordering, providing, or evaluating the service furnished. Further review revealed that a medical record shall not be permanently filed until it is completed by the responsible practitioner or is ordered filed by the Medical Records Committee. Medical records shall be considered delinquent 30 days after discharge. A temporary suspension in the form of withdrawal of a practitioner's admitting privileges, effective until medical records are completed shall be imposed automatically after a warning of delinquency has been given.

Review of the Health Information Management (HIM) policy entitled Chart Analysis revealed the following, in part:
I. Policy:
Qualitative and quantitative analysis will be performed on all discharged patients' medical records to check for both completeness and consistency. Concurrent review of open charts will be performed by Health Information Management staff every 2 weeks at the time of coding for billing.
II. Purpose:
To provide thorough, accurate and complete medical record.
III. Procedure
A. All medical records of discharged patients will be picked up by HIM department personnel the next business day after discharge.
C. The charts are reviewed for deficiencies and missing items are tagged for appropriate staff. The deficiencies are then entered on the deficiency list. Deficient charts are maintained in the HIM Department for completion of deficiencies.
A colored indicator tag is used whenever a signature is needed. Use different colored tag for each service that needs to complete the record.
D. The chart is checked for the following items:
4. History and Physical:
ALL records must have a History and Physical completed and signed by a physician within 24 hours of admission.
d. Contains date, full signature and credentials of physician.
6. Physician orders:
Physician orders must be dated, signed, and timed by the responsible physician. All verbal orders must be signed and dated within 48 hours of the order.

Review of the HIM policy entitled delinquent records revealed the following, in part:
I. Policy:
The patient's medical record will be considered complete when the required contents are assembled and authenticated, including recording of final diagnosis, dictation of discharge summary and the insertion of any reports, but not longer than 30 days from discharge. If a record is not completed by the physician within 90 days of discharge, it may result in suspension of the physician's admitting or consulting privileges until the records are completed.
III. Procedure:
HIM Personnel:
A. A deficiency list is generated weekly for physicians and staff.
B. Medical records that are not completed by the physician 90 days following discharge may result in suspension of the physician's admitting or consulting privileges.
D. HIM department will prepare a delinquent record list weekly.
E. Deficiency lists and/or reminder letters will be sent weekly to physicians with incomplete charts, encouraging them to complete these charts before they become delinquent.
F. If the records are not complete after the 90 days, a letter will be sent by certified mail to the doctor notifying him/her that their admitting privileges may be suspended unless the records are completed before 90 days post discharge.
G. The suspension list is distributed by the HIM Department to Administration, Admitting, Medical Director, and Nursing Service.
I. HIM is responsible for notifying Administration, Admitting, the Medical Staff Office and Nursing Service as soon as the physician on the suspension list has completed his/her records.

1) Having unsigned History and Physical (H&P) examinations
Patient #14
Review of Patient #14's medical record revealed she was an 88-year-old female admitted on 03/14/14 and discharged on 03/28/14. Diagnoses included Dementia Disorder, Depression, Anxiety, Hypertension, and Unsteady Gait. Review of Patient #14's H&P revealed it was dictated on 03/15/14 by S9Physician and transcribed on 03/15/14. Further review revealed the H&P had not been authenticated, dated, and timed by S9Physician.

Patient #18
Review of Patient #18's medical record revealed he was a 63 year old male admitted on 03/20/14 and discharged to an acute care hospital on 03/21/14. Diagnoses included Dementia, Inappropriate Behavior, Hypertension, and Late Effects from a Stroke. Review of Patient #18's H&P revealed it was dictated on 03/21/14 by S9Physician and transcribed on 03/21/14. Further review revealed the H&P had not been authenticated, dated, and timed by S9Physician (39 days after discharge).

Patient #22
Review of Patient #22's medical record revealed she was a 63 year old female admitted on 03/25/14 and discharged on 03/27/14. Review of her H&P revealed it was dictated on 03/26/14 by S9Physician and transcribed on 03/26/14. Review of Patient #22's medical record on 05/01/14 revealed that her H&P had not been authenticated by S9Physician (34 days after discharge).

2) Having incomplete physician order entries which were not authenticated, dated or timed and/or authenticated, but not dated and timed which remained incomplete in excess of 30 days after discharge.

Patient #15
Review of Patient #15's medical record revealed he was a 55 year old male admitted on 04/16/14 and discharged on 04/28/14. Further review of the patient's medical record revealed the following incomplete entries by S3Medical Director:
04/16/14 5:15 p.m.: telephone admission order signed and dated, not timed;
04/16/14 6:30 p.m.: telephone order not signed, dated or timed;
04/16/14 10:20 p.m.: telephone order signed, not dated or timed;
04/18/14 8:00 p.m.: telephone order not signed, dated, or timed.
Review of the medical record revealed the following incomplete entries by S9Physician:
04/17/14 2:00 a.m.: telephone order signed, not dated or timed.

Patient #16
Review of Patient #16's medical record revealed she was a 78 year old female admitted on 03/17/14 and discharged on 04/1/14. Further review of the patient's medical record revealed the following incomplete entries by S9Physician:
3/22/14 4:55 p.m.: telephone order signed, not dated or timed
3/24/14 7:15 a.m.: telephone order signed, not dated or timed;


Patient #26
Review of Patient #26's medical record revealed he was a 87 year old male admitted on 01/31/14 and discharged on 02/12/14. Further review of the patient's medical record revealed the following incomplete entries by S9Physician:
1/31/14 8:50 p.m.: telephone order signed, not dated or timed;
2/3/14 1:00 p.m.: telephone order signed, not dated or timed;
2/4/14 10:45 a.m.: telephone order signed, not dated or timed;
2/4/14 6:15 p.m.: telephone order signed, not dated or timed;
2/5/14 3:36 p.m.: telephone order signed, not dated or timed;
2/8/14 6:00 p.m.: telephone order signed, not dated or timed;
2/9/14 9:40 a.m.: telephone order not signed, dated or timed;
2/9/14 6:55 p.m.: telephone order not signed, dated or timed;
2/10/14 6:40 p.m.: telephone order not signed, dated, or timed;

Patient #28
Review of Patient #28's medical record revealed he was a 86 year old male admitted on 01/3/14 and discharged on 02/6/14. Further review of the patient's medical record revealed the following incomplete entries by S9Physician:
1/10/14 2:25 p.m.: telephone order signed, not dated or timed
1/14/14 11:15 a.m.: telephone order signed, not dated or timed
1/31/14 9:20 a.m.: telephone order signed, not dated or timed
2/1/14 3:55 p.m.: telephone order signed, not dated or timed
2/3/14 8:45 a.m.: telephone order signed, not dated or timed

In an interview on 5/1/14 at 9:01 a.m. with S17Medical Records, she explained medical records were not considered completed until all entries were signed, dated and timed. She explained medical records that had not been completed within 30 days after patient discharge were considered delinquent. S17Medical Records said she kept a list of delinquent medical records with the patients' admission and discharge dates to enable them to track the number of days the chart was deficient. She said the list was arranged by discipline (Doctors, Nurses, Techs, Dietary, etc.). S17Medical Records also said she printed the list weekly and gave a copy to the nursing staff and S2DON. She explained the list was used by the nursing staff to identify incomplete medical records requiring physician signatures. S17Medical Records said she had not sent out any letters related to delinquent medical records because S2DON was responsible for sending out the letters.

In an interview on 5/1/14 at 9:30 a.m. with S2DON, she explained tracking of delinquent medical records was conducted by utilizing 24 hour chart audits. She said color coded tabs were used to mark incomplete entries. She explained any patient records with remaining incomplete entries were placed on the delinquent record list compiled by S17Medical Records. S2DON said she received a copy of the list and any doctor or advanced practitioner with medical records delinquent in excess of 30 days should have received a letter indicating possible disciplinary action and a deadline for completion of the deficient record. She said if the employee with deficient records was a nurse she would have handled disciplinary action including possible suspension. S2DON explained doctors or advanced practice nurses with deficient records would have been disciplined by Administration and the Medical Director. S2DON said no letters related to delinquent charts had been sent out because they didn't have any medical records that were in excess of 30 days delinquent. She was read entries from the list prepared by S17Medical Records for the survey team and acknowledged there were medical records in excess of 90 days delinquent on the list. She agreed no medical record should have been 90 days delinquent. She confirmed a letter should have been sent and disciplinary action should have been taken through the Medical Executive Committee as set forth in the Medical Staff Rules and Regulations.

In an interview on 5/1/14 at 12:39 p.m. with S2Medical Director, he said according to the Medical Staff Rules and Regulations he would have contacted a physician if the physician had some records that were out of compliance. S2Medical Director also said he assumed there would have been some sort of disciplinary action that needed to be taken. S2Medical Director explained he had only been Medical Director for two weeks, and he had not been made aware of any medical records being out of compliance. S2Medical Director agreed that action needed to be taken when medical records were deficient. He also agreed medical records should not have been in excess of 90 days delinquent without actions being taken.

In an interview on 5/1/14 at 4:36 p.m. with S2DON, she said, to be honest, she had someone in medical records previously, and it had been a mess. She said she had not been aware she had that many deficient charts. S2DON confirmed she did not have an action plan in place at this time to address the medical record issues.




31048

Based on record review and interview, the pharmacist failed to review all first dose medications for appropriateness, duplication, interactions, allergies, sensitivities or other contraindications before the first dose was dispensed and administered to patients.
Findings:

Review of the policy entitled First Dose Procedure revealed the following, in part:
I.Policy:
It is the policy of this hospital that a pharmacist reviews all medication orders (except in emergency situations) for appropriateness before the first dose is administered.
II. Purpose:
To ensure medication orders are reviewed by a pharmacist for therapeutic appropriateness of medication regimen, duplication of medications, appropriateness of the drug, dose, frequency, route, and method of administration; real or potential medication-medication, medication-food, medication-laboratory test and medication-disease interactions; real or potential allergies or sensitivities; variation from organizational criteria for use; and/or other contraindications prior to first dose administration to patients.
III. Procedure:
A. This hospital maintains a contract with an area pharmacy. Pharmacy hours are Monday- Friday from 8:30 a.m. until 5:00 p.m. A pharmacist may be reached during business hours by dialing 1-985-626-9726 or after hours by dialing the On-Call Pharmacist's contact number provided monthly by the contracted pharmacy.
B. RN or LPN shall fax medication written physician orders to the contract pharmacy by dialing the provided fax number and calling the pharmacy to alert them that orders were faxed. Written orders shall be faxed 24 hours a day. Outside of business hours, the RN or LPN will fax and call the on-call pharmacist.
C. Prior to medication administration all medication orders shall be reviewed by a pharmacist for therapeutic appropriateness of medication regimen, duplication of medications, appropriateness of the drug, dose, frequency, route, and method of administration; real or potential medication-medication, medication-food, medication-laboratory test and medication-disease interactions; real or potential allergies or sensitivities; variation from organizational criteria for use; and/or other contraindications prior to first dose administration to patients.
D. Adverse patient medication profile findings shall be communicated by the pharmacist to the unit nurse or physician by phone or fax.

In an interview on 4/30/14 at 10:08 a.m. with S8Pharmacist, he said he was one of the pharmacists who helped with oversight of the pharmaceutical services which were provided through contractual agreement with the hospital. S8Pharmacist explained first dose review was performed during the day but a medication ordered during the night, like at 2:00 a.m., would have been given before the pharmacist had an opportunity to perform first dose review of the new medication.
In an interview on 4/30/14 at 10:55 a.m.with S2DON, she said she was under the impression the pharmacy had been performing first dose review on new medication orders prior to administration. S2DON said no one had made her aware that the pharmacy had not been performing first dose review on all new medication orders.
In an interview on 5/1/14 at 8:40 a.m. with S19RN, she explained medication orders received on both day and night shifts were faxed to the pharmacy. She said the new medications should have been reviewed by the pharmacist prior to administration of the first dose. S19RN explained first dose review had not always been performed prior to administration of the first dose when the medication had been ordered after hours.

Based on record reviews and interviews, the hospital failed to meet the requirements for the Condition of Participation for Radiologic Services as evidenced by:

1) Failing to ensure there was a radiologist who was a member of the medical staff and supervised the radiology services and interpreted the radiological tests on either a full-time, part-time, or consulting basis. (see findings in tag A-0546)

2) Failing to develop policies and procedures that addressed proper safety precautions against radiation hazards to provide for the safety of staff and patients during radiological procedures performed in the hospital by Company B. (see findings in tag A-0536)

Based on record reviews and interview, the hospital failed to develop policies and procedures that addressed proper safety precautions against radiation hazards to provide for the safety of staff and patients during radiological procedures performed in the hospital by Company B. Findings:

Review of the contracts provided by S2DON revealed the hospital had a contract with Company B to provide mobile x-ray services.

Review of the hospital's only policy related to radiology services, presented as the current policies by S2DON, revealed no documented evidence that it addressed procedures for proper safety precautions against radiation hazards such as adequate shielding for patients and personnel and determining that a female patient was not pregnant prior to performing the procedure.

In an interview on 04/30/14 at 10:30 a.m., S2DON indicated Company B took the patient's x-ray when ordered in the hospital setting. S2DON confirmed the above mentioned policy was the only policy for radiology services, and the policy did not address procedures for the safety of patients and personnel during x-ray tests. S2DON also indicated there was no monitoring of the services provided by Company B by the hospital's Quality Assurance and Performance Improvement committee.

Based on record review and interview, the hospital failed to ensure there was a radiologist who was a member of the medical staff and supervised the radiology services and interpreted the radiological tests on either a full-time, part-time, or consulting basis.
Findings:

Review of the list of credentialed physicians on the Medical Staff, presented as a current list by S5HR Director (Human Resources Director), revealed no documented evidence that a radiologist was credentialed and privileged as a member of the Medical Staff.

Review of the contracts provided by S2DON (Director of Nursing) revealed the hospital had a contract with Company A to provide radiology services, and a contract with Company B to provide mobile x-ray services.

In an interview on 04/30/14 at 10:30 a.m., S2DON indicated the hospital did not have a credentialed and privileged Radiologist on its medical staff to supervise radiology services, and she was not aware that the hospital needed a director of radiology since the services were contracted services. S2DON also indicated the radiologists for Company A and Company B interpreting radiologic tests were not credentialed and privileged by the hospital's Medical Staff and Governing Body. S2DON also indicated there was no monitoring of the services provided by Company A and Company B by the hospital's Quality Assurance and Performance Improvement committee.

Based on record review and interview, the hospital failed to ensure that a written description of the laboratory services provided by Company A were available to the medical staff. Findings:
Review of the contracts provided by S2DON (Director of Nursing) revealed the hospital had a contract with Company A to provide emergency and after-hours laboratory services. Further review revealed there was no written description of the laboratory services provided by Company A available to the medical staff of the hospital.
In an interview on 04/30/14 at 5:15 p.m., S2DON verified there was no written description of laboratory services provided by Company A available for the medical staff.

Based on record review and staff interview, the hospital failed to meet the Condition of Participation for Respiratory Care Services as evidenced by:

1) The hospital failed to ensure that the scope of diagnostic and/or therapeutic respiratory services was defined in writing and approved by the Medical Staff as evidenced by failure to have the Governing Body By-laws designate Respiratory Services as one of the clinical and ancillary services provided by the hospital. The Medical Staff By-laws failed to include approval of the scope of diagnostic and/or therapeutic respiratory services provided by the hospital (see findings in A-1152).

2) The hospital failed to have Respiratory Therapy Technician/s employee/s or contract employee/s to administer respiratory therapy services to patients should they require these services and failed to have written qualifications specified by the Medical Staff (see findings in A-1154).

3) The hospital failed to ensure the personnel qualified to perform specific respiratory therapy services and the amount of supervision required for personnel to carry out the specific respiratory therapy procedures were designated in writing (see findings in A-1161).

Based on record review and interview, the hospital failed to ensure that the scope of diagnostic and/or therapeutic respiratory services was defined in writing and approved by the Medical Staff as evidenced by failure to have the Governing Body By-laws designate Respiratory Services as one of the clinical and ancillary services provided by the hospital. The Medical Staff By-laws failed to include approval of the scope of diagnostic and/or therapeutic respiratory services provided by the hospital.
Findings:

Review of the Governing Body By-laws, presented as the current by S2DON (Director of Nursing), revealed that Respiratory Services was not listed as clinical and ancillary service offered by the hospital. Review of the Medical Staff By-laws revealed no documented evidence that respiratory services was addressed in the by-laws.

Review of the hospital policies for respiratory therapy, contained in the policy manual presented as the current policies by S2DON, revealed the only policies related to respiratory therapy were nursing policies for aerosol treatments, oxygen concentrators, incentive spirometry, and pulse oximetry.

In an interview on 05/01/14 at 10:10 a.m., S2DON verified the hospital did not have respiratory therapist on staff or contracted. S2DON stated if a patient needed respiratory therapy they would send the patient to Company A. S2DON stated the nursing staff administered oxygen and respiratory treatments to patients and stated the nurses were checked off in respiratory treatments by S15RN/Dietary Manager. S2DON verified S15RN/Dietary Manager had not received training or competency evaluation in respiratory treatments, and stated she had, "just nursing experience." S2DON verified the hospital had not defined the scope of diagnostic and/or therapeutic respiratory services and had not defined in writing the specific respiratory services provided by the hospital.

Based on record review and staff interview, the hospital failed to have Respiratory Therapy Technician/s employee/s or contract employee/s to administer respiratory therapy services to patients should they require these services and failed to have written qualifications specified by the Medical Staff. Findings:

Review of the Medical Staff Bylaws revealed they failed to include approval of the scope of diagnostic and/or therapeutic respiratory services and to define in writing the specific respiratory services provided by the hospital.

Review of the Governing Body Bylaws/meeting minutes revealed the Respiratory Therapy services were not defined in writing and approved as evidenced by failure of the Governing Body to designate Respiratory Services as one of the clinical services provided by the hospital.

Review of the hospital contract with Company A dated 01/01/14 revealed Company A would provide Respiratory testing information, education, communication and consultation. There was no documented evidence in the contract that Company A would provide Respiratory Therapy Technicians to respond to the respiratory care needs of hospital's patients.

Review of the hospital staff list provided as current revealed no documented evidence of Respiratory Therapy Technicians.

Patient #1
Review of the clinical record for Patient #1 revealed the patient was a 59 year old male with a diagnosis of Emphysema that was currently on 3 inhaled medications, Oxygen as needed, Pulse oximetry every shift, and as needed aerosol treatments.

In an interview on 05/01/14 at 10:10 a.m., S2DON stated no respiratory therapists come to the hospital. S2DON verified the hospital did not have respiratory therapist on staff or contracted. S2DON stated if a patient needed respiratory therapy they would send the patient to Company A. S2DON stated the nursing staff administered oxygen and respiratory treatments to patients and stated the nurses were checked off in respiratory treatments by S15RN/Dietary Manager. S2DON verified S15RN/Dietary Manager had not received training or competency evaluation in respiratory treatments, and stated she had, "just nursing experience." S2DON verified the hospital had not defined the scope of diagnostic and/or therapeutic respiratory services and had not defined in writing the specific respiratory services provided by the hospital.

Patient #6
Review of Patient #6's "Physician's Orders" revealed an order on 04/23/14 at 3:00 a.m. for oxygen per nasal cannula at 2 liters per minute as needed for an oxygen saturation less than 92% (per cent) or complaints of shortness of breath.

Review of Patient #6's "Nursing Progress Note" and "Integrated Progress Notes" from the time of admission on 04/22/14 at 10:30 p.m. through 04/30/13 at 8:00 a.m. revealed no documented evidence that Patient #6's oxygen saturation was assessed by a nurse to determine if she needed to have oxygen administered as ordered by the physician except on 04/24/14 at 8:45 p.m.(only documented assessment).

In an interview on 04/30/14 at 3:35 p.m., S21RN indicated he would not check a patient's oxygen saturation unless it was ordered to be assessed by the physician. When asked if an as needed order for oxygen based on an oxygen saturation of less than 92% would be considered a physician's order to assess the oxygen saturation level, he answered, "No." He indicated that the order would mean to check the oxygen saturation level only if the patient had a problem.

Based on record reviews and interview, the hospital failed to ensure the personnel qualified to perform specific respiratory therapy services and the amount of supervision required for personnel to carry out the specific respiratory therapy procedures were designated in writing. Findings:

Review of policies/procedures for respiratory therapy included:
A. Policy Number NU.435 titled Intermittent Aerosol Therapy: I. POLICY To provide a method for the aerosolization of pharmacologic agents for administration via oral inhalation as ordered by the physician. VII....Nurses perform intermittent aerosol therapy as ordered by the physician....

B. Policy Number NU.435 titled Oxygen Concentrator...I. POLICY It is the policy of [Hospital] to provide supplemental oxygen via an oxygen concentrator, set at a specific flow setting to meet physician orders....II. PROCEDURE...

C. Policy Number NU.436 titled Incentive Spirometry...I. POLICY To provide clinically proven treatments to improve the patient's cardiopulmonary status with lung expansion therapy....

D. Policy Number NU.437 titled Pulse Oximetry...I. POLICY [Hospital] nurses will monitor the adequacy of arterial oxyhemoglobin saturation as ordered by a patient's physician...

Continued review of the Respiratory Services policies/procedures revealed the above (A through D) were the only respiratory therapy service policies given to the surveyor for review.

Review of the clinical record for Patient #1 revealed the patient was a 59 year old male with a diagnosis of Emphysema that was currently on 3 inhaled medications, Oxygen as needed, Pulse oximetry every shift, and as needed aerosol treatments.

In an interview on 05/01/14 at 10:10 a.m., S2DON verified the hospital did not have a respiratory therapist/s on staff or contracted. S2DON stated if a patient needed respiratory therapy they would send the patient to Company A. S2DON stated the nursing staff administered oxygen and respiratory treatments to patients and stated the nurses were checked off in respiratory treatments by S15RN/Dietary Manager. S2DON verified S15RN/Dietary Manager had not received training or competency evaluation in respiratory treatments, and stated she had, "just nursing experience." S2DON verified the only policies regarding respiratory services were for oxygen administration, incentive spirometry, pulse oximetry and aerosol therapy. S2DON verified the hospital did not have a policy that defined the education/training/experience of personnel authorized to perform each type of respiratory care service. S2DON verified the hospital did not have a policy on the amount of supervision required for personnel to perform the procedures, or the type of personnel qualified to provide the direct supervision.

Based on record reviews and interviews, the hospital failed to meet all special provisions applying to psychiatric hospitals as evidenced by:

1) Failing to meet the requirements for the Condition of Participation for the Special Medical Records Requirements For Psychiatric Hospitals (see findings in tag B0103)

Based on record reviews and interviews, the hospital failed to meet the requirements of the Condition of Participation for:

1) Quality Assessment and Performance Improvement (QAPI) as evidenced by:
a) The hospital failed to ensure the QAPI program was an ongoing program that showed measurable improvement in indicators as evidenced by failing to analyze the data collected to improve performance and processes of care and identify opportunities for improvement. The QAPI program failed to improve performance in quality indicators of medical staff credentialing, delinquent medical records, and food temperatures (see findings in A-0273).

b) The hospital failed to set priorities for high-risk, high volume and problem-prone areas as evidenced by:
1) failing to monitor the hospital process for compliance with the Pharmacist review of the patient's medication profile prior to the first dose of a new medication, and;
2) failing to monitor the hospital process for treatment planning (see findings in A-0283).

c) The governing body failed to ensure that the hospital's Performance Improvement Program reflected the hospital's organization and services as evidenced by not having all hospital departments and services including those services furnished under contract involved in the Performance Improvement Program (see findings in A-0308).


2) Medical Staff as evidenced by:
a) Failing to ensure that the medical staff examined the credentials of candidates for medical staff membership and made recommendations to the governing body for appointment/reappointment for 3 of 3 (S3Medical Director, S9Physician, S10NP) practitioner credentialing files reviewed from a total of 5 credentialed practitioners (S3Medical Director, S9Physician, S10NP, S22Physician, S23NP) (see findings in tag A0341);
b) Failing to ensure the medical staff conducted periodic appraisals of its members for 2 of 2 (S9Physician, S10NP) credentialing files reviewed for medical staff appraisals out of 5 current credentialed practitioners (S3Medical Director, S9Physician, S10NP, S22Physician, S23NP) (see findings in tag A0340); and
c) Failing to ensure the medical staff enforced the by-laws and the rules and regulations adopted by the medical staff as evidenced by failing to ensure that an effective system was in place for addressing delinquent medical records (greater than 30 days delinquent) and its failure to discipline a physician (S9Physician) and an Advanced Practice Nurse (S10NP) who had delinquent medical records greater than 90 days after patients' discharge (see findings in A0353);

3) Radiologic Services as evidenced by:
a) Failing to ensure there was a radiologist who was a member of the medical staff and supervised the radiology services and interpreted the radiological tests on either a full-time, part-time, or consulting basis (see findings in tag A0546); and
b) Failing to develop policies and procedures that addressed proper safety precautions against radiation hazards to provide for the safety of staff and patients during radiological procedures performed in the hospital by Company B (see findings in tag A0535).

4) Respiratory Services as evidenced by:
a) Failing to ensure that the scope of diagnostic and/or therapeutic respiratory services was defined in writing and approved by the Medical Staff as evidenced by failure to have the Governing Body By-laws designate Respiratory Services as one of the clinical and ancillary services provided by the hospital. The Medical Staff By-laws failed to include approval of the scope of diagnostic and/or therapeutic respiratory services provided by the hospital (see findings in tag A1152);
b) Failing to have Respiratory Therapy Technician(s)/employees/ or contract employees to administer respiratory therapy services to patients should they require these services and failed to have written qualifications specified by the Medical Staff (see findings at tag A1154); and
c) Failing to ensure the personnel qualified to perform specific respiratory therapy services and the amount of supervision required for personnel to carry out the specific respiratory therapy procedures were designated in writing (see findings in tag A1161).

Based on record reviews and interviews, the hospital failed to meet the requirements for the Condition of Participation for the Special Medical Records Requirements For Psychiatric Hospitals as evidenced by:

1) Failing to ensure each patient received a psychiatric evaluation for 2 (#2, #15) of 29 sampled patients (see findings in tag B0110);

2) Failing to ensure that each patient had an individual comprehensive treatment plan as evidenced by failing to address a patient's (Patient #5) non-compliance with therapy and include the development of alternative interventions to meet his needs relative to this non-compliance for 1 of 8 active patients' records reviewed for treatment plan development from a total sample of 29 patients (#5). (see findings in tag B0118);

3) Failing to ensure that each patient's treatment plan was based on an inventory of the patient's strengths and disabilities that is derived from information contained in the psychiatric evaluation and assessments collected by the total treatment team for 1 of 8 active patients' records reviewed for treatment plan development from a total sample of 29 patients (#5).
(see findings in tag B0119);

4) Failing to ensure that the written treatment plan included short-term and long-range goals that were stated as expected behavioral outcomes for the patient and written as observable, measurable patient behaviors to be achieved for 3 of 8 active patients' records reviewed for treatment plan development from a total sample of 29 patients (#4, #5, #6) (see findings in tag B0121).

Based on record review and staff interview, the hospital failed to ensure each patient received a psychiatric evaluation for 2 (#2, #15) of 29 sampled patients. Findings:

Review of the hospital's policy for psychiatric evaluations provided by S2DON as the current policy revealed the attending physician or designated admitting physician shall complete a thorough psychiatric evaluation within sixty (60) hours of admission and record in the patient's medical record. The policy revealed the psychiatric evaluation would include at least the following: All diagnosis, both medical and psychiatric; a notation of the onset of illness, the circumstances leading to admission, attitudes, and behavior; an inventory of the patient's assets in descriptive, not interpretive, fashion; a summary of present medical findings; the patient's medical history; a mental status examination and results; the patient's memory, mental, intellectual and physical functional capacity and orientation; the patient's prognosis; and a recommendation concerning admission to the hospital.

Patient #2
Patient #2 was a 73-year-old male admitted to the hospital on 04/23/14. His diagnoses included Alzheimer's dementia with disturbance in behaviors, Diabetes Type II, Congestive Heart Failure, Hypertension, Gout, Chronic Cystitis, and Osteoarthritis.
Review of Patient #2's medical record revealed Patient #2 was initially admitted to the psychiatric hospital on 04/18/14 and subsequently discharged to an acute care facility on 04/19/14. Patient #2 was readmitted to the psychiatric hospital on 04/23/14. Review of Patient #2's medical record revealed a Psychiatric Evaluation was completed by S3Medical Director on 04/18/14 at 12:00 p.m. Further review revealed a document entitled "Psychiatric Evaluation Addendum" was completed on 04/30/14 by S3Medical Director. There was no documented psychiatric evaluation performed on Patient #2 for his admission to the psychiatric hospital on 04/23/14 in Patient #2's medical record.
In an interview on 05/01/14 at 12:40 p.m., S3Medical Director indicated he was not aware a new psychiatric evaluation had to be completed on patients if they were discharged from the hospital and readmitted to the hospital. S3Medical Director also indicated he thought the completion of the Psychiatric Evaluation Addendum form completed on 04/30/14 indicating there were no changes in Patient #2 since the evaluation was initially completed on 04/18/14 was sufficient.

Patient #15
Review of the patient's clinical record revealed the patient was a 55 year old male admitted to the hospital on 04/16/14 under a PEC (Physician Emergency Certificate) for attempted suicide by hanging. Further review of the record revealed the patient was admitted to an acute care hospital intensive care unit on 04/15/14 and was transferred to [Hospital] on 04/16/14. Review of the record revealed only a "Psychiatric Addendum" was documented on 04/17/14 by S10NP for S3Medical Director, and included only the following: History of Present Illness, Medications on Admit, Changes Since Last Assessment, and Admit Diagnoses.

In an interview on 05/01/14 at 12:35 p.m., S3Medical Director stated an addendum can be done if the patient had a psychiatric evaluation within the last 30 days. S3Medical Director was informed that time frame was for the history and physical and a psychiatric evaluation was required within 60 hours of the patient's admission to the hospital. S3Medical Director stated he remembered Patient #15 and verified a psychiatric evaluation was not done for this patient.






31048

25065

Based on record reviews and interviews, the hospital failed to ensure that each patient had an individual comprehensive treatment plan as evidenced by failing to address a patient's (Patient #5) non-compliance with therapy and include the development of alternative interventions to meet his needs relative to this non-compliance for 1 of 8 active patients' records reviewed for treatment plan development from a total sample of 29 patients. (see findings in tag B0118).
Findings:

Review of the hospital's policy for treatment plans provided by S2DON as the current policy revealed a comprehensive individualized written treatment plan shall be developed pursuant to the staffing process and comprehensive medical, psychiatric, psychosocial, and nursing, activity/leisure, dietary, and other evaluations as indicated, in accordance with applicable law and regulations.

Patient #5
Review of Patient #5's medical record revealed he was a 77 year old male admitted on 04/02/14 with diagnoses of Impulse Control Disorder, Dementia Alzheimer's Type with Behavioral Disturbance, Hypertension, Non-Insulin Dependent Diabetes Mellitus, Hypercholesterolemia, Degenerative Joint Disease, and Coronary Artery Disease.

Review of Patient #5's "Master Treatment Plan Cover Sheet" dated 04/02/14 revealed his identified problems were Poor Impulse Control, Dementia with Psychosis/Behavioral Disturbance, Decreased Cardiac Output, Imbalanced Nutrition, and Risk for Injury/Falls. Review of each treatment plan for the identified problem revealed that it was a generic printed treatment plan that had not been individualized with treatment goals and interventions specific to Patient #5's problems, strengths, and disabilities. His treatment plan for "Psychosis With Behavioral Disturbance," "Decreased Cardiac Output," "Impaired Nutrition," and "Risk For Injury/Falls" was the same as that of Patient #4 with no changes other than the ordered diet being written.

Review of Patient #5's group therapy progress notes revealed he consistently did not attend or participate in therapy. There was no documented evidence that his treatment plan was revised to address his non-compliance with therapy with development of alternative interventions to meet his needs.

In an interview on 05/01/14 at 3:50 p.m., S2Director of Nursing (DON) confirmed that the patients' treatment plans were generic and were not individualized for each patient. She indicated that Patient #5 should have had an alternate intervention implemented when he did not attend or participate in group therapy.

Based on record reviews and interviews, the hospital failed to ensure that each patient's treatment plan was based on an inventory of the patient's strengths and disabilities that is derived from information contained in the psychiatric evaluation and assessments collected by the total treatment team for 1 of 8 active patients' records reviewed for treatment plan development from a total sample of 29 patients (#5).
Findings:

Review of the hospital's policy for treatment plans provided by S2DON as the current policy revealed a comprehensive individualized written treatment plan shall be developed pursuant to the staffing process and comprehensive medical, psychiatric, psychosocial, and nursing, activity/leisure, dietary, and other evaluations as indicated, in accordance with applicable law and regulations. Further review of the policy revealed the initial psychiatric evaluation shall include an inventory of the patient's assets in descriptive, not interpretive, fashion.

Review of the psychiatric evaluation for Patients #5 revealed no documented evidence that his disabilities were identified.

Review of Patient #5's medical record revealed he was a 77 year old male admitted on 04/02/14 with diagnoses of Impulse Control Disorder, Dementia Alzheimer's Type with Behavioral Disturbance, Hypertension, Non-Insulin Dependent Diabetes Mellitus, Hypercholesterolemia, Degenerative Joint Disease, and Coronary Artery Disease.

Review of Patient #5's "Master Treatment Plan Cover Sheet" dated 04/02/14 revealed his identified problems were Poor Impulse Control, Dementia with Psychosis/Behavioral Disturbance, Decreased Cardiac Output, Imbalanced Nutrition, and Risk for Injury/Falls.

Review of Patient #5's group therapy progress notes revealed he consistently did not attend or participate in therapy. There was no documented evidence that his treatment plan was revised to address his non-compliance with therapy with development of alternative interventions to meet his needs.

In an interview on 05/01/14 at 12:35 p.m., S3Medical Director confirmed that the psychiatric evaluations addressed only the patients' assets and did not address their weaknesses or disabilities.

In an interview on 05/01/14 at 3:50 p.m., S2Director of Nursing (DON) confirmed that the patients' treatment plans were generic and were not individualized for each patient. She indicated that Patient #5 should have had an alternate intervention implemented when he did not attend or participate in group therapy.

Based on record reviews and interviews, the hospital failed to ensure that the written treatment plan included short-term and long-range goals that were stated as expected behavioral outcomes for the patient and written as observable, measurable patient behaviors to be achieved for 3 of 8 active patients' records reviewed for treatment plan development from a total sample of 29 patients (#4, #5, #6).
Findings:

Review of the hospital's policy for treatment plans provided by S2DON as the current policy revealed a comprehensive individualized written treatment plan shall be developed pursuant to the staffing process and comprehensive medical, psychiatric, psychosocial, and nursing, activity/leisure, dietary, and other evaluations as indicated, in accordance with applicable law and regulations.

Patient #4
Review of Patient #4's medical record revealed she was an 82 year old female admitted on 04/17/14 with diagnoses of Bipolar Disorder Type I, most recent episode Manic with Psychotic Features, Hypertension, Emphysema, Parkinsonian Symptoms, COPD (Chronic Obstructive Pulmonary Disease), Diabetes Mellitus Type II, and Osteomalacia.

Review of Patient #4's treatment plan for "Psychosis With Behavioral Disturbance" revealed the long-term goal was stated as "patient's thought processes and behavior will be more organized and appropriate by discharge." There was no documented evidence that the goal was stated as an expected behavioral outcome for the patient and was written as an observable, measurable patient behavior to be achieved. Further review revealed some of the short-term goals that were not written as observable and measurable behaviors were as follows: patient will establish meaningful communication and trust with others within 3 days; patient will demonstrate no or reduced physical aggression; patient will be medication compliant. Review of the treatment plan for "Decreased Cardiac Output" revealed the long-term goal was to demonstrate "adequate cardiac output as evidenced by blood pressure and pulse rate and rhythm within normal parameters for client..." There was no documented evidence of what the patient's normal parameters were to determine when the goal was met.


Patient #5
Review of Patient #5's medical record revealed he was a 77 year old male admitted on 04/02/14 with diagnoses of Impulse Control Disorder, Dementia Alzheimer's Type with Behavioral Disturbance, Hypertension, Non-Insulin Dependent Diabetes Mellitus, Hypercholesterolemia, Degenerative Joint Disease, and Coronary Artery Disease.

Review of Patient #5's treatment plan for "Poor Impulse Control" revealed the long-term goal was stated as "patient will exhibit medication compliance and improved self-control." There was no documented evidence that the goal was stated as an expected behavioral outcome for the patient and was written as an observable, measurable patient behavior to be achieved. His short-term goals for "Psychosis With Behavioral Disturbance" and "Decreased Cardiac Output" were stated and written the same as that of Patient #4 (listed above).

Patient #6
Review of Patient #6's medical record revealed she was an 82 year old female admitted on 04/22/14 with diagnoses of Dementia with Behavioral Disturbance complicated by Major Depressive Disorder, Hypertension, Parkinson's Disease, COPD, Seizure Disorder, and frequent Urinary Tract Infections.

Review of Patient #6's treatment plan for "Psychosis With Behavioral Disturbance" revealed the long-term and short-term goals were stated and written the same as for Patients #4 and #5 above. Her treatment plan for "Decreased Cardiac Output" revealed the long-term goal was to demonstrate "adequate cardiac output as evidenced by blood pressure and pulse rate and rhythm within normal parameters for client..." Her blood pressure was listed as 130/80, and her pulse was listed as "8."

In an interview on 05/01/14 at 3:50 p.m., S2Director of Nursing (DON) confirmed that the patients' treatment plans were generic and were not individualized for each patient. She also confirmed that the patient goals were not stated as expected behavioral outcomes for the patient and written as observable, measurable patient behaviors to be achieved.

Based on record reviews and interview, the hospital failed to ensure that each patient's medical record included adequate documentation to justify the treatment activities carried out for 1 of 8 active patients' records reviewed for treatment interventions from a total sample of 29 patients (#6). Patient #6's record had no documented evidence that her oxygen saturation was assessed once per shift and as needed for signs of respiratory complications.
Findings:

Review of Patient #6's medical record revealed she was an 82 year old female admitted on 04/22/14 with diagnoses of Dementia with Behavioral Disturbance complicated by Major Depressive Disorder, Hypertension, Parkinson's Disease, COPD (Chronic Obstructive Pulmonary Disease), Seizure Disorder, and frequent Urinary Tract Infections.

Review of Patient #6's "Physician's Orders" revealed an order on 04/23/14 at 3:00 a.m. for oxygen per nasal cannula at 2 liters per minute as needed for an oxygen saturation less than 92% (per cent) or complaints of shortness of breath.

Review of Patient #6's "Nursing Progress Note" and "Integrated Progress Notes" from the time of admission on 04/22/14 at 10:30 p.m. through 04/30/13 at 8:00 a.m. revealed no documented evidence that Patient #6's oxygen saturation was assessed by a nurse to determine if she needed to have oxygen administered as ordered by the physician except on 04/24/14 at 8:45 p.m. (only documented assessment).

In an interview on 04/30/14 at 3:35 p.m., S21RN indicated he would not check a patient's oxygen saturation unless it was ordered to be assessed by the physician. When asked if an as needed order for oxygen based on an oxygen saturation of less than 92% would be considered a physician's order to assess the oxygen saturation level, he answered, "No." He indicated that the order would mean to check the oxygen saturation level only if the patient had a problem.

In an interview on 05/01/14 at 8:40 a.m., S12RN indicated it's a standard of practice to check a patient's oxygen saturation when the physician has ordered oxygen to be administered as needed for a oxygen saturation of less than 92%.

In an interview on 05/01/14 at 12:35 p.m., S3Medical Director indicated that he would expect the nurse to assess a patient's oxygen saturation level when the order for as needed oxygen based on the oxygen saturation level was given.

25065

Based on record reviews and interviews, the hospital failed to ensure registered nurses (RNs) and licensed practical nurses (LPNs) were trained and evaluated for competency to provide the nursing care necessary under each patient's active treatment program according to hospital policies and procedures for 1 of 2 nursing personnel files reviewed from a total of 27 employed nurses (S12RN) and for 2 of 2 staffing agency nurses' files reviewed (S25RN, S26LPN).
Findings:

Review of the hospital policy titled "Clinical Orientation," presented as a current policy by S5Human Resource (HR) Director, revealed that successful completion of CPR (cardiopulmonary resuscitation) is required of all clinical staff during orientation. Further review revealed that clinical staff is required to attend and complete CPI (Crisis Prevention Intervention) and complete a restraint and Seclusion Policy and Procedure and restraint application competency assessment during initial orientation and annually.

Review of the hospital policy titled "Reference Checks," presented as a current policy by S5HR Director, revealed that reference checks will be performed on all candidates being considered for employment. After receiving favorable reference information, the Director of Nursing (DON) or Administrator can offer employment to the candidate.

S12RN
Review of S12RN's personnel file revealed she was hired on 04/03/14. Review of her resume' revealed she had not been employed as an inpatient psychiatric RN since 2009. Further review revealed no documented evidence that her references were checked as required by hospital policy. Further review revealed she had no documented evidence of CPR certification and CPI training as required by hospital policy. Review of S12RN's competency assessments/evaluations revealed they were all done by S15Dietary Manager (also a Nursing Supervisor) on the day that S12RN was hired.

In an interview on 05/01/14 at 8:40 a.m., S12RN indicated her most recent employment was as a case manager. She indicated that she works as a charge RN on nights.

In an interview on 05/01/14 at 3:50 p.m., S2DON confirmed that she did not check references as required by hospital policy for S12RN, and references were supposed to be checked by S5HR Director. She confirmed that S12RN was sharing charge nurse duties on the night shift and was not certified in CPR or CPI as required by hospital policy.



S25RN
Review of the personnel record for S25RN revealed she was an agency nurse and had documentation of orientation to the hospital dated 04/20/14. There was no documented evidence of CPI training. Review of the record revealed only a self-assessment of psychiatric nursing skills from the agency.


S26LPN
Review of the personnel record for S26LPN revealed she was an agency nurse and had documentation of only a license verification, a Tuberculosis test, and a nursing test from the agency. There was no documented evidence of any orientation to the hospital There was no documented evidence of CPI training or CPR.

In an interview on 05/01/14 at 8:45 a.m., S12RN stated S25RN and S26LPN had both worked at the hospital.

In an interview on 05/01/14 at 3:30 p.m., S5HR Director (Human Resource Director) verified S25RN's personnel record did not have documentation of any CPI training. S5HR Director verified S26LPN's personnel record did not have doumentation of CPR, CPI, or orientation to the hospital.