HospitalInspections.org

Based on observation, interview and record review, the Governing Body failed to be responsible for the quality of the healthcare provided at the hospital because:

1. The Governing Body did not ensure the implementation of an ongoing, data-driven quality assurance program that reflected the complexity of the patients using the hospital and the services offered (see A-263).

2. The rights of all patients were not protected and promoted.

a) Patient 21 was not protected from physical abuse while in the facility.

b) Patients 3, 26, 28 and 41 were not protected from abuse when they were discharged to environments in which they had complained of bullying or abuse.

c) Patients 1, 2 and 23, rights to advanced directives were not promoted. (see A-115)

3. Nursing services were not organized to meet the needs of the patients (see A-385).

4. The accuracy and integrity of the medical records were not assured (see A-431).

5. The pharmacy services supplied by the hospital did not ensure medication administration that minimized the risk of medical errors and maximized the effectiveness of medication regimens (see A-490).

6. The dietary service did not ensure that the nutrition needs of all of the patients were met, that food storage and production was managed safely, and that emergency food supplies were sufficient to provide nutrition in the event of a disaster (see A-618).

7. The discharge planning process was not applied to all social, psychiatric and medical conditions that the patients presented with, and was not routinely applied to all of patients being discharged by the hospital (see A-799).

The cumulative result of these systemic failures resulted in the Governing Body's inability to ensure high quality healthcare delivered in a safe environment for all patients.

Based on interview and record review the hospital failed to protect and promote the rights of all patients.

1. For Patient 21, the hospital failed to protect the patient from assault (a violent physical attack) on 6/11/12 by another patient (Patient 24). Patient 24 had exhibited aggressive behavior two days (on 6/9/12) prior to the physical attack on Patient 21. (Refer to A-0145)

2. For Patient 41, the hospital failed to ensure prompt reporting of an allegation of abuse by the patient's parents to child protective services (CPS). The hospital failed to follow up with CPS prior to attempting to discharge the patient home to his parents. (Refer to A-0145)

3. For Patients 3 and 28, the hospital failed to ensure that the patients' allegations of being bullied at school were investigated prior to both patients being discharged back to the same environment. (Refer to A-0145 and A-818)

4. For Patient 36, the hospital failed to ensure that the environment that the patient was being discharged to was not an abusive environment. The patient indicated, when he was admitted to the hospital, that he had been abused by his mother. The hospital discharged Patient 36 home where he lived with his mother. (Refer to A-0145)

5. For Patients 1, 2 and 23, the hospital failed to promote the patients' right to formulate a Healthcare Advance Directive. (A-0132)

6. For Patient 38, the hospital failed to ensure that the patient's medical record content was kept confidential. (A- 0147)

The cumulative effect of these systemic failures resulted in the hospital's inability to promote patient rights in accordance with the Condition of Participation for Patient Rights.

Based on interview and record review, the hospital failed to promote the right of the patients to formulate a Healthcare Advance Directive (AD, a written instruction, such as a living will or durable power of attorney for health care, relating to the provision of health care when the individual is incapacitated) for 3 of 35 sampled patients (Patients 23, 1 and 2), and failed to accurately present information to all patients, due to incomplete statements in the facility's pre-printed Advance Directive Acknowledgement form. This failure increased the risk of patients to not have their rights to have Advance Directive healthcare wishes to be known and honored by outside healthcare professionals in the event of an emergency transfer from the hospital.

Findings:

1. On 6/13/12, a review of the hospital's policy titled, "Psychiatric and Medical Advance Directives," dated 2/12, indicated that the hospital's policy was to provide information of Advance Directives and to assess if the patient has a current Medical or Psychiatric Advance Directive. The Purpose statement showed, "To protects the patient's rights to self-determination regarding specific aspects of care planning at end of life and treat the patient/family with discretion and sensitivity."The Procedure section include, "If the patient would like more information, the request is forwarded to the Case Manager. This individual will record in the patient's medical record any information given to the patient to assist with this procedure.

On 6/13/12, a review of Patient 23's medical record was conducted.

A review of the face sheet indicated that Patient 23 was admitted to the facility on 9/11/11, with diagnoses that included depression.

A review of the facility's Advance Directive Acknowledgement (ADA) document was conducted and revealed that the patient did not submit an executed a Health Care (Advance Directive) on admission. The ADA document section that indicated whether the patient wished to execute a Healthcare Advance Directive was blank. There were no hospital staff signatures on the document to indicate that the hospital's AD policy was followed.

On 6/15/12 at 2:10 PM, an interview was conducted with the Chief Nursing Officer (CNO). The CNO reviewed the patient's Advance Directive Acknowledgement document and confirmed that the documentation was incomplete. She stated that the hospital was in the process of revising the document to ensure that patients' right to formulate an advance directive was promoted.




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2. The medical record of Patient 1 was reviewed, and contained a form, Advance Directive Acknowledgement. The top section of the pre-printed form contained instruction, "Place your initials after each statement.", with six statements regarding the patient's wishes and a line to the left of each statement for the patient to initial. However, for Patient 1, only one set of initials was provided, in the margin opposite statement 4. The bottom portion of the pre-printed form contained a series of incomplete statements, such as, "I have not executed a health care."

In an interview with the Director of Program Services (DPS) on 6/13/12 at 8:40 AM, she reviewed the Advanced Directives Acknowledgement pre-printed form in the medical record of Patient 1. The DPS stated that the six questions should have been bracketed as she believed that the initials were intended to apply to all six statements. She also concurred that some of the pre-printed statements on the form, such as, "I have not executed a health care" were incomplete. She stated that she had not previously noted that the form contained incomplete statements.

3. The medical record of Patient 2 was reviewed, and contained the form, Advance Directive Acknowledgement. The top section of the pre-printed form contained the six statements and the instructions to "Place your initials after each statement". However, Patient 1 had initialed only one statement, "I understand that (Hospital name) does not provide advance cardiac life support." Other statements such as, "I have been given material about my right to accept or refuse medical treatments", had not been acknowledged by the patients with his initials.

During an interview with the DPS on 6/13/12 at 8:40 AM, she stated that each of the statements on the top of the form were to have been initialed by the patient, to document that the patient received the information.

Based on interview and record review the facility failed to ensure that 5 of 35 sampled patients (Patient 21, 3, 41, 28 and 36) were protected from all forms of abuse.

1. For Patient 21, the hospital failed to ensure that the patient was not assaulted (a violent physical attack) on 6/11/12 by Patient 24 who had exhibited aggressive behavior two days (on 6/9/12) prior to the physical attack. The facility's failure to implement measures to prevent Patient 24's progressive escalation in behaviors contributed to harm for Patient 21 and Patient 24.

2. For Patient 3, the hospital failed to ensure that the patient's allegation of bullying at school was investigated and his safety promoted prior to the patient being discharged back to the same environment. This resulted in Patient 3 returning to the facility with recurrent suicidality related to bullying.

3. For Patient 41, the hospital failed to ensure prompt reporting of an allegation of abuse by the patient's parents to child protective services (CPS). The hospital also failed to follow up with CPS prior to attempting to discharge the patient home to his parents. This failure had the potential for the patient to suffer continuing abuse and continuing harm including death.

4. For Patient 28, the hospital failed to ensure that the patient's allegation of being bullied at school was investigated and reported to her group home prior to her discharge back to the same environment. This failure had the potential for the patient to continue to suffer abuse.

5. For Patient 36, the hospital failed to ensure that patient's allegation of abuse by his mother was investigated. The hospital discharged Patient 36 without ensuring that he was not going back to an abusive environment. This failure had the potential to contribute to harm to the patient.

These failures contributed to the Patient to Patient abuse for Patient 21 and created the risk for all patients that received care and/or services in the hospital to experience different forms of abuse.

Findings:

1. A review of the facility's policy, "Patient Abuse or Neglect," dated 3/12, did not address Patient to Patient abuse.

A review of the facility's Nursing policy, "Assault/Aggression/Homicidal Ideation Precautions," dated 1/2012 was conducted and revealed the following:

Policy: Patients assessed to be at heightened risk of assault, aggression towards others or destruction of property as determined in the conclusion of core assessments such as Assessments and Referral, Nursing Assessment, Psychiatric Evaluation, or based upon patient statements and or behaviors, may be placed on Assault/Aggression Precautions commensurate with the assessed level of risk, homicidal ideation. Staff responsible for monitoring patients on assault precautions shall maintain the patient in a safe environment and take measures to protect the patient and others from harm.

Definitions: 15-minute checks - staff may make contact with the patient and confirm that the patient is safe and in no physical distress at frequent intervals not to exceed 15 minutes apart. Whenever possible, verbally interact with patient to assess safety and well-being.

1 to 1 - a dedicated staff member is assigned to remain within arm ' s reach of the patient at all times.

Limit Setting - offering the patient reasonable choices and consequences in response to threatening or unsafe behavior.

Procedure: A Registered Nurse (RN) may immediately increase the level of observation based upon assessment/reassessment without a physician order.

The observation flow sheet shall clearly indicate if a patient is on Assault/Aggression precautions.

Treatment Planning (TP) and Documentation: Routine Observation Sheets should indicate that the patient is on Assault/Aggression Precautions.

The TP should indicate separate problems and/or goals which address aggressive behaviors, and interventions to be used by staff in response.

Any individual behavior plans should be included in the TP.

Nursing progress notes should reflect re-assessment of aggressive behaviors, response to as necessary medication and effectiveness of de-escalation techniques.

On 6/15/12, a review of Patient 21's medical record was conducted with RN 2 and the Director of Program Services (DPS).

A review of Patient 21's medical record face sheet showed that the patient was admitted to the hospital on 5/19/12, with diagnoses that included paranoid schizophrenia (psychiatric disorder).

A review of the "Daily Treatment Plan Update/RN Assessment," dated 6/11/12, showed that Patient 21 was involved in an altercation with a peer (Patient 24). Patient 21 was punched on the face and swelling was noted. The plan of care section showed, "continue to monitor for safety, ice pack to swelling."

A review of Patient 21's physician order (PO), dated 6/11/12, revealed an order for an ice compress to right forehead and left hand swelling every 2 hours for 24 hours as tolerated, and Motrin (pain medication) 400 milligrams (mg) orally every 4 hours as necessary for pain.

A review of Patient 21's Medication Administration Record, dated 6/11/12, revealed that the patient required an ice compress for face swelling.

A review of the "Progress Note Documentation," dated 6/11/12 at 2 PM, revealed that the patient stated, "I was in my room lying down and a peer came and punched me on my face." The physical assessment section revealed that the patient acquired swelling to his face. The nursing actions/interventions section noted ice compress was applied to the patients face swelling. The document noted that the patient's TP was updated.

A review of patient's TP did not reflect an update to address the assault as the Progress Note Documentation indicated.

On 6/15/12 at 11 AM, an interview was conducted with RN 1 and the DPS regarding the incident. RN 1 verified that she was on duty on the day and at the time of the Patient to Patient altercation, and that she observed the patient's injuries. When asked what measures the facility took to protect Patient 21 from further harm and others from harm, RN 1 and the DPS stated that the aggressor (Patient 24) had been discharged from the facility. The DPS suggested that the surveyor speak with the facility's Risk Manager (RM) who was responsible for conducting the investigation.

On 6/15/12, a review of Patient 24's (aggressor) medical record was conducted and revealed that the patient was admitted to the facility on 6/9/12 with diagnoses that included depression. The patient was on a 72 hour detention (involuntary hold) related to being a danger to self. The patient was discharged from the facility on 6/14/12.

A review of the initial Interdisciplinary Treatment Plan (TP), dated 6/9/12, showed that the patient's problem list addressed self harm and depression.

A review of the "Daily Treatment Plan Update/RN Assessment," dated 6/9/12, showed that Patient 24 was agitated and threw a chair at a window. The patient stated that he wanted to harm others.

A review of the PO, dated 6/9/12 at 1:10 PM, revealed an order to administer Benadryl (antihistamine) 50 mg orally now, "patient agitated, threw chair against window, threatening peer."

A review of the "Patient Observation/Rounds Precautions," dated 6/9/12, was conducted and revealed that after the incident the patient remained on the every 15 minute observation monitoring by staff. The documentation failed to show that the patient was placed on Assault/Aggression Precautions (included - to tell nurse ''now" of increased agitation, paranoia, anger, hallucinations, homicidal ideations; 5 feet separation from "at risk" peers; document all acting our behavior/add to shift report).

A review of the "Progress Note Documentation", dated 6/9/12 at 1:10 PM, revealed that the patient got in an argument with a peer. Patient 24 picked up a chair and threw it at a window. The documentation indicated that the patient's treatment plan was updated on 6/9/12.

A review of the patient's medical record failed to show documented evidence that a TP was implemented to address the aggressive behaviors.

A review of the "Daily Treatment Plan Update/RN Assessment," dated 6/11/12, showed that Patient 24 had increased agitation and punched a peer on the face. The plan of care section revealed that the patient received Haldol (an antipsychotic medication), Ativan (a medication to treat anxiety) and Benadryl.

A review of Patient 24's "Patient Observation/Rounds Precautions", dated 6/11/12 was conducted and revealed that after the incident the patient remained on the every 15 minute observation monitoring by staff. There was no documented evidence to show that the patient was placed on Assault/Aggression Precautions.

A review of the "Progress Note Documentation," dated 6/11/12 at 2 PM, revealed that the patient went inside a peer's (Patient 21) room and started punching the peer on the face. Swelling was noted on the peer's face. The nursing interventions/action section showed that the patient received Haldol (antipsychotic medication) 5 milligrams (mg), Ativan (antianxiety medication) 2 mg, and Benadryl 50 mg for increased agitation. The patient was encouraged to verbalize feelings. The intervention included monitor every 15 minutes for safety. The documentation indicated that the treatment plan was updated on 6/11/12.

A review of the patient's medical record failed to show documented evidence that a TP was implemented to indicate separate problems and/or goals which address assaultive behaviors and interventions.

A review of the "Progress Note Documentation," dated 6/13/12 at 2 PM, revealed that the patient became increasingly agitated, picked up a chair and gestured as if he were going throw the chair at the staff. When the chair was removed from the patient by a staff member, the patient attacked the staff member. A "Code Grey" (occurs when a patient is physically held down by the staff to gain control over a combative patient) was conducted. During the physical hold, the patient acquired injuries to his forehead (a laceration) and his left and right upper arms. The patient complained of head (left side and back) pain at a of level 7 (on the 1 to 10 pain scale).

A review of PO, dated 6/13/12 at 2:25 PM, showed an order to, "send the patient to the emergency department (ED) for an evaluation of his head injury."

A review of the ED documentation showed the patient sustained abrasions (skin scrapes) and bruises (collection of blood under the skin causing discoloration).

A review of the Aggression/Assaultive Behavior TP, dated 6/13/12, was implemented after the 6/13/12 incident.

On 6/18/12 at 9:50 AM, an interview was conducted with the Risk Manager (RM) regarding the facility's practice for the investigation of abuse and/or unsafe behaviors.

The RM stated that the RN on duty completes the Progress Note Documentation for all incidents and place the document in the patients medical record.

When asked about her role in the investigation regarding assault on Patient 21 by Patient 24, the RM stated that her role was to ensure that the staff on the unit conducted their 15 minute checks prior to the 6/11/12 incident. She stated that that was accomplished by reviewing taped footage.

The RM submitted a document titled, "Supervisor Checklist for Incidents." She stated that the staff were to follow the steps listed on the document after each incident. The checklist included the following:

Progress Note Documentation (if incident involved 2 patients, 2 incident reports are needed each patient) inside of the medical chart filled out completely (who, what, where, when, why and how): Was the re-assessment filled out on the shift of the event (Daily RN update): Does the patient need to be placed in the history and physical log: doctor notified: supervisor notified: was there resolution noted in the medical record.

The RM stated that it was the RN's responsibility to immediately place the patient on Assault/Aggression Precautions and/or to also implement an Aggression/Assaultive TP. The RM confirmed that these responsibilities were not reflected on the check list.

The RM confirmed that after the 6/9/12 and 6/11/12 incidents, Patient 24 was not placed on Assault/Aggression Precautions, nor was an Aggression/Assaultive TP implemented for the patient. She stated that those measures should have been immediately started to protect the patient and others from harm.

The RM confirmed that Patient 24 exhibited aggression on 6/13/12 that required a "Code Gray" intervention. She confirmed that the patient acquired injuries during the 6/13/12 incident. The RM stated that she investigated the Crisis Prevention Intervention (CPI- physical hold) by reviewing the taped footage to ensure that there were no violations in the procedure.

She confirmed that the nursing staff did not implement measures on 6/9/12 to address Patient 24's unsafe behaviors to prevent the progressive escalation in the behaviors that contributed to the harm for Patient 21 on 6/11/12, and the harm for Patient 24 on 6/13/12.

On 6/18/12 at 10:15 AM, an interview was conducted with the RN 2 that was on duty 6/9/12 when the patient threw the chair and made the statements regarding wanting to harm others. RN 2 was also on duty when the patient attempted to throw a chair at a staff member on 6/13/12 that resulted in a physical hold in which the patient acquired injuries. She confirmed that Assault/Aggression Precautions were not implemented after the 6/9/12 incident. RN 2 stated that she did not implement an Aggression/Assaultive towards other TP to protect the patient and others from harm until the 6/13/12 incident occurred. She stated that an Aggression/Assaultive towards other TP should have been implemented on 6/9/12 to prevent the progressive escalation in the patient's behaviors on 6/11/12 and 6/13/12.

On 6/18/12 at 3 PM, an interview was conducted with the RN 1 that was on duty on 6/11/12 during the day shift when Patient 24 assaulted Patient 21. She confirmed that Assault/Aggression Precautions were not implemented after the 6/11/12 incident. RN 2 confirmed that she did not implement an Aggression/Assaultive towards others TP after the 6/11/12 incident. She stated that she forgot to implement the TP. RN 1 stated it should have been implemented to prevent the progressive escalation in the patient's behaviors on 6/13/12.



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2. The medical records of Patient 3 from April, 2012 and June, 2012 admissions were reviewed on 6/15/12. The Psychiatric Progress Note completed after admission to the facility on 4/17/12 included the chief complaint, "I was depressed and suicidal because the kids were bullying me at school." Patient 3 was discharged from the facility 4/24/12 and readmitted in June, 2012, with the same complaint of suicidality related to bullying.

During an interview with the Medical Director on 6/15/12 at 10:10 AM, he reviewed the medical record of Patient 3, who complained of bullying by peers. The Medical Director reviewed the medical record from the April, 2012 admission and stated that the staff would intervene on behalf of a child who complained of bullying. However, he was not able to find evidence of such an intervention in the medical record. He stated that the staff might not have documented the intervention.

In an interview with the Director of Case Management (DCM) on 6/14/12 at 2:45 PM and 3:10 PM, she stated that the subject of bullying should have been addressed in a family meeting prior to discharge. She reviewed the progress notes and concurred that there was no documentation that the issue was addressed. She stated that the case manger should call the school or make additional reports regarding bullying if needed, but there was no evidence this was done for Patient 3 during the April, 2012 admission.




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3. A review of the medical record for Patient 41 was conducted on 6/14/12. The review revealed that the patient was admitted to the hospital on 2/26/12 with diagnoses that included bipolar disorder (a mood disorder characterized by periods of mania and depression) and depression.


A review of the intake information, dated 2/26/12 at 4:32 PM, revealed that the patient stated, "My mom started cussing me out for no reason...then they (the patient's mom and stepfather) started hitting me." Further review revealed that the patient stated that he, "wanted to shoot himself in the shoulders and bleed to death in front of his family."


A review of the physician's psychiatric evaluation, dated 2/26/12 at 6:30 PM, revealed that the patient stated, "I don't want to go home. I don't want to be there. I don't want to be beaten up. Both my mother and father are physically beating me up."


A review of the nursing admission form titled "Child/Minor Abuse Symptom Checklist", undated, done on admission, revealed that in the area for "Indicators of Physical Abuse" there were no boxes that were checked. There was a box for no symptoms noted for the indicators that was not checked. At the bottom, the nurse checked that there was no reasonable suspicion of abuse.


A review of the medical record revealed that there was no documentation of a report made to Child Protective Services (CPS) on 2/26/12, 2/27/12, or 2/28/12.


A review of the physician's progress notes, dated 2/28/12, revealed that the patient was reporting being physically beaten up by his parents and a CPS evaluation would be obtained.


Further review of the medical record revealed that a report was filed on 2/29/12 (3 days after the patient reported the abuse to the hospital).


A review of the facility policy tilted, "Reporting Suspected Child Abuse", dated 2/12, revealed that the staff member receiving the information regarding abuse will be responsible for reporting the abuse. The policy stated that the abuse must be reported immediately to the appropriate authorities.


A review of the physician's orders revealed that the patient had an order to discharge home (to his mother and father) on 3/2/12.


A review of the physician's notes, nursing notes, therapy notes and the case management notes revealed that there was no further mention of the patient's allegation of abuse by his family in relation to his discharge.


An interview was conducted with the Chief Nursing Officer (CNO) on 6/18/12 at 9 AM. She confirmed that the patient had reported abuse to several members of the treatment team and that no one had reported the abuse to CPS until 3 days after the initial report. She stated that the report of abuse should have been made by the intake person, as she was the first person that the patient told of the abuse. The CNO could not explain why the nursing indicators for abuse did not identity a reasonable suspicion of abuse. She stated that the patient had made the allegation and had stated hostile behaviors and should have triggered for a report to be made. The CNO confirmed that the discharge plan did not take into consideration the patient's allegation of abuse and that there was no documented evidence that the staff had contacted CPS for a decision prior to planning the patient's discharge.


4. A review of the medical record for Patient 28 was conducted on 6/13/12. The review revealed that the patient was admitted to the hospital on 4/19/12 with diagnoses that included depression.


A review of the intake information, dated 4/19/12, revealed that the patient "reported being bullied."


A review of the "Adolescent Psychosocial Assessment", dated 4/19/12, revealed, "Pt (patient) reported being bullied at school and is unresolved." The report further documented, "Pt is unable to connect with peers at school and is bullied."


A review of the case management notes, dated 4/20/12, documented, "Pt indicated being bullied at school and is still unresolved."


A review of the physician's notes, nursing notes, therapy notes, and the case management notes revealed that there was no further mention of the patient's allegation of being bullied.


A review of the discharge plan, dated 4/27/12, revealed that the patient was discharged to the same living arrangement she had prior to being admitted into the facility. There was no documented evidence that the allegation of the patient being bullied was investigated or that the home was notified that the patient complained of being bullied at school.


An interview was conducted with the Director of Program Services (DPS) on 6/13/12 at 2:45 PM. She confirmed the documentation that the patient stated she was being bullied at school and acknowledged that being bullied could lead to serious injury for the patient. She confirmed that there was no follow up on the allegation made by the patient and stated that the staff should have followed up. She stated that there was no documentation of a conversation between the facility and the patient's home to see if the patient's home had already worked with the school regarding the matter and there was no documentation to show that the staff had contacted the patient's home regarding the allegation.





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5. A review on 6/14/12 of Patient 36's record shows that the patient was admitted to the hospital on 11/25/11 with diagnoses that included major depressive disorder, suicide attempt and alcohol abuse. He was admitted as a 5150 hold (a law that allows for a 72 hour hold in the hospital due to the patient being a danger to himself or others).

A review of a form titled, "Section I -- Point of Contact -- Assessment", dated 11/25/11 indicated that Patient 36 reported that his mother physically abused him. Patient 36 also stated that he felt that his mother and ex-wife were conspiring against him.

A review of Patient 36's personal history shows that his parents are supporting him financially as he is unemployed.

There was no indication in the record that the hospital did a follow up to ensure that the patient would be safe from abuse upon discharge.

A review of the Psychiatric Discharge/Aftercare Plan indicated that Patient 36 was discharged home with his mother.

In an interview on 6/14/12 at 4:00 PM with a RN (Registered Nurse) case manager, she acknowledged that the patient's statement that he was abused by his mother was not followed up and should have been before the patient was discharged. The RN case manager stated that there should have been documentation that the patient felt safe to go home with his mother.



An Immediate Jeopardy (IJ) was called on 6/18/12 at 5:10 PM in the presence of the facility's Chief Executive Officer, Chief Nursing Officer, Director of Program Services, and the Corporate Director of Clinical Services.

On 6/11/12, an incident of Patient to Patient abuse occurred and resulted in harm for one of the two patients involved (Patient 21). The hospital failed to implement measures after it identified that the aggressor (Patient 24)exhibited aggressive behaviors two days (6/9/12) prior to the assault.

The IJ was abated on 6/18/12 at 7:18 PM after an acceptable plan of correction was submitted to the survey team.

Based on observation and interview, the hospital failed to ensure that the contents of one (1) unsampled patient's medical record were kept confidential. This failure had the potential for all patients receiving care and services in the hospital to have their confidential medical record viewed by unauthorized persons.

Findings:

On 6/12/12 at 11 AM, a patient's open medical record was observed to be lying on the Unit 3's nursing station desk. There was no staff present at the desk to ensure that safeguards were in place to promote the confidentiality of the patient's medical record information.

At 11:05 AM, the Chief Nursing Officer confirmed that the record was left opened by a nurse. She stated that the patient's medical record should have been closed when the nurse walked away.

Based on observation, interview and record review, the hospital did not ensure to develop and maintain a quality assurance program that reflected the complexity of the hospital's organization and services because:

1. The quality assurance program failed to monitor processes of care such as acuity assessments, needs assessments, nursing competencies, care planning, pharmacy, medical records and food and nutrition services, creating the risk of poor health outcomes for all patients using the facility (see A-267).

2. The medical staff were not routinely subject to appraisals of the quality of their work (see A-340).

3. The discharge planning process was not subject to regular quality assurance review (see A-843).

The cumulative effect of these systemic failures resulted in the hospital's inability to provide quality health care in a safe setting to all patients using the facility.

Based on interview and record review the hospital failed to measure, analyze, and track quality indicators that assessed the processes of care and hospital services, creating the risk for a poor health outcome for all patients receiving care from the hospital.

1. The hospital failed to ensure that the Quality Program evaluated the discharge planning process on an on-going basis to help ensure that they are responsive to the patient's discharge needs.

2. The hospital failed to ensure that the Quality Program evaluated the contracted services provided by the Pharmacist.

3. The hospital failed to ensure that the Quality Program evaluated the patient classification system for validity and for nursing knowledge of the system. The hospital also failed to ensure that each patient was assigned a primary nurse responsible for his or her care.

4. The hospital failed to ensure that the Quality Program evaluated nursing services to ensure that all nursing staff had the competencies required to provide safe patient care.

5. The hospital failed to ensure that the Quality Program evaluated medical records to ensure that patient records were accessible at all times.

6. The hospital failed to ensure that the Quality Program evaluated the process of the development and implementation of a patient's plan of care.

7. The hospital's food service department failed to measure, analyze and track quality indicators related to the provision of nutrition services.

These failures had the potential to result in substandard care provided by the facility for a universe of 87 patients and created the possibility of missed opportunities for improvement in care provided to the patients.

Findings:

1a. A review of several of the discharge patient medical records revealed that there were factors identified, such as allegations of abuse and being bullied at school that were not reassessed and addressed at the time of discharge. (Refer to A 821)

A review of the hospital policy titled "Discharge Planning", dated 6/11, revealed that there was no requirement for a reassessment of the discharge plan when factors are identified that may affect the patient's continuing care needs or the appropriateness of the discharge plan.

An interview was conducted with the Director of Case Management (DCM) on 6/15/12 at 11 AM. She confirmed that the policy does allow the discharge planning forms to be updated at anytime; however, the policy did not direct discharge planning staff to reassess the discharge plan when the factors were identified that could affect the patient's continuing care needs or the appropriateness of the discharge plan.

In the same interview, with the DCM and the Director of Performance Improvement (DPI), they were asked if the hospital had conducted a quality review of the discharge planning process. The DCM stated that they had reviewed some elements of discharge planning; however, it would not constitute a reassessment of the discharge planning process. The DPI stated that the discharge planning process was not a scheduled item on the quality roster and confirmed that the quality review was not being done on an on-going basis.

b. The medical records were reviewed for Patients 1, 2 and 3. The facility failed to perform discharge planning for health related conditions such as eating disorders and substance abuse disorders and failed to follow-up on patient complaints of conditions that threatened their well-being, creating a risk of a poor health outcome for those patients (see A818). For one of 1 of 35 sampled patients (Patient 2) the facility failed to ensure that the patient was discharged to a home and that he was safe from access to firearms (see A820).

During an interview with the DPI on 6/13/12 at 2 PM, she stated that the facility reviewed discharge planning only for elements of family contact, a single referral, and a discharge safety plan. She stated that referrals for secondary problems and whether the patient had a home to be discharged to, had not been the subject of quality assurance review.

2a. A review of the list of "Users" for the hospital's automated drug delivery system, PIXIS, was reviewed and compared with a list of active employees on 6/15/12.

The comparison revealed that there were several employees who were active on the PIXIS list that were not on the active employee list.

An interview was conducted with the hospital's Pharmacist on 6/14/12 at 10:15 AM. He stated that there was no updated list and that the pharmacy had not reviewed the employees that were terminated from the hospital, so that their PIXIS access could be removed, since July 2011. He stated that there was no process for Human Resources (HR) to notify pharmacy regarding previous staff members who no longer worked in the hospital. The Pharmacist confirmed that it was his responsibility to ensure the security of medications, especially controlled medications. He acknowledged that the security of medications was an important part of his supervision of pharmaceutical services.

An interview was conducted with the DPI on 6/15/12 at 11 AM. She stated that the hospital had not conducted a review of the contracted pharmacy services.

b. An interview was conducted with Registered Nurse (RN) 2, on Unit 1, on 6/12/12 at 2 PM. She stated that if a medication order was received from a physician for a patient on hours that the pharmacy was not open, the nurse would give the medication if it was available in the PYXIS (automated drug delivery system). She stated that the only time the nurse would call the pharmacist was if the medication was not available.

An interview was conducted with RN 3, on Unit 2, on 6/12/12 at 2:30 PM. She stated that if the physician ordered a medication for a patient when the pharmacy was closed, the nurse gave the medication if it was available. She stated that they would call the Pharmacist, only if the medication was not available. RN 3 was asked if the nurse faxed the order to the Pharmacist for review prior to administration, if it was a first time dose for the patient. She replied "no". She stated that a copy of the order was placed in the medication room and the pharmacy picked up the order the next day.

A review of the hospital's pharmacy policy and procedure manual was conducted on 6/13/12. There was no policy found outlining the process for the Pharmacist to review the first dose of a medication before the medication was given to the patient, except in the event of an emergency.

An interview was conducted with the Pharmacist of the hospital on 6/14/12 at 9 AM. He stated that he did not have a process for the nursing staff to notify him, on hours when the pharmacy was closed (the pharmacy hours are Monday through Friday 6:30 AM to 2 PM and on the weekend, 9 AM to 1 PM), of new medication orders so that he could review the medications prior to the first dose being administered to the patient. He stated that the medication could be held and not given until the next day. The Pharmacist acknowledged that some medications are scheduled to be given at night, so the patient would have to wait over 24 hours before the first dose. The Pharmacist confirmed that supervision of the pharmaceutical services included reviewing a medication prior to the first dose being administered and that making the patient wait for the first dose could be a patient safety concern.

An interview was conducted with the DPI on 6/15/12 at 11 AM. She stated that the hospital had not conducted a review of the contracted pharmacy services.

c. A review of the employee file for the hospital Pharmacist was conducted on 6/18/12. The review revealed that the last performance evaluation of the Pharmacist was conducted on 1/9/09.

An interview was conducted with the Human Resource Director on 6/18/12 at 11 AM. She confirmed that a performance evaluation had not been conducted on the Pharmacist, who provided a contracted service, since 1/9/09.

An interview was conducted with the DPI on 6/15/12 at 11 AM. She stated that the hospital had not conducted a review of the contracted pharmacy services.

3a. A review of the hospital's patient classification system was conducted on 6/12/12. The classification system assigns a numerical value to patients' care needs to assist in assigning nursing personnel in accordance with the patients' needs and the specialized qualifications and competencies of the nursing staff required to provide for the needs.

Several observations and reviews of the patient classification sheet on all of the units of the hospital (Units 1, 2 and 3) were conducted throughout the survey. Nurses were interviewed and were not fully informed regarding the classification system of patients by the patients' needs and the specialized competencies needed by the nurse staff assigned. The record was reviewed for 2 patients (Patients 28 and 44) and the justification for the numeric value assigned to the patients for the level of care needed was not evident by the documentation. The level of care assigned to a patient who was to be discharged was the lowest level with the least amount of time. Interviews with the nursing staff confirmed that a patient who was being discharged required a great deal of care. The staffing grid used by the staffing coordinator had not been approved by the Governing Body. (Refer to A 397)

An interview was conducted with the Chief Nursing Officer (CNO) on 6/14/12 at 2:30 PM. She stated that the patient classification system had not been studied or had a quality review to check the validity of the system. She confirmed that a patient who was ready to be discharged from the facility required a great deal of nursing time. She confirmed that the system was not always used in the way that it was intended. She stated that she thought that the nurses had been trained on using the system; however, she acknowledged that nurses said that they were not familiar with the definition sheet, which guides the process. She acknowledged that patients were not being assigned according to the system that the hospital had in place and that the grid system for nurse staffing was not an approved system.

b. An observation was conducted on 6/12/12 at 10 AM on Unit 2B. The census of the unit was 35 patients.

A review of the patient assignment sheets was conducted. The assignment sheet revealed that 14 of the patients were assigned a nurse.

An interview was conducted with the charge nurse, RN 2, on 6/12/12 at 10 AM. She stated that she only assigned the patients who required an assessment on her shift. RN 2 stated that both RNs take care of all of the patients.

An observation was conducted on 6/12/12 at 10:20 AM on Unit 2B. The census of the unit was 19 patients.

A review of the patient assignment sheets was conducted. The patients were not assigned to any specific nurse.

An observation of the care provided in Unit 3 was conducted on 6/12/12 at 10:45 AM. The census of the unit was 24 patients.

A review of the patient assignment sheets was conducted. The assignment sheet revealed that 8 of the patients were assigned a nurse.

An interview was conducted with the CNO on 6/14/12 at 2:30 PM. She confirmed that each patient should be assigned a nurse responsible for their care. She acknowledged that it was a patient safety issue. She stated that she thought that the patients were being assigned a specific nurse to provide for their care. She stated that the hospital's Quality Program had looked at nurse staffing; however, not at the actual patient assignment.

c. During an interview with the CNO on 6/14/12 at 12:10 PM, she stated that the nurses assigned acuity levels to the patients using an instrument, but that there had been no validation of the instrument to determine its effectiveness. She stated that the instrument had been developed by the Medical Staff, without input from the nursing staff. She stated that after nurses assigned an acuity level to the patients, the number of staff assigned were determined using an acuity grid. She stated that the grid had been in use for at least 7 years, and that there had been no study of whether the nurses were using the grid correctly in planning staffing.

4. A review of three (3) nursing employee files was conducted on 6/18/12. The three nursing files did not contain complete competency evaluations. There were tests taken by the staff to indicate an understanding of the competency, but there were no recorded observations of the staff performing the tasks to ensure that they were competent of the required care tasks.

In an interview on 6/12//12 at 3:15 PM with LPT (Licensed Psychiatric Technician) 1, LPT 1 stated that the nurses administer hand-held nebulizer (a device that delivers medication in a mist form to be inhaled) medications, as there were no respiratory therapists in the hospital. LPT 1 stated that a staff member trained her to use the hand-held nebulizer but that she never had an official in-service training for the hand-held nebulizer.

In an interview on 6/18/12 at 5:45 PM with the Chief Nursing Officer (CNO), she stated that the nursing staff needed to be competent in the following areas: De-escalation (calming an agitated patient), Medical emergencies and Suicide risk assessment. The CNO stated that there had been no training conducted for the use of hand-held nebulizers. The CNO acknowledged that the competency evaluations for the staff were not complete.

An interview was conducted with the DPI on 6/15/12 at 11 AM. She stated that the hospital had not conducted a review of the competency validation of the nursing staff.

5. On 6/12/12 at 3:15 PM Patient 25's record was requested for review.

In an interview on 6/12/12 at 3:20 PM with Administrative Staff 1, she stated that the record was from 2007 (five years ago) and that the record would not be available until the following morning.

A review of the facility policy titled "Closed Medical Record Storage" and with a review date of 3/12 showed the following: "For record requests after business hours, requesting staff must leave a voice message for medical record staff to request the record the next business morning."

In an interview on 6/12/12 at 3:40 PM with the CEO, he acknowledged that the regulation requires access to the medical records at all times for at least five (5) years.

An interview was conducted with the DPI on 6/15/12 at 11 AM. She acknowledged that the hospital had not conducted a review of the medical records service and had not determined that there was a problem with access to the patient's records.















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6. The medical records of Patients 1 and 2 were reviewed on 6/13/12 and showed that the patients had problems for which no care plans had been formulated (see A396) and Patients 2 and 8 had problems that were subjects of care plans, but that the care plans were not fully implemented (see A396).

During interviews on 6/13/12 at 2 PM and on 6/14/12 at 11:30 AM with the DPI, she stated that the facility was not reviewing nursing care plans to see if conditions such as substance abuse or nutritional problems were being addressed, and there was no study of whether care plan goals were being met. She stated that she did chart reviews after discharge only, using a checklist. She stated that the checklist for care plans included only whether a care plan had been formulated for the primary presenting problem, and that it was signed. She stated that she had provided feedback to mental health workers who were not documenting dietary intake.

The hospital policy, Performance Improvement Plan (date effective 12/89), read in part, "Data are systematically collected for improvement priorities and continuing measurement of those processes having the greatest impact on patient care and clinical performance, whether or not problems are suspected. Assessment findings are used to: monitor the performance of processes and systems that affect patient care and organizational outcomes..."







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7. During the survey from 6/12/12 to 6/15/12 deficient practices were observed as it related to the following:

a. Safe food storage and handling practices were not in place when leftover foods were not monitored for safe cooling, the ice machine was not cleaned and sanitized to prevent the build-up of a black/brown residue in the storage bin, the patient refrigerators were not maintained in a sanitary manner, the shelf life of perishable juices were not monitored. (Refer to A 749)

b. The nutrition needs of the patients were not met in accordance to recognized standards of practices when the hospital failed to ensure the menus met the recommended dietary allowances, and the hospital failed to have a system to ensure patients at nutrition risk were assessed and followed by a Registered Dietitian and the nutrition plans of care were being followed. (Refer A 630)

c. The hospital failed to ensure the overall environment was developed and maintained in such a manner that assured the safety and well-being of the patients when the hospital failed to maintain adequate disaster food supplies to meet the needs of the patients and staff in the event of a disaster. (Refer A 701)

A review of the hospital's Performance Improvement (PI) Plan, dated 2/12, revealed that the scope of the plan was to provide a mechanism for measurement and assessment of important processes or outcomes related to patient care and organizational functions. It stated that data was to be systematically collected for improvement priorities and continuing measurement of these processes having the greatest impact on patient care and clinical performance.

During an interview with the Director of Support Services (DSS) on 6/14/12 at 3:00 PM, he stated that the contracted Registered Dietitian (RD) collected data on PI for the food and nutrition services department and submitted it to the PI department. He stated that she maintained the data and analyzed it.

During an interview with the RD on 6/15/12 at 11:15 AM, she stated that she doesn't collect data for the performance indicators that she reported to the PI committee. She stated that she submitted only a summary of practices in the food and nutrition department based on general observations, not on collected data. She was unable to state how she could determine a measurement of improvement without collecting data.

During an interview with the Director of PI on 6/15/12 at 2:40 PM, she stated that she was not aware that the summary information provided to the PI committee by dietary was not data driven. She stated that she depended on the dietary department to collect the data and present the material to the PI committee.

During an interview with the DSS on 6/15/12 at 3:00 PM, he stated that he was not aware that the RD was not collecting data and basing her summary report on that data. He verified that the RD had not been collecting data to measure, track and analyze the dietary quality indicators as they relate to the deficient practices observed during the survey.

Based on interview and record review, the facility failed to conduct routine appraisals of its medical staff because routine peer review was not accomplished. This increased the risk of harm to the patients related to the substandard healthcare provided for all patients using the facility.

Findings:

During a review of medical records on 6/13/12 through 6/16/12, evidence was seen that the hospital physicians failed to provide the expected services to some patients. The physicians were noted to not be in compliance with the medical staff bylaws because the physicians were not completing discharge summaries and the medical record documentation created by the physicians were not complete and accurate for some patients (see A-353).

During an interview with the Medical Director on 6/15/12 at 10:10 AM, he stated that at the time of reappointment, medical staff candidates' credentials were reviewed but no other quality review was done. He stated that peer review was done in response to incidents or issues only and not as part of a routine quality review.

Based on interview and record review, the medical staff failed to follow the Medical Staff Bylaws for 6 of 35 sampled patients (Patients 1, 12, 2, 5, 41, and 22) because:

1. For Patients 1 and 12, the discharge summaries were not completed by the medical staff, and the discharge summaries were incomplete, creating the risk of substandard healthcare for all patients discharged from the facility due to the possibility of inaccurate and incomplete discharge summaries.

2. For Patient 2, the medical staff did not follow-up on an abnormal lab test result, creating the risk of a poor health outcome for Patient 2.

3. For Patient 5, the physician omitted significant information from the medical records of that patient, creating the risk of a poor health outcome for Patients 5.

4. For Patient 1, the physicians omitted information from the psychiatric evaluation, history and physical examination, contributing to the risk of untreated conditions.

5. For Patient 41, the medical staff failed to ensure that the physician responsible for Patient 41 documented that he had evaluated the patient on the day of patient discharge to determine if the patient was still a danger to himself. Patient 41 was on a 14 day hold for being a danger to himself. This failure had the potential for the patient to be discharged from the hospital and cause himself harm including death.

6. For Patient 22, the hospital failed to ensure that the Medical Staff complied with the Bylaws. Patient 22's history and physical (H&P) evaluation was incomplete. This failure created the risk for the patient's history and physical evaluation to not be communicated to all authorized persons involved in the patient's care to ensure continuity of care.

Findings:

1. During an interview with the Medical Director on 6/15/12 at 10:10 AM, he stated that other staff members were completing the discharge summaries for patients leaving the facility, and that the physicians were signing the summaries.

In an interview with the Director of Case Management (DCM) on 6/14/12 at 2:45 PM, she stated that one of the Director of Program Services's (DPS) employees was completing the discharge summary, which was then signed by the physician. She stated that if the physician left information off of the handwritten discharge information form, it was not included on the typed discharge summary.

The discharge summary of Patient 12 was reviewed with the DCM on 6/14/12 at 3:10 PM. She stated that the physician had not included all information regarding patient discharge conditions on the handwritten discharge order, and hence it had not been included on the discharge summary.

During a interview with the Medical Director on 6/15/12 at 10:10 AM, he stated that the discharge summary should include all relevant medical diagnoses, including drug abuse.
He stated that the omissions on the discharge summaries were the physician's responsibility.

The Medical Staff Rules and Regulations, chapter 2, was reviewed, and included the requirement that the medical staff were to complete a discharge summary on each patient.

2. The medical record of Patient 2 was reviewed on 6/13/12 and showed that the patient reported in the admission assessment on 3/22/12 that he was feeling out of control and very anxious. The admitting clinician recorded that he was agitated and irritable. Upon testing at the psychiatrist's order, on 3/23/12, Patient 2 had a lab result of TSH (thyroid stimulating hormone) 0.011 mIU/L (milli-international units per liter) (this value is abnormally low, and suggestive of an abnormally elevated thyroid hormone level). There was no evidence of confirmatory testing or treatment for an elevated thyroid hormone level prior to discharge on 4/5/12.

According to the Medline Plus reference of the National Institute of Health, symptoms of elevated thyroid level (hyperthyroidism) include nervousness, restlessness and difficulty concentrating.

During an interview with the Medical Director on 6/15/12 at 12 PM, he stated that he was unable to find evidence of follow-up of a low TSH for Patient 2 in the medical record, and that the lab value should have been followed up by the physician.

3a. The medical record of Patient 1 was reviewed and her Discharge Summary dated 4/11/12 included a list of "Admitting Diagnoses" from her 4/7/12 admission including major depression with anxiety and suicidal ideation, anorexia and bulimia nervosa, marijuana abuse and alcohol abuse. The "Discharge Diagnoses" included only that of major depression. A review of the medical record did not show evidence that her eating disorders or chemical dependency problems had been resolved during the admission.

b. The medical record of Patient 5 was reviewed and showed an admitting diagnosis of bipolar NOS (not otherwise specified) with psychotic features. The discharge diagnosis was listed as schizoaffective disorder on the discharge summary. The progress notes during the patient's stay indicated that the diagnosis was "unchanged from treatment plan", which indicated bipolar disorder.

The discharge summary of Patient 5 was reviewed with the DPS on 6/15/12 at 9:35 AM, and she stated that the typed discharge summary was dictated by a social worker who culled information from the medical record that the physician then signed.

During an interview with the Medical Director on 6/15/12 at 12 PM, he concurred that there was a discrepancy between the admitting and discharge diagnoses, and stated that the physician should have clarified the change in diagnosis in his chart documentation, but he did not see such clarification in the record.

During a interview with the Medical Director on 6/15/12 at 10:10 AM, he stated that the discharge summary should include all relevant medical diagnoses, including drug abuse.
He stated that the omissions on the discharge summaries were the physician's responsibility.

4. The medical record of Patient 1 was reviewed and showed a pre-printed Psychiatric Evaluation form in which there was a list of possible reasons for admission. However, none of the reasons were indicted for Patient 1, the section was left blank.

Patient 1's History and Physical Evaluation form had a section to record the patient's medical history, but the section was left blank, despite the patient's report of anorexia and bulimia. The section for illegal drugs used indicated only THC (marijuana), while elsewhere in the record multiple substances were listed, including the use of heroin the day prior to admission. The section for Family Medical History contained the note, N/C (noncontributory), despite the fact that elsewhere in the record a history of depression and suicidally in the grandmother were reported.

Further review of Patient 1's medical record showed that she did not receive inpatient treatment or outpatient referrals for anorexia or bulmia, and she did not receive a referral for substance abuse/chemical dependency upon discharge.

The Medical Staff Rules and Regulations section 2.8 specified that the psychiatric evaluation should include, "reason for hospitalization". Section 2.7 specified that the History and Physical Evaluation should include, "sufficient information necessary to provide the care and services required to address the patient's present conditions and needs", and was to include "substance abuse history", and "family medical history".


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5. A review of the medical record for Patient 41 was conducted on 6/14/12. The review revealed that the patient was admitted to the hospital on 2/26/12 with diagnoses that included bipolar disorder and depression.

A review of the physician's psychiatric evaluation, dated 2/26/12 at 6:30 PM, revealed that the patient stated that he, "reported feeling extremely depressed and wanted to commit suicide. He stated that he wanted to shoot himself in the shoulders and bleed to death in front of his family."

A review of the hearing officer's determination regarding the patient's 14 day hold, dated 3/1/12, revealed that the hospital had probable cause to keep the patient because he was a danger to himself.

A review of the physician's progress notes, dated 3/11/12, revealed that the physician documented that the patient, "continues to make threats for self-harm." The physician also documented, "Unresolved risk of self-harm."

A review of the nurse's notes, dated 3/12/12 (the day of discharge) revealed that the nurse documented that the patient's "Assault" assessment was "unpredictable". The nurse also documented, "Pt (patient) anxious, restless, uncooperative, disruptive and overall poor behavior. Pt cursing staff and inciting poor behaviors in peers. Pt depressed and appearing to lose hope."

Further review of the medical record revealed that there was no follow up on the day of discharge, by the physician, regarding the patient's unresolved risk of self-harm.

A review of the physician's "Rules and Regulations" (R&R), approved 3/21/12, revealed that "A progress note shall be recorded at each visit by the Member (of the medical staff) making the visit and dated." The R&R further stated that "At the time of discharge, the attending Member shall complete the discharge according to the approved guidelines, state final diagnosis...and sign the record."

An interview was conducted with the Chief Nursing Officer (CNO) and the Director of Case Management (DCM) on 6/18/12 at 9 AM. They confirmed that the physician did not document on the day of discharge. The DCM confirmed that the physician's last documentation on the day prior to discharge stated that the patient still had a risk of self harm and that the physician was required to evaluate the patient prior to discharge for a risk of self harm.






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6. On 6/14/12, the Medical Staff Rules and Regulations were reviewed. It indicated that within 24 hours of admission, the complete physical examination shall be performed.

On 6/14/12, a review of Patient 22's medical record was conducted.

A review of the face sheet revealed that the patient was admitted to the hospital on 4/4/12, with diagnoses that included bipolar disorder. Patient 22 was discharged on 4/6/12.

A review of the History and Physical (H&P), dated and signed by the physician on 4/5/12, was conduced and revealed that the four page H&P was blank on pages two and three.

On 6/15/12 at 2:30 PM, the Director of Program Services reviewed the patient's H&P evaluation and confirmed the documentation was incomplete. She stated the evaluation should have been completed by the physician.

Based on interview and record review, the hospital failed to ensure that the nursing services were well organized to meet the needs of all patients by failing to:


1. Develop a policy regarding a current facility practice pertaining to patients who were at a risk for harming themselves. This practice was called "Contracting for Safety" by the facility. (Refer to A-0386)

2. Ensure that the nursing staff had competency evaluations for the tasks that were needed for patient care. (Refer to A-0386)

3. Ensure that the patients' treatment plan goals were documented and met. The hospital further failed to ensure that the patients' suicide risk assessments were accurate. (Refer to A-0395)

4. Ensure that a patient was monitored after a new medication was administered to the patient to ensure that the patient was protected from injury due to a potential fall. (Refer to A-0395)

5. Ensure that the nurse notified the physician that the patient was "verbally threatening assault" prior to discharge. (Refer to A-0395)

6. Ensure that the patients' Nutrition Risk Screens were accurately completed by the nursing staff. (Refer to A-0395)

7. Ensure that the physician was notified of the patients' significant weight changes. (Refer to A-0395)

8. Ensure that the treatment plan for a patient was kept current when the patient sustained a second fall, there were no new interventions or an evaluation of the treatment plan to prevent further falls. (Refer to A-0396)

9. Ensure that the nursing care of each patient was assigned in accordance with the patient's needs and the specialized qualifications of the nursing staff. The hospital also failed to ensure that each patient was assigned to a member of the nursing staff on each shift, that the hospital's patient classification system provided accurate information that was used to ensure nursing care assignments were made to meet each patient's needs. (Refer to A-0397)

10. Ensure that all drugs were given in accordance with a physician's order for a medication. (A-0405)

The cumulative effect of these systemic problems resulted in the hospital's failure to deliver patient care in a safe manner and in compliance with the Condition of Participation for Nursing Services.

Based on interview and record review the hospital failed to have an organized nursing service as evidenced by:

1. The hospital's failure to develop a policy regarding a current facility practice pertaining to patients who were at a risk for harming themselves. This practice was called "Contracting for Safety" by the facility.

2. The hospital's failure to ensure that the nursing staff had competency evaluations for the tasks that were needed for patient care.

For a universe of 87 patients, these failures had the potential to contribute to the increase risk of patient harm related to patients who verbally agree to not harm themselves and still have the intent to do otherwise as well as patients who receive care from a nursing staff that may not be adept in providing the necessary care required by the patients.

Findings:

1. On 6/12/12 through 6/14/12 several patient medical records were reviewed. On the nursing "Suicide Risk Assessment" a number for the patient's risk was assigned. On many of the record a hand written note was observed that stated "Contract for Safety." A review of the medical records revealed that there was no document that discussed further the contract for safety.

An interview was conducted with the Chief Nursing Officer (CNO) on 6/15/12 at 10 AM. When the CNO was asked to define/explain what was "Contract for Safety". She responded that contract for safety was when the patient gives the nurse a verbal agreement that they will not attempt to hurt themselves. Given this agreement, even if the patient's suicide risk assessment number was high, the patient was assessed to require less monitoring. The CNO stated that the nurse asked for the verbal contract from the patient upon admission, during the patient's suicide risk assessment; however, the CNO stated that often the patients have repeated their story to the police, the staff in the emergency room and the intake staff at the hospital. She stated that the patient may be tired at that time and may just agree to contract for safety, so they can get some sleep.

During the same interview, the CNO was asked if the hospital had a policy related to the "Contract for Safety" and she stated that they did not have a policy to direct staff on how and when to ask the patient regarding contracting for safety.



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2. A review of three (3) nursing employee files was conducted on 6/18/12. The three nursing files did not contain complete competency evaluations. There were tests taken by the staff to indicate an understanding of the competency, but there were no recorded observations of the staff performing the tasks to ensure that they were competent of the required care tasks.

In an interview on 6/12/12 at 3:15 PM with LPT (Licensed Psychiatric Technician) 1, LPT 1 stated that the nurses administer hand-held nebulizer (a device that delivers medication in a mist form to be inhaled) medications, as there were no respiratory therapists in the hospital. LPT 1 stated that a staff member trained her on how to use the hand-held nebulizer but that she never received an official in-service training for the hand-held nebulizer.

In an interview on 6/18/12 at 5:45 PM with the CNO, she stated that the nursing staff needed to be competent in the following areas: De-escalation (calming an agitated patient), Medical emergencies and Suicide risk assessment. The CNO stated that there had been no training conducted for the use of hand-held nebulizers. The CNO acknowledged that the competency evaluations for the staff were not complete.

Based on interview and record review the hospital failed to ensure that an RN supervised and evaluated the nursing care for 10 of 35 sampled patients (Patient 36, 40, 41, 28, 29, 43, 1, 30, 32, 34).

For Patients 36, 40, 41, 28, 29 and 43 the hospital failed to ensure that the treatment plan goals were documented and met. The hospital further failed to ensure that the patients' suicide risk assessments were accurate. These failures had the potential (1) to contribute to substandard nursing care provided to the patients, (2) for patients to be discharged from the facility without meeting their treatment goals and (3) for patients to not have the care necessary for safety related to their suicide risk.

For Patient 40 the hospital failed to ensure that the patient was monitored after a new medication was administered to the patient to ensure that the patient was protected from a potential injury due to a potential fall. This may have contributed to the patient hitting his forehead on the floor.

For Patient 28, the hospital failed to ensure that the nurse notified the physician that the patient was "verbally threatening assault" prior to discharge. This failure had the potential to result in harm to the patient or to others after the patient's discharge

For Patients 1, 32 and 34, the hospital failed to ensure that the nursing staff accurately completed the Nutrition Risk Screens.

For Patients 32 and 30, the hospital failed to ensure that the physician was informed of the patients' significant weight changes.

Findings:

1. A review of Patient 36's record on 6/14/12 showed that the patient was admitted to the hospital on 11/25/11 with diagnoses that included recurrent depression, alcohol dependency and suicide attempt. The patient was discharged from the hospital on 11/27/11.

A review of the treatment plan showed the following goals:

Patient will develop aftercare plan for finding assistance for self-harm feelings/impulses. Date resolved: 11/27/11
Patient will learn two coping skills. Date resolved: 11/27/11
Patient will identify trigger to self-harm. Date resolved: 11/27/11

There was no clear documentation in the patient's record of how Patient 36 met the treatment plan goals.

In an interview on 6/15/12 at 10:00 AM with the Chief Nursing Officer (CNO), she acknowledged that there should be documentation in the record of how the patient met the treatment plan goals.

2. A review of Patient 40's record on 6/15/12 showed that the patient was admitted to the hospital on 3/18/12 with a diagnosis of schizophrenia, chronic, paranoid type (a psychiatric condition characterized by gross distortion of reality, disturbances of language and communication, withdrawal from social interaction and disorganization and fragmentation of thought, perception and emotional reaction). The patient was discharged from the hospital on 3/27/12.

A review of the treatment plan showed the following goals for a fall risk:

Patient will follow medical recommendations. Date resolved: 3/27/12.
Patient will verbalize identified hazards in living environment. Date resolved: 3/27/12

There was no clear documentation in the record of how Patient 40 met the treatment plan goals.

In an interview on 6/15/12 at 10:00 AM with the CNO, she acknowledged that there should be documentation in the record of how the patient met the treatment plan goals.

3. A review of Patient 36's record on 6/14/12 showed that the patient was admitted to the hospital on 11/25/11 with diagnoses that included recurrent depression, alcohol dependant and suicide attempt. The patient was discharged from the hospital on 11/27/11.

A review of the Suicide Risk Assessment showed that if the score was 0-7 the suicide risk was low and that the patient may be placed on routine every 15 minute observations and monitored for any change of status. If the score was 8-14 the suicide risk was moderate and the patient was to be monitored every 15 minutes for safety and initiate the risk for self harm treatment plan. If the score was 15-29 the suicide risk was high and the patient was to be evaluated for 1 on 1 monitoring (a staff member would be continuously watching the patient) and initiate the suicide precautions treatment plan.

Further review of the Suicide Risk Assessment showed that Patient 36 was scored by the nurse as a "7" which indicated that the patient was a low suicide risk. Even though the reason the patient was hospitalized was due to a suicide attempt.

In an interview on 6/15/12 at 9:00 AM with the Chief Nursing Officer, she acknowledged that the patient's suicide attempt should have been taken into account when assessing the patient for suicide risk.

4a. A review of Patient 40's record on 6/15/12 showed that the patient was admitted to the hospital on 3/18/12 with diagnosis that included schizophrenia, chronic, paranoid type (a psychiatric condition characterized by gross distortion of reality, disturbances of language and communication, withdrawal from social interaction and disorganization and fragmentation of thought, perception and emotional reaction) and a suicide attempt. The patient was discharged from the hospital on 3/27/12.

A review of the Suicide Risk Assessment showed that if the score was 0-7 the suicide risk was low and that the patient may be placed on routine every 15 minute observations and monitored for any change of status. If the score was 8-14 the suicide risk was moderate and the patient was to be monitored every 15 minutes for safety and initiate the risk for self harm treatment plan. If the score was 15-29 the suicide risk was high and the patient was to be evaluated for 1 on 1 monitoring (a staff member would be continuously watching the patient) and initiate the suicide precautions treatment plan.

Further review of the Suicide Risk Assessment showed that Patient 40 was scored by the nurse as a "1" which indicated that the patient was a low suicide risk. Even though the reason the patient was hospitalized was due to a suicide attempt.

In an interview on 6/15/12 at 1:45 PM with the Chief Nursing Officer, she acknowledged the suicide risk assessment did not take into account the reason for the patient's admission and recent past behavior and should be considered when assessing for suicide risk.

b. A review of Patient 40's record on 6/15/12 showed that the patient was admitted to the hospital on 3/18/12 with a diagnosis of schizophrenia, chronic, paranoid type (a psychiatric condition characterized by gross distortion of reality, disturbances of language and communication, withdrawal from social interaction and disorganization and fragmentation of thought, perception and emotional reaction).

A review of a Patient Fall Progress Note, dated 3/20/12 and timed 9:00 PM, indicated that Patient 40 was found on the floor in the hallway asleep. The Patient Fall Progress Note further indicated that the patient was easily awakened, appeared drowsy and was able to follow directions. There was no apparent injury.

A treatment plan for Fall Risk was initiated on 3/20/12, the night that the patient was found on the floor. The documented reason for the fall risk was "Drugs that alter LOC (level of consciousness) or behavior - Seroquel (an antipsychotic medication that can cause drowsiness) increased to 800 mg (milligrams)." Under the short-term goals was the instruction to "Monitor patient after administration of new medication."

A review of a Patient Fall Progress Note dated 3/23/12 and timed 9:15 PM indicated that Patient 40 was "asleep on chair and fell forward, according to peer." The patient had "pink to red small area on forehead."

The two falls occurred during the same time in the evening, approximately half (1/2) an hour after Seroquel was given to the patient.

There were no new interventions to prevent falls on the treatment plan or evidence that the treatment plan was evaluated for effectiveness in preventing patient falls.

In an interview on 6/15/12 at 1:45 PM with the CNO (Chief Nursing Officer), the CNO acknowledged that the treatment plan for Patient 40 should have been evaluated and updated to reflect the second fall.



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5. A review of the medical record for Patient 28 was conducted on 6/13/12. The review revealed that the patient was admitted to the hospital on 4/19/12 with diagnoses that included depression.

A review of the physician's discharge summary, dated 5/3/12, revealed that on admission, the patient stated, "I wanted to kill myself. I can't stop it." The physician also documented that the patient was stating suicidal ideations and was not able to contract for safety.

A review of the physician's progress notes on the day prior to discharge, 4/26/12, revealed that "the patient has been expressing active thoughts of how she is going to hurt herself..." The physician further documented, "This patient continues to be gravely disabled and a danger to self and danger to others."

A review of the physician's orders revealed an order written on 4/27/12 for the patient to discharge home. There was an entry by the physician under the area for "Mental Status at Discharge" that was not legible. There were no other physician progress notes on the day of discharge.

A review of the nurse's assessment on the day of discharge, 4/27/12, revealed that the nurse documented that the patient was "Verbally threatening assault." There was no documentation that the nurse notified the physician that the patient was threatening assault or other documentation regarding the patient's threats.

A review of the discharge plan, dated 4/27/12, revealed that the patient was discharged to a group home. There was no documented evidence that the group home was notified of the patient's threats or that the issue was addressed in the discharge plan.

An interview was conducted with the Director of Case Management (DCM) on 6/14/12 at 9 AM. She confirmed that the nurse documented that the patient had verbally threatened assault on the day of discharge and that there was no documentation that the nurse notified the physician or the case manager of the threat. The DCM confirmed that there was no documentation regarding the patient's threat of assault at discharge and that the patient had documented safety concerns on the day prior to discharge.

6a. A review of the medical record for Patient 41 was conducted on 6/14/12. The review revealed that the patient was admitted to the hospital on 2/26/12 with diagnoses that included bipolar disorder and depression.

A review of the 72 hour hold that was completed by the police department, dated 2/25/12, revealed that the patient was having suicidal thoughts and thoughts of killing his family.

A review of the intake information from the hospital, dated 2/26/12, revealed that the patient had a plan to shoot himself in the shoulders and bleed to death.

A review of the phychiatric evaluation, dated 2/26/12, revealed that the patient wanted to shoot himself in the shoulder and bleed to death in front of his family.

A review of the nursing suicide risk assessment, dated 2/26/12, revealed that the patient rated a 0 on the scale (with 0 being the lowest risk and 29 being the highest risk). Further review of the risk assessment revealed that a number 0 was the lowest risk patient and required the least amount of monitoring by nursing.

b. A review of the medical record for Patient 28 was conducted on 6/13/12. The review revealed that the patient was admitted to the hospital on 4/19/12 with diagnoses that included depression.

A review of the intake information from the hospital, dated 4/19/12, revealed that the patient "has been scratching self and attempting to burn self."

A review of the physician's discharge summary, dated 5/3/12, revealed that the patient was admitted on 4/19/12 on a 72 hour hold for being a danger to herself. The physician documented that the patient stated, "I wanted to kill myself. I can't stop it."

A review of the nursing suicide risk assessment, dated 2/26/12, revealed that the patient rated a 7 on the scale (with 0 being the lowest risk and 29 being the highest risk). Further review of the risk assessment revealed that a number 7 was a low risk patient and required the least amount of monitoring by nursing.

c. A review of the medical record for Patient 29 revealed that she was admitted to the hospital on 3/28/12 with diagnoses that included major depression.

A review of the intake information from the hospital, dated 3/28/12, revealed that the patient was on a 72 hour hold for "having thoughts of harming herself by cutting or overdose on pills."

A review of the physician's discharge summary, dated 4/4/12, revealed that the patient was admitted for "being a danger to herself with thoughts of wanting to hurt herself and cut herself." The physician documented that the patient did cut herself in the abdomen.

A review of the nursing suicide risk assessment, dated 3/28/12, revealed that the patient rated a 4 on the scale (with 0 being the lowest risk and 29 being the highest risk). Further review of the risk assessment revealed that a number 4 was a low risk patient and required the least amount of monitoring by nursing.

d. A review of the medical record for Patient 43 was conducted on 6/14/12. The review revealed that the patient was admitted to the hospital on 3/28/12 with diagnoses that included bipolar disorder (extreme mood swings from mania to severe depression).

A review of the intake information, dated 3/28/12, revealed that the patient, "was running into traffic and threatening staff (at his group home), aggressive, confrontational, jumped onto the hood of a moving vehicle."

A review of the phychiatric evaluation, dated 3/29/12, revealed that the patient, "was running into traffic and threatening staff."

A review of the nursing suicide risk assessment, dated 3/29/12, revealed that the patient rated a 0 on the scale (with 0 being the lowest risk and 29 being the highest risk). Further review of the risk assessment revealed that a number 0 was the lowest risk patient and required the least amount of monitoring by nursing.

An interview was conducted with the Chief Nursing Officer (CNO) on 6/15/12 at 10 AM. She acknowledged that the suicide risk assessments did not match the other suicide risk information contained in the record. The CNO stated that when the nurse did their suicide risk assessment many of the patients have repeated their story to the police, the staff in the emergency room and the intake staff at the hospital. She stated that the patient may be tired at that time and may say anything, so they can get some sleep. The CNO stated that the suicide risk assessment did provide a basis for the level of care that the patient received and so it should include the all of the information regarding the patient's risk for self harm.

7a. A review of the medical record for Patient 41 was conducted on 6/14/12. The review revealed that the patient was admitted to the hospital on 2/26/12 with diagnoses that included bipolar disorder and depression.

A review of the treatment plan problem sheets, dated 2/25/12, 2/26/12 and 3/7/12 revealed the following goals for the patient:

2/25/12 - Patient will identify triggers to self harm
2/26/12 - Patient will identify triggers to substance abuse
3/7/12 - Patient will identify stressors precipitating aggressive behaviors

All of the goals were dated resolved on the day of discharge, 3/12/12.

Review of the treatment team notes, the nursing notes, the physician progress notes, the group meeting notes, and the case management notes for the patient's hospitalization revealed no mention of the patient identifying triggers or stressors.

b. A review of the medical record for Patient 28 was conducted on 6/13/12. The review revealed that the patient was admitted to the hospital on 4/19/12 with diagnoses that included depression.

A review of the treatment plan problem sheets, dated 4/22/12 revealed the following goals for the patient:

Patient will utilize calming strategies to cope with stressful events

The goals was dated resolved on the day of discharge, 4/27/12.

Review of the treatment team notes, the nursing notes, the physician progress notes, the group meeting notes, and the case management notes for the patient's hospitalization revealed no mention of the patient's ability to use calming strategies to cope with stressful events.

c. A review of the medical record for Patient 29 revealed that she was admitted to the hospital on 3/28/12 with diagnoses that included major depression.

A review of the treatment plan problem sheets, dated 3/28/12 revealed the following goals for the patient:

Patient will identify triggers to self harm feelings
Patient will identify triggers to substance abuse

All of the goals were dated resolved on the day of discharge, 3/30/12.

Review of the treatment team notes, the nursing notes, the physician progress notes, the group meeting notes, and the case management notes for the patient's hospitalization revealed no mention of the patient identifying triggers.

An interview was conducted on 6/15/12 at 10:00 AM with the CNO. She acknowledged that there was no documented evidence of how the goals were met by the patients. She stated that there should be documentation in the record of how the patient met the treatment plan goals.

d. A review of the medical record for Patient 43 was conducted on 6/14/12. The review revealed that the patient was admitted to the hospital on 3/28/12 with diagnoses that included bipolar disorder (extreme mood swings from mania to severe depression).

A review of the treatment plan problem sheets, dated 3/28/12, revealed the following goals for the patient:

Patient will not assault peers or staff for 0 consecutive hours/days
Patient will not verbally lash out/threaten others for 0 days
Patient will seek staff counseling, prior to lashing out towards others for 0 days

An interview was conducted with the Director of Case Management (DCM) on 6/14/12 at 2:55 PM. She confirmed that the goals should have been set for a specific amount of time, not 0 time. She stated that the goals did not mean anything for the patient because they were for 0 amount of time.





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8a. A review of the medical record for Patient 1 revealed that the patient was admitted to the hospital on 4/7/12 with a history of eating disorder. A review of the psychiatric evaluation dated 4/7/12 stated, "The patient stated that her eating disorder is out of control." A review of the Point of Contact Assessment dated 4/7/12 stated, "appetite - eating disorder; reduced weight 15 - 20 pounds in 2 months." A review of the Nutritional Risk Screen on the initial Nursing Assessment form showed that no nutrition risk factors were identified on the screen. No nutrition assessment was completed.

b. A review of the medical record for Patient 32 revealed that the patient was admitted to the hospital on 6/4/12. A review of the History and Physical dated 6/4/12 revealed a medical diagnosis of partial edentulous (the patient was missing some teeth). The Nutrition Risk Screen on the initial Nursing Assessment showed no nutrition risk factors identified, including no chewing problems. Also noted was a physician order dated 6/4/12 for a soft mechanical (easy to chew) diet and a dentist, routine exam. No nutrition assessment was completed.

c. A review of the medical record for Patient 34 revealed that the patient was admitted to the hospital on 6/8/12 with medical diagnoses which included Type 1 Diabetes (a lifelong disease in which there are high levels of sugar in the blood) maintained on insulin (a medicine to help control levels of sugar in the blood). A review of the Nutrition Risk Screen on the Nursing Assessment indicated that the patient was on a "special diet". The boxes labeled "Diabetes" and "on insulin" were not checked. The boxes should have been checked to indicate nutrition risk factors requiring a referral to the physician for a potential nutritional consult. The referral to the physician was not made and a nutritional consult was not ordered. No nutrition assessment was completed.

A review of the hospital's policy titled, "Multidisciplinary Admission Assessment Procedure" date 2/11 revealed that the policy was to obtain a full and accurate multidisciplinary database on every patient. It stated that the purpose was to provide guidelines for assessment and referral. For the Nutrition Risk Assessment, it stated that the Registered Nurse will identify and document patients at nutritional risk by utilizing the Nutrition Risk Screen. Indicators of nutrition risk included: eating binges/purges/anorexia, diabetes, weight loss/gain, and chewing, swallowing/denture edentulous. It stated that if any risk factors were checked, including eating binges/purges/anorexia or weight loss/gain, the patient was to be referred to the physician for a potential nutritional consult.

During an interview with the Chef Nursing Officer (CNO) on 6/15/12 at 9:30 AM, she verified that the Nutrition Risk Screens for Patients 1, 32 and 34 were not accurate and referrals to the physician and the RD were not made. She verified that the physician should have been asked for a nutritional consult for Patient 1 for eating disorder, for Patient 32 for chewing problems and for Patient 34 due to her diagnosis. These referrals were not made.

During an interview with the CEO and the Director of Support Services (DSS) on 6/14/12 at 2:30 PM, they verified that the current system of determining which patients need to have a nutritional assessment "needs some work." They verified that patients who would benefit from nutrition assessment and follow up were not being assessed by the RD.

8. A review of the medical record for Patient 32 revealed that the patient was admitted to the hospital on 6/4/12. A review of the patient's Vital Signs record showed the patient's admit weight on 6/4/12 was 153 pounds. Five days later, on 6/9/12, the patient's weight was recorded as 158 pounds. There was no documentation in the medical record that the physician or the RD were informed of the 5 pound weight gain in 5 days. A review of the Interdisciplinary Treatment Plan did not address the weight change.

During an interview with the Charge Nurse for Patient 32 on 6/13/12 at 11:15 AM, he stated that the physician should have been notified of the patient's significant weight gain. He verified that there was documentation that the physician was notified. At 11:30 AM the Charge Nurse stated that the patient had been re-weighed and remained at 158 pounds.

A review of the medical record for Patient 30 revealed that the patient was admitted to the hospital on 6/6/12 with medical diagnoses which included an eating disorder. A review of the Vital Signs form showed a weight on 6/6/12 of 153 pounds and 6/9/12 of 149 pounds. This was a 4 pound weight loss in 3 days. A review of the Interdisciplinary Treatment Plan did not address the weight change or the eating disorder.

During an interview with the CNO on 6/15/12 at 9:45 AM, she verified that the physicians were not informed of the patients' significant weight changes. She verified that the physicians should have been notified of the significant weight changes in these patients.

Based on interview and record review the hospital failed to keep current a treatment plan for 4 of 35 sampled patients (Patients 40, 1, 2 and 8). When Patient 40 sustained a second fall, there were no new interventions or an evaluation of the treatment plan to prevent further patient falls. The facility did not ensure that care plans were initiated for Patient 1 who had an eating disorder. For Patients 1 and 2, there were no care plans initiated for the substance abuse disorders. Care plans were not initiated for falls and seizure precautions for Patient 2. For Patient 8, not all of the elements of the care plan were reassessed, creating the risk of poor health outcomes for those patients due to untreated health problems.

Findings:

1. A review of Patient 40's record on 6/15/12 showed that the patient was admitted to the hospital on 3/18/12 with a diagnosis of schizophrenia, chronic, paranoid type (a psychiatric condition characterized by gross distortion of reality, disturbances of language and communication, withdrawal from social interaction and disorganization and fragmentation of thought, perception and emotional reaction).

A review of a Patient Fall Progress Note dated 3/20/12 and timed 9:00 PM indicated that Patient 40 was found on the floor in the hallway, asleep. The Patient Fall Progress Note further indicated that the patient was easily awakened, appeared drowsy and was able to follow directions. There was no apparent injury.

A treatment plan for Fall Risk was initiated on 3/20/12 the night the patient was found on the floor. The documented reason for the fall risk was "Drugs that alter LOC (level of consciousness) or behavior-Seroquel (an antipsychotic medication that can cause drowsiness) increased to 800 mg (milligrams)."

A review of a Patient Fall Progress Note dated 3/23/12 and timed 9:15 PM indicated that Patient 40 was "asleep on chair and fell forward, according to peer." The patient had "pink to red small area on forehead."

There were no new interventions to prevent falls on the treatment plan or evidence that the treatment plan was evaluated for effectiveness in preventing falls.

In an interview on 6/15/12 at 1:45 PM with the CNO (Chief Nursing Officer), the CNO acknowledged that the treatment plan for Patient 40 should have been evaluated and updated to reflect the second fall.

A review of a hospital policy titled, "Treatment Plan Protocol" and with a revision date of 5/11 showed the following: "Daily team collaboration may be documented on the Daily Treatment Plan/Assessment form. The RN (Registered Nurse) will complete the Plan/Assessment and coordinating disciplines will record update(d) information, as applicable."



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2. The medical record of Patient 1 was reviewed on 6/13/12. The initial assessment included a history of polysubstance abuse (abuse of multiple substances), with heroin use the day prior to admission by Patient 1 and a report of anorexia and bulimia (eating disorders) with a 20 pound weight loss in the two months prior to admission. The nursing assessment for Patient 1 was reviewed, and did not identify Patient 1 as having an eating disorder or substance abuse problem.

During an interview with the Director of Program Services (DPS) on 6/13/12 at 8:40 AM, she concurred that Patient 1 had not been identified by the nurse as having an eating and substance abuse disorders.

3. The medical record of Patient 2 was reviewed on 6/13/12, and showed that the patient had a history of chemical dependency. The care plans were reviewed, and there was no care plan for chemical dependency for Patient 2. The medical record also showed that the patient had a history of seizures and falls. The patient flow sheet for Patient 2 was reviewed and there was no indication on the flow sheets that the patient needed to be observed for risk of falls or seizures.

During an interview with the DPS on 6/13/12 at 2 PM, she reviewed the record of Patient 2 and stated that she would have expected a treatment plan for chemical dependency. She also stated that she would have expected the categories for falls and seizure precautions to be circled on the flow sheets. She stated that circling of the conditions for which the patient was at risk for was part of the hospital's policy for preventing falls and seizures.

4. The medical record of Patient 8 was reviewed on 6/14/12 and showed that the patient had a significant substance abuse problem. A care plan goal included that the patient be able to identify triggers to chemical dependency/substance abuse. The goal was marked "resolved 3/23/12", the date that the patient left against medical advice. The progress and treatment notes were reviewed, and there was no documentation that the patient identified triggers prior to leaving the facility.

The Director of Performance Improvement (DPI) reviewed the medical record of Patient 8 on 6/14/12 at 11:30 AM and concurred that there was no documentation that the care plan goal regarding identifying triggers had been met, and she did not know why it was listed as "resolved". She stated that follow-up of care plans was done at the time of the interdisciplinary treatment plan meeting, which was held weekly by the physician. She concurred that since the average length of stay was 3-5 days, and the treatment team did not always meet to follow-up on the care plans prior to the patients leaving the facility.

Based on observation, interview and record review, the hospital failed to ensure that the nursing care of each patient was assigned in accordance with the patient's needs and the specialized qualifications of the nursing staff. The hospital failed to ensure that each patient was assigned to a member of the nursing staff on each shift, that the hospital's patient classification system provided accurate information that was used to ensure assignments were made to meet each patient's needs, that mental health workers (MHW) were assigned so they had the ability to complete the every 15 minute patient safety checks and that specific staff members were assigned to respond to emergency health crisis situations. These failures had the potential to result in patient's needs not being met and potential to contribute to patient harm.

Findings:

1a. An observation was conducted on 6/12/12 at 10 AM on Unit 1. The census of the unit was 35 patients.

A review of the patient assignment sheets was conducted. The assignment sheet revealed that 14 of the patients were assigned a nurse.

An interview was conducted with the charge nurse RN 2 on 6/12/12 at 10 AM. She stated that she only assigned the patients who required an assessment on her shift. RN 2 stated that both RNs take care of all of the patients.

b. An observation was conducted on 6/12/12 at 10:20 AM on Unit 2B. The census of the unit was 19 patients.

A review of the patient assignment sheets was conducted. The patients were not assigned to any specific nurse.

An interview was conducted with the charge nurse of the unit, Registered Nurse (RN) 3 on 6/12/12 at 10:45 AM. She stated that there was one RN assigned to the unit and one RN assigned as a float between Unit 2B and Unit 2A. She was asked how they determined who was responsible for the care of any given patient and she responded, "we both take care of any patient". She confirmed that there was no documented evidence of which nurse was assigned to which patient.

c. An observation of the care provided in Unit 3 was conducted on 6/12/12 at 10:45 AM. The census of the unit was 24 patients.

A review of the patient assignment sheets was conducted. The assignment sheet revealed that 8 of the patients were assigned a nurse.

An interview was conducted with the Director of Program Services (DPS) on 6/12/12 at 11 AM. She stated that there were 2 RNs on the unit. She stated that the nurses only assign patients who are due for an assessment that shift. The DPS stated that all of the nurses help to take care of all of the patients. She confirmed that all patients needed to be assigned a specific nurse who takes the responsibility for each patient. She acknowledged that the assignment of nurses to be responsible for the care of patients helps ensure patient safety.

2a. An observation was conducted on 6/12/12 at 10:20 AM on Unit 2B. The census of the unit was 19 patients.

A review of the patient assignment sheets was conducted. There was one mental health worker (MHW) to cover the needs of the 19 patients.

A review of the assignments for the MHW included rounds (every 15 minute checks on patients for location, activity, behavior, and if sleeping required observation for breathing), goals/closure groups/concern log, supply/snack ordering, contraband checks, and assistance with visitors.

An observation was conducted of MHW 1 on 6/12/12 at 10:25 AM. The MHW was cleaning a patient bed. He was asked what were his responsibilities in the unit. MHW 1 stated that he was responsible for every 15 minute checks, doing daily contraband checks which included checking all belonging and patient areas, doing group in the morning, cleaning beds and rooms of patients that have been discharged, monitoring patient behaviors and monitoring patients during patio smoking breaks. He was asked what the process was when he could not complete the every 15 minute rounds and he stated "someone else does it." He confirmed that there was no standardized method for observations to be conducted while he performed other duties. He confirmed that the every 15 minute checks of patients takes up most of his time.

b. An observation was conducted on 6/12/12 at 10:20 AM on Unit 2A. The census of the unit was 13 patients.

A review of the patient assignment sheets was conducted. There was one mental health worker (MHW) to cover the needs of the 13 patients.

A review of the assignments for the MHW included rounds (every 15 minute checks on patients for location, activity, behavior, and if sleeping required observation for breathing), activity of daily living forms, goals/closure groups/concern log, supply/snack ordering, patient fridge checks, contraband checks, assistance with visitors, patient meals, and taking patients blood pressures.

An observation was conducted at the same time. The survey team was in the nurse's station for 25 minutes and the MHW for Unit 2A was sitting with a new patient and assisting to the new patient's needs for the 25 minute period of time.

c. An observation was conducted on 6/12/12 at 10:20 AM on Unit 2A. The census of the unit was 13 patients.

A review of the patient assignment sheets was conducted. There was one mental health worker (MHW) and a licensed phychiatric technician (LPT) on duty. The MHW was assigned to a patient for 1 to 1 observation. The LPT was assigned to the every 15 minute rounds, activity of daily living forms, goals/closure groups/concern log, supply/snack ordering, contraband checks, assistance with visitors, patient meals, and taking patients blood pressures.

d. A review of the last 2 weeks of patient care assignments was conducted on 6/13/12. The review revealed a similar pattern of assignments for each day of the two (2) weeks.

e. On 6/13/12 from 10:35 AM to 11 AM an observation was conducted on Unit 1 in hallway B. Two (2) survey team members were either at the desk or in the hallway for the period of time. There were patients in 2 rooms, asleep, within hallway B. The observation revealed that there were no staff members that went into the patient's rooms during the 25 minute period of time.

An interview was conducted with the Chief Nursing Officer (CNO) on 6/13/12 at 2 PM. She stated that if a patient was asleep in the room, the person doing the every 15 minute checks would have to go into the room and observe the patient at arms length, to ensure that the patient was breathing. She acknowledged that the assignment sheets did not provide for coverage for the every 15 minute checks when the MHWs were busy doing other tasks.

In a follow up interview with the CNO on 6/14/12 at 2:30 PM. The CNO stated that the person doing every 15 minute checks should not have other duties. She stated that the every 15 minute checks take all of the staff's time.

3. A review of the hospital's patient classification system was conducted on 6/12/12. The classification system gives patient care needs a numerical value to assist in assigning nursing personnel in accordance with the patient's needs and the specialized qualifications and competence of the nursing staff.

An observation was conducted on 6/12/12 at 10:20 AM on Unit 2A. The census of the unit was 13 patients. The patient care assignment sheets were reviewed along with the patient classification sheets.

The patient care assignment sheets revealed that under the area for patient assignments the word "all" was written.

An interview was conducted with the charge nurse of the unit, RN 4, on 6/12/12 at 10:30 AM. She stated that there was another RN on the unit that was a float RN between Unit 2A and 2B. She stated that she did not assign patients to this RN. RN 4 was not able to explain why she assigned all of the patients to herself. She was asked about the patient classification system that was used by the hospital and she stated "All the patients on this floor are a 2." She was asked how she did the patient classification system to help ensure that patient care was assigned according to patient need. She stated that most patients were a 2 if they required minimal assistance and they would be a 3 if they required more help. RN 4 was asked if she used the hospital's definition sheet for the classification system and she stated "no." She was asked if the definition sheet was on the unit for reference and she stated that she did not know. RN 4 looked for the definition sheet and she was not able to find it on either Unit 2A or 2B.

An interview was conducted with the staffing coordinator (SC) on 6/12/12 at 11:45 AM. He stated that the nursing staff fill out the patient needs sheet every shift and send it to him. He stated that he takes the numbers and uses a "grid" to determine staffing needs. The SC stated that the staffing was done by numbers of patients, not by the patient care needs numbers, most of the time.

A review of the staffing grid was conducted. The staffing grid had numbers of staff that were not whole numbers (such as 6.5 staff). In the same interview, the SC was asked how .5 of a person was accomplished. He stated that they have a staff person for half of the shift.

A review was conducted of the hospital policies titled "Assignment of Personnel", dated 2/12 and the policy "Nurse Staffing Acuity", dated 2/12, and neither policy mentioned the staffing grid.

An interview was conducted with the CNO on 6/13/12 at 2 PM. She confirmed that the staffing grid was not approved in policy and that the grid had not been reviewed by the Governing Body.

An visit was made to Unit 1 on 6/13/12 at 10 AM. The patient classification number for Patient 44 was reviewed. The patient was listed as a level 3.

An interview was conducted with the charge nurse of the unit RN 2 at the same time. The RN stated that she assigned patient's by number based on what she had been told by previous staff. She stated that most patients are a number 2 except if a patient was newly admitted or had aggressive behaviors. RN 2 stated that if a patient was getting ready to be discharged they would be a number 1. She stated that that patient would, according to the system require the least amount of nursing time.

During the same interview, RN 2 was shown the hospital's definition sheet for the levels of patient care. She stated that she "had never seen that sheet before."

RN 2 reviewed the hospital's definition sheet and confirmed that a patient who was going to be discharged was a level 1 and would require the least amount of care. She was asked what extra work was needed to provide care for a patient who was getting ready to discharge. RN 2 stated that the aftercare instruction sheet needed to be filled out and explained to the patient, the patient's belonging needed to be confirmed and given to the patient, there was a review of the patient's medications that needed to be done along with teaching on any new medications, there was a variety of educational sheets that had to be obtained and reviewed with the patient, there was a patient satisfaction survey that the nurse needed to ensure that the patient completed, the patient needed to be cleared through the business office, and the nurse was responsible for any medical follow up that the patient might need. She stated that sometimes there were other needs as well before the patient was discharged. She confirmed that these tasks took a great deal of nursing time and that the patient was listed as needing the least amount of care.

RN 2 stated that Patient 44 was a number 3 (level 3 for cares) because he had aggressive behaviors. She reviewed the medical record and could find no recent documentation of his aggressive behaviors. She stated that the assigned numbers were given by the previous shift and she could not confirm what the aggressive behaviors were that Patient 44 exhibited.

A review of the medical record for Patient 28 was conducted on 6/13/12. The review revealed that the patient was admitted to the hospital on 4/19/12 with diagnoses that included bipolar disorder (exaggerated mood swings from mania to sever depression).

A review of the physician's discharge summary, dated 5/3/12, revealed that on 4/24/12, the patient "became agitated toward peers and threw water at another girl and was picking at scabs." The physician stated that the patient required medication for her behaviors.

A review of the patient classification documentation for 4/24/12, revealed that the patient was listed as a level 1 or 2 for the entire day.

An interview was conducted with the CNO on 6/13/12 at 2:10 PM. She confirmed that the physician documented behaviors that would place the patient at a higher level of care and that the nursing staff did not evaluate the patient's care needs correctly.

An interview was conducted with the CNO on 6/14/12 at 2:30 PM. She stated that the patient classification system had not been studied or had a quality review to check the validity of the system. She confirmed that a patient who was ready to be discharged required a great deal of nursing time. She confirmed that the system was not always used in the way that it was intended. She stated that she thought that the nurses had been trained on using the system; however, she acknowledged that nurses said that they were not familiar with the definition sheet. She acknowledged that patients were not being assigned according to the system that the hospital had in place and that the grid system for nurse staffing was not an approved system.

4. A visit was made to Unit 2 on 6/12/12 at 10:20 AM. A review of the assignment sheet was conducted. There was no assignment made for a response to a medical emergency within the hospital.

An interview was conducted with the CNO on 6/12/12 at 10:30 AM. She stated that if there was a medical emergency in the hospital, a certain code would be called. She stated that a nurse would come from Unit 2 and staff from Unit 2 would bring the oxygen, the automated defibrillator, and a pack of supplies for an emergency. She was asked how the staff knew who was to bring which supplies and who was assigned to respond to the emergency. She stated that it was listed on the assignment sheet. The CNO reviewed the assignment sheets and confirmed that the assignment did not list the staff to respond in the event of an emergency. She confirmed that in an emergency situation, unless things were planned in advance, the response can be very stressful for staff and could effect patient safety.

Based on observation, interview and record review the hospital failed to ensure that all drugs were given in accordance with a physician's order for a medication for 2 of 35 sampled patients (Patients 34 and 35).

1. For Patient 34, the hospital failed to ensure the correct insulin dose was administered. Patient 34 was administered incorrect insulin doses on 3 occasions according to the physician order. This failure had the potential to cause the patient to experience altered blood sugar control including elevated blood sugar levels which could lead to coma.

2. For Patient 35, nursing failed to clarify the physician's order before giving a medication. This failure had the potential to contribute to the patient receiving the wrong medication or the wrong dose of a medication.

Findings:

1. A review of the medical record for Patient 34 revealed that the patient was admitted to the hospital on 6/8/12 with medical diagnoses which included Type 1 Diabetes (a lifelong disease in which there are high levels of sugar in the blood) maintained on insulin (a medicine to help control levels of sugar in the blood). A review of the physician orders included a sliding scale insulin order as follows:

Accucheck (blood sugar testing method) 2 hours after each meal, cover with [insulin] sliding scale as follows:

[if blood sugar level is:]
0-70 give juice and call MD (Medical Doctor)
70-139 = 0 units [of insulin]
140-180 = 1 unit [of insulin]
181-221 = 2 units [of insulin]
222-262 = 3 units [of insulin]
263-303 = 4 units [of insulin]
304-344 = 5 units [of insulin]
345-305 = 6 units [of insulin]
306-426 = 7 units [of insulin]
If greater than 426 call MD.

A review of the patients Insulin and Diabetic Flow Sheet showed that on 6/9/12 at 2:30 PM the blood sugar level was 268 and 6 units of insulin were given when 4 units should have been given. On 6/11/12 at 11:30 AM the blood sugar level was 307 and 4 units of insulin were given when 7 units should have been given. On 6/12/12 at 2:30 PM the blood sugar level was 329 and 4 units of insulin were given when 5 units should have been given.

During an interview with the Chef Nursing Officer on 6/15/12 at 9:45 AM, she verified that the physician orders were not followed on the 3 occasions and the wrong insulin doses were given to Patient 34.




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2. During an observation of a medication pass on 6/14/12 at 8:30 AM, it was observed that the nurse administered lisinopril 10 mg (milligrams) 1 tablet and 1 tablet of hydrochlorothiazide (HCTZ) 12.5 mg (medications for blood pressure) to Patient 35.

A review of Patient 35's physician orders dated 6/11/12 for lisinopril-HCTZ 10 mg-12.5 mg 1 tablet by mouth daily. First dose when available.

In an interview with LPT (Licensed Psychiatric Technician) 2 on 6/14/12 at 9:40 AM, LPT 2 stated that the combination tablet was not available so she gave the two separate tablets.

In an interview on 6/14/12 at 10:00 AM with RN 3, RN 3 acknowledged that the medication order should have been clarified with the physician to see if it was acceptable to give the lisinopril and HCTZ separately as the combination tablet was not available before the medications were given.

Based on observation, interview and record review, the hospital failed to ensure that the medical record services had administrative responsibility for medical records.

The hospital failed to:

1. Ensure that medical records were accessible at all times. A patient medical record was requested in the late afternoon and was not available until the next day. This failure had the potential to contribute to a patient receiving incomplete care due to the physician not having the information available to plan a patient's care and treatment. (Refer to A-0438)

2a. Ensure that for Patient 6, the suicide assessment tool in use in the facility contained information regarding the patient's risk of suicide, including suicidal thoughts and statements.

b. Ensure that the discharge summary for Patient 1 was not missing information such as a history of substance abuse.

c. Ensure that for Patients 1 and 2, portions of the medical record were complete, creating the risk of substandard healthcare for those patients. (Refer to A-449)

3. Ensure that all patient medical record entries were legible when a physician documented the patient's mental status, who had been expressing suicidal ideations the previous day, on discharge in an illegible manner. This failure had the potential for the patient to have a discharge that was may not have been safe to the patient or others. (Refer to A-0450)

4. Ensure that all verbal orders were authenticated by the practitioner within 48 hours for 1 of 35 sampled patients (Patient 26). This deficient practice had the potential for a transcription error and a risk to patient safety due to treatments that were not specifically ordered by the attending physician. (Refer to A-0457)

The cumulative effect of these systemic problems resulted in the hospital's failure to provide prompt and accurate medical record services.

Based on interview and record review, the hospital failed to ensure that medical records were accessible at all times. A medical record from a patient was requested in the late afternoon and was not available until the next day. This failure had the potential to contribute to a patient receiving incomplete care due to the physician not having the information available to plan a patient's care and treatment.

Findings:

On 6/12/12 at 3:15 PM Patient 25's record was requested for review.

In an interview on 6/12/12 at 3:20 PM with Administrative Staff 1, she stated that the record was from 2007 (five years ago) and that the record would not be available until the morning.

A review of the facility policy titled "Closed Medical Record Storage" and with a review date of 3/12 showed the following: "For record requests after business hours, requesting staff must leave a voice message for medical record staff to request the record the next business morning."

In an interview on 6/12/12 at 3:40 PM with the CEO, he acknowledged that the regulation requires access to the medical records at all times for at least 5 years.

The requested record was received on 6/13/12 at 10:30 AM.

Based on interview and record review, the facility failed to (1) ensure that for 1 of 35 patients (Patient 6), the suicide assessment tool in use within the facility contained information regarding the patient's risk of suicide, including suicidal thoughts and statements, creating the risk of inadequate assessment and care planning for suicidal patients, and (2) the discharge summaries 1 of 35 records reviewed (for Patient 1) were missing information such as a history of substance abuse and (3) for 2 of 35 patients (Patients 1 and 2), portions of the medical record had been left blank, creating the risk of substandard healthcare for those patients.

Findings:

1. The medical record of Patient 6 was reviewed and the forms dated 4/12/12 at 11:12 AM, sent from the referring psychiatric therapist, indicated that the patient was suicidal, with a plan to commit suicide by overdosing or driving off of a cliff, and was unable to contract for safety (unable to commit to take measures to ensure that she is safe from suicide). The facility form, Hospital Integrated Assessment, page 1, completed on 4/12/12 at 2 PM, indicated that the patient was referred from another facility due to suicidal thoughts with a plan, and at the time of the assessment noted active suicidal thoughts with a plan to cut herself. The Suicide Risk Assessment completed on 4/12/12 at 3:15 PM in response to the questions, "How often do you think about harming yourself?" recorded, "never", and in response to, "Do you have a plan as to how you would harm yourself?" recorded, "no". The cumulative score in response to the Suicide Risk Assessment recorded for Patient 6 was 0-no risk. The patient was discharged from the facility against medical advice on 4/12/12.

During an interview with the Medical Director on 6/15/12 at 10:10 AM, he reviewed the medical record of Patient 6 and concurred that there was information in the record that was not reflected on the Suicide Risk Assessment tool.

2. The medical record of Patient 1 was reviewed and her Discharge Summary dated 4/11/12 included a list of "Admitting Diagnoses" from her 4/7/12 admission including major depression with anxiety and suicidal ideation, anorexia and bulimia nervosa, marijuana abuse and alcohol abuse. The "Discharge Diagnoses" included major depression. A review of the medical record did not show evidence that her eating disorders or chemical dependency problems had been resolved during the admission.

During a interview with the Medical Director on 6/15/12 at 10:10 AM, he stated that the discharge summary should include all relevant medical diagnoses, including drug abuse.
He stated that the omissions on the discharge summaries were the physician's responsibility.

3. The medical record of Patient 1 was reviewed and showed a pre-printed Psychiatric Evaluation form in which there was a list of possible reasons for admission. However, none of the reasons were indicated for Patient 1-the section was left blank.

Patient 1's History and Physical Evaluation form had a section to record the patient's medical history, but the section was left blank, despite the patient's report of anorexia and bulimia. The section for illegal drugs used indicated only THC (marijuana), while elsewhere in the record multiple substances were listed, including the use of heroin the day prior to admission. The section for Family Medical History contained the note, N/C (noncontributory), despite the fact that elsewhere in the record a history of depression and suicidality in the grandmother were reported.

The Medical Staff Rules and Regulations were reviewed, and chapter 2 stipulated that the missing elements should have been included in the psychiatric evaluation and history and physical evaluation for the patient.

The medical record of Patient 2 was reviewed on 6/13/12, and the spaces on the intake form for vital signs were blank.

During an interview with the Director of Performance Improvement (DPI) on 6/13/12 at 2:40 PM, she stated that the vital signs should have been filled in.

Based on interview and record review, for 1 of 35 sampled patients (Patient 28), the hospital failed to ensure that all patient medical record entries were legible when a physician documented the mental status of a patient who had been expressing suicidal ideations the previous day, on discharge in an illegible manner. This failure had the potential for the patient to have a discharge from the facility that was not safe for the patient and others.

Findings:

A review of the medical record for Patient 28 was conducted on 6/13/12. The review revealed that the patient was admitted to the hospital on 4/19/12 with diagnoses that included depression.

A review of the physician's discharge summary, dated 5/3/12, revealed that on admission, the patient stated, "I wanted to kill myself. I can't stop it." The physician also documented that the patient was stating suicidal ideations and was not able to contract for safety.

A review of the physician's progress notes on the day prior to discharge, 4/26/12, revealed that, "the patient has been expressing active thoughts of how she is going to hurt herself..." The physician further documented, "This patient continues to be gravely disabled and a danger to self and danger to others."

A review of the physician's orders revealed an order written on 4/27/12 for the patient to discharge home. There was an entry by the physician under the area for "Mental Status at Discharge" that was not legible. There were no other physician progress notes on the day of discharge.

A review of the nurse's assessment on the day of discharge, 4/27/12, revealed that the nurse documented that the patient was "Verbally threatening assault." There was no documentation that the nurse notified the physician that the patient was threatening assault or other documentation regarding the patient's threats.

A review of the discharge plan, dated 4/27/12, revealed that the patient was discharged to a group home. There was no documented evidence that the group home was notified of the patient's threats or that the issue was addressed in the discharge plan.

An interview was conducted with the Director of Case Management (DCM) on 6/14/12 at 9 AM. She confirmed that the nurse documented that the patient had verbally threatened assault on the day of discharge. The DCM confirmed that the physician's assessment of the patient on the day of discharge was not legible and that the assessment was important to determine the patient's mental state at the time of discharge to ensure a safe discharge.

Based on staff interview and facility record review, the facility failed to ensure that all verbal orders were authenticated by the practitioner within 48 hours for 1 of 35 sampled patients (Patient 26). This deficient practice had the potential for a transcription error and a risk to patient safety as a result of treatments provided to the patient that were not as ordered by the attending physician.

Findings:

A review on 6/13/12 of the medical record for Patient 26 revealed that she was admitted to the hospital on 3/22/12 with diagnoses that included Bi-Polar disorder, recently manic (a major mental disorder characterized by episodes of mania [hyperactivity, agitation and excitability], depression or mixed mood).

A review of the physician orders for Patient 26 showed an order with no date to send the patient to the emergency room due to the patient complaints of chest pain. The patient went to the emergency room on 3/23/12. The physician order was not authenticated until 4/10/12 at 5:23 PM (eighteen days after the initial physician order).

In an interview on 6/13/12 at 3:40 PM with the Director of Program Services, she stated that the nurse receiving the telephone order did not indicate in the record that it had been a telephone order and she did not indicate that the order was read back to the physician for accuracy check. She acknowledged that the nurse did not date or time when the order was received and that the physician did not authenticate the order within 48 hours.

Based on observation, interview and record review the hospital failed to have pharmaceutical services that met the needs for a universe of 87 patients.

1. The pharmacy failed to ensure that only authorized personnel had access to the automated drug delivery system. The system, PYXIS, contained routine medications and controlled medications, such as narcotics and antianxiety medications. The hospital had no system to immediately take a staff member off of the list of people who could access the medications when these individuals no longer worked for the hospital. (Refer to A 504)

2. The pharmacy failed to ensure that medications and biologicals were controlled and distributed in accordance with standards of practice.

a. The pharmacy failed to ensure that each medication was reviewed by the Pharmacist for accuracy before the first dose was dispensed. (Refer to A 500)

b. The pharmacy failed to supply the medication Narcan (a narcotic reversal agent) for emergency use. The hospital did administer narcotics, so a commonly used reversal agent should be available to the nursing staff. (Refer to A 500)

c. The pharmacy failed to ensure the control over all medications when injectable medications Haldol (an antipsychotic), cogentin (a medication used to treat the side effects of other medications) and benadryl (an antihistamine that can cause drowsiness) were found on an open shelf with oral house medications. (Refer to A 500)

d. The pharmacy failed to follow their policy for "Medications Brought Into the Facility", when a patient's own medications, brought from outside of the hospital, were found in the "use area" without prior clearance to use these medications by the pharmacist. (Refer to A 500)

3. The pharmacy failed to ensure that all drugs listed in the Schedule section (list of drugs that have abuse potential and likelihood of dependence) of the Comprehensive Drug Abuse Prevention and Control Act were kept locked within a secure area. (Refer to A 503)

The cumulative effect of these systemic problems resulted in the hospital's inability to provide the patients with pharmaceutical services in a safe environment.

Based on observation, interview and record review, the hospital failed to ensure that medications and biologicals were controlled and distributed in accordance with standards of practice.

1. The hospital failed to ensure that the pharmacist reviewed each medication for appropriateness before the first dose was dispensed.

2. The pharmacy failed to supply the medication Narcan (a narcotic reversal agent) for emergency use. The hospital did administer narcotics, so a commonly used reversal agent should be available to the nursing staff.

3. The pharmacy failed to exercise control over all medications when injectable medications Haldol (an antipsychotic medication), cogentin (a medication used to treat side effects of other medications) and benadryl (an antihistamine that may causes drowsiness) were found on an open shelf with oral house supply medications.

4. The the hospital failed to ensure that that the pharmacy followed their policy for "Medications Brought Into the Facility", when a patient's own medications, brought from outside of the facility, were found in the "use area" without prior clearance for use by the pharmacist.

5. The hospital failed to ensure that a multi-use medication vial was dated when opened, creating the increased risk of infection for patients receiving medication from the undated vial.

These failures had the potential to result in a negative outcome due to a medication error for all patients admitted to the acute care unit of the hospital.

Findings:

1. An interview was conducted with RN 2, on Unit 1, on 6/12/12 at 2 PM. She stated that if a medication order was received from a physician for a patient during hours that the pharmacy was not open, the nurse would give the medication if it was available in the PYXIS (automated drug delivery system). She stated that the only time the nurse would call the pharmacist was if the medication was not available.

An interview was conducted with RN 3, on Unit 2, on 6/12/12 at 2:30 PM. She stated that if the physician ordered a medication for a patient when the pharmacy was closed, the nurse gave the medication if it was available. She stated that they would call the Pharmacist, only if the medication was not available. RN 3 was asked if the nurse faxed the order to the Pharmacist for review prior to administration, if it was a first time dose for the patient. She stated "no". She stated that a copy of the order was placed in the medication room and the pharmacy picked up the order the next day.

A review of the hospital's pharmacy policy and procedure manual was conducted on 6/13/12. There was no policy found outlining the process for the Pharmacist to review the first dose of a medication before the medication was given to the patient, except in the event of an emergency.

An interview was conducted with the Pharmacist of the hospital on 6/14/12 at 9 AM. He stated that he did not have a process for the nursing staff to notify him of new medication orders so that he could review the medications prior to the first dose when the pharmacy was closed (pharmacy hours, Monday through Friday 6:30 AM to 2 PM and weekend 9 AM to 1 PM). He stated that the medication could be held and not given until the next day. The Pharmacist acknowledged that some medications are scheduled to be given at night, so the patient would have to wait over 24 hours before the first dose. The Pharmacist confirmed that supervision of the pharmaceutical services included reviewing a medication prior to the first dose and that making the patient wait for the first dose could be a patient safety concern.

2. An observation of the hospital Units 1, 2, and 3 was conducted on 6/12/12 at 2 PM through 3:30 PM.

On each unit the medication nurses (Licensed Vocational Nurse 1, Licensed Psychiatric Technician 1 and 2) were asked if the patients on the unit received narcotic pain medications. The medication nurses stated that some patients did receive narcotics. The nurses were asked if the unit had a supply of Narcan to reverse the effects of a possible overdose or reaction to narcotics. On each unit the medication nurses stated that there was no Narcan available.

An interview was conducted with the hospital's Pharmacist on 6/14/12 at 9 AM. He stated that there was no Narcan within the hospital; however, since the hospital administered narcotics and there was always a potential for a patient to have a problem requiring reversal of the narcotic, the hospital should have Narcan on, at least, one of the units.

3. An observation was conducted on Unit 3 of the hospital on 6/12/12 at 3:15 PM. On a shelf that contained oral house supply medications, there were 5 vials of injectable medications found. The medications were 3 vials of Haldol and 1 vial each of Cogentin and Benadryl.

An interview was conducted with the medication nurse Licensed Psychiatric Technician (LPT 2). She confirmed the finding and stated that the medications should be secured and not just sitting on a shelf for patient use.

4. An observation was conducted on Unit 1 on 6/12/12 at 2:30 PM. On a shelf there were 2 boxes of medications that had a patient label; however, no initials by the Pharmacist were recorded on the label. The medications were over-the-counter medications, Midol (used for relief of menstrual symptoms) and Dramamine (used for motion sickness).

A review of the hospital policy tilted "Medications Brought Into the Facility, dated 6/12, revealed that "The Pharmacist must make a positive identification of the drug...then sign and date the container signifying that the drug has been checked by pharmacy." The policy further stated that the medication must be kept in the patient cassette during the hospital stay."

An interview was conducted with LPT 1, during the policy review. She stated that the medications were brought in by a patient and that they had a label on the box indicating which patient the medications belonged to. She stated that they were on the shelf where the patient's own medications were stored until the patient needed the medications. LPT 1 was asked if the pharmacist had reviewed the medications and she stated no, because there were no initials of the pharmacist that were recorded on the label. She stated that the medications should have been sent to the pharmacy prior to being available for patient use.






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5. During a tour of the medication room on unit 1 on 6/12/12 at 9:20 AM, the refrigerator contained an opened vial of Lantus insulin 100 units. The vial was not labeled with the date it was opened.

During a concurrent interview with LPT 1, she concurred that the vial was undated, and that it should have been dated when opened.

The facility policy, Expiration Dating, effective 12/01, read in part, "Multiple dose vials are given a 28-day expiration date once first used."

Based on observation and interview, the hospital failed to ensure that all drugs listed in the Schedule section (a list of drugs that have abuse potential and likelihood of dependence) of the Comprehensive Drug Abuse Prevention and Control Act were kept locked within a secure area. This failure had the potential for scheduled medications to be used without following established hospital procedures and the increased risk for diversion of a controlled medication.

Findings:

An observation was conducted on 6/12/12 at 2 PM on Unit 2. In an unsecured drawer there were two (2) fentanyl (A synthetic narcotic analgesic similar to but more potent than morphine, a Schedule II drug because of the potential for abuse and associated risk of fatal overdose due to respiratory depression.), 75 milligram patches were found.
An interview was conducted with the medication nurse, Licensed Vocational Nurse (LVN) 1, during the observation. She confirmed the finding and stated that the medication must have been placed in the drawer in error, because the drawer was not locked. She stated that all controlled medications should be locked and accounted for each shift.

Based on interview and record review, the hospital failed to ensure that only authorized personnel had access to the automated drug delivery system. The system, PYXIS, contained routine medications and controlled medications, such as narcotics and antianxiety medications. The hospital had no system to immediately take a staff member off the list of people who could access the medications when they no longer worked for the hospital. This failure had the potential for all licensed staff, who no longer work for the hospital, to access medications, including controlled medications, and had the potential for drug diversion to occur in the hospital. This failure contributed in the hospital Pharmacist not providing supervision over pharmaceutical services.

Findings:

A review of list of "Users" for the hospital's automated drug delivery system, PIXIS, was reviewed and compared with a list of active employees on 6/15/12.

The comparison revealed that there were several employees who were active on the PIXIS list that were not on the active employee list.

An interview was conducted with the Pharmacist of the hospital on 6/15/12 at 9 AM. He stated that the pharmacy technician was the person who removed an employee's access to the PIXIS when the employee was terminated from service. He stated that he would check with the technician to see if he had an updated list.

A review of the hospital policy titled "Automated Drug Dispensing Machines", dated 6/12, was conducted. The policy outlined a process for Human Resources (HR) to provide pharmacy "immediate" information about licensed employees who are no longer working at the hospital.

An interview was conducted with the Director of Human Resources (DHR) on 6/15/12 at 10 AM. She confirmed that there were employees who had terminated their service with the hospital; however, they remained on the active PIXIS list.

A follow up interview was conducted with the hospital's Pharmacist on 6/14/12 at 10:15 AM. He stated that there was no updated list and that the pharmacy had not reviewed the employees that were terminated from the hospital to revise the PIXIS access list since July 2011. He stated that there was no process for HR to notify pharmacy regarding former staff that no longer working in the hospital. The Pharmacist confirmed that it was his responsibility to ensure the security of medications, especially controlled medications. He acknowledged that the security of medications was an important part of his supervision of pharmaceutical services.

Based on observation, interview and document review, the hospital failed to ensure the dietary services met the needs of the patients as evidenced by the failure to:

1. Ensure that the nutrition needs of the patients were met in accordance with recognized standards of practice (Refer to A 630);

2. Ensure safe and sanitary food production and storage practices (Refer to A 749);

3. Ensure a comprehensive disaster food plan and disaster food supplies were available in the event of a disaster (Refer to A 701); and,

4. Implement an effective performance improvement plan that measured tracked and analyzed aspects of nutrition services and care (Refer to A 267)

The cumulative effects of these systemic problems resulted in the inability of the hospital's food and nutrition services to ensure that the nutritional needs of the patients were met in accordance to acceptable standards of practice.

Based on record reviews and interviews:

1. The hospital failed to ensure that the nutrition needs were met for 5 of 7 patients whose records were reviewed for nutrition care (Patients 1, 32, 34, 37 and 31) when:

a. Patient 1 was admitted with a recent history of an eating disorder that was out of control, a recent severe weight loss and there was no facility conducted nutrition assessment of the patient;

b. Patient 32 had a five pound weight increase in five days and there was no facility conducted nutrition assessment of the weight gain;

c. Patient 34 was an adolescent with Type 1 Diabetes with poorly controlled blood sugars. There was no facility conducted nutrition assessment;

d. Patient 37 had nutrition recommendations from the Registered Dietitian to encourage healthy food choices that were not communicated to the other members of the health care team;

e. Patient 31 had nutrition recommendations from the Registered Dietitian to monitor purging activity after meals that were not communicated to the other members of the health care team.

2. The hospital failed to ensure that the patient menus met the nutritional needs of the patients in accordance with recognized dietary practices when they failed to do a nutritional analysis of the menus.

These failures resulted in the nutrition needs of the patients either not being met or not being monitored and had the potential to further compromise their nutritional and medical status. They also had the potential to contribute in nutrition needs of the patients not being met in accordance with physician's orders and/or current national standards for recommended dietary allowances.

Findings:

1. a. A review of the medical record for Patient 1 revealed that the patient was admitted to the hospital on 4/7/12 with a history of eating disorder. A review of the psychiatric evaluation dated 4/7/12 stated, "The patient stated that her eating disorder is out of control." A review of the Point of Contact Assessment dated 4/7/12 stated, "appetite - eating disorder; reduced weight 15 - 20 pounds in 2 months." A review of the Nutritional Risk Screen on the initial Nursing Assessment form showed that no nutrition risk factors were identified on the screen.

Further review of the medical record showed that the patient was not referred to the Registered Dietitian for a nutrition assessment or follow up. The record did not contain a nutrition assessment despite reports of recent severe weight loss and patient reports of an eating disorder out of control.

A review of the hospital's policy titled, "Multidisciplinary Admission Assessment Procedure" date 2/11 revealed that the policy was to obtain a full and accurate multidisciplinary database on every patient. It stated that the purpose was to provide guidelines for assessment and referral. For the Nutrition Risk Assessment, it stated that the Registered Nurse will identify and document patients at nutritional risk by utilizing the Nutrition Risk Screen. It stated that if any risk factors were checked, including eating binges/purges/anorexia or weight loss/gain, the patient was to be referred to the physician for a potential nutritional consult.

During an interview with the Chief Nursing Officer (CNO) on 6/15/12 at 9:30 AM, she stated that the patient should have been referred for a nutritional consult. She was unable to explain why the Nutritional Risk Screen on the Nursing Assessment did not identify that the patient was at nutrition risk related to the recent weight loss and reports of eating disorder out of control. She verified that there was no nutrition assessment for Patient 1.

During an interview with the Registered Dietitian (RD) on 6/15/12 at 11:15 AM, she stated that she does not have a system for identifying patients who are at nutrition risk. She stated she only completes a nutrition assessment on patients who have a physician order for a consult. She stated that although the hospital admitted an average of 400 - 500 patients a month, she receives only 10 - 12 nutrition consult orders a month. She stated that she hasn't done any evaluation or studies of the hospital's process to determine if patients were appropriately referred for nutrition care. She stated that the nutrition consults she receives was "just scratching the surface of the patients who are at nutrition risk," and that she "would like to be more involved in the nutrition care of the patients".

b. A review of the medical record for Patient 32 revealed that the patient was admitted to the hospital on 6/4/12. A review of the patient's Vital Signs record showed the patient's admit weight on 6/4/12 was 153 pounds. Five days later, on 6/9/12, the patient's weight was recorded as 158 pounds. There was no documentation in the medical record that the physician or the RD were informed of the 5 pound weight gain in 5 days.

During an interview with the Charge Nurse for Patient 32 on 6/13/12 at 11:15 AM, he stated that the physician should have been notified of the patient's significant weight gain. He verified that there was no documentation that the physician was notified. At 11:30 AM the Charge Nurse stated that the patient had been re-weighed and remained at 158 pounds.

During an interview with the RD on 6/13/12 at 11:25 AM, she stated that she did not receive a nutritional consult order and that there was no nutrition assessment of the patient to address the significant weight gain. She agreed that the weight gain should have triggered an RD consult for a nutrition assessment to help prevent further undesirable weight gain.

c. A review of the medical record for Patient 34 revealed that the patient was admitted to the hospital on 6/8/12 with medical diagnoses which included Type 1 Diabetes (a lifelong disease in which there are high levels of sugar in the blood) maintained on insulin (a medicine to help control levels of sugar in the blood). A review of the Nutrition Risk Screen on the Nursing Assessment indicated only that the patient was on a "special diet". The boxes labeled "Diabetes" and "on insulin" were not checked. The boxes should have been checked to indicate nutrition risk factors requiring a referral to the physician for a potential nutritional consult. The referral to the physician was not made and a nutritional consult was not ordered.

During an interview with the CNO on 6/15/12 at 9:30 AM, she verified that the Nutrition Risk Screen was not accurate and a referral to the physician and the RD were not made. She verified that the physician should have been asked for a nutritional consult for Patient 34 due to her diagnosis.

Further review of Patient 34's medical record revealed blood sugars ranging from 69 to 458 with all but one over 200. The National Institute of Health states blood sugar levels of 70 - 130 before meals and less than 180 after meals is normal. Blood sugars greater than 180 are considered too high. There was no nutrition consult ordered based on the patient's elevated blood sugars over the 7 day admission.

During an interview with the RD on 6/13/12 at 11:25 AM, she stated that she did not received a nutritional consult and there was no nutrition assessment of the patient to address the elevated blood sugars. She was unable to explain why the patient was not referred to the physician for a nutritional consult order. The RD verified that diet has an important role in the management of Type 1 Diabetes.

d. A review of the medical record for Patient 37 revealed that the patient was admitted to the hospital on 6/11/12 with diagnoses which included a history of fatty liver. A physician order was noted, dated 6/12/12, for a nutrition consult for elevated triglycerides (one of the types of fats transported in the bloodstream). Elevated triglyceride levels are considered to be a risk factor for developing hardening of the arteries.

A nutrition assessment dated 6/13/12 was reviewed. The recommendations on the RD assessment stated, "Motivate [the] patient to eat healthy foods and avoid fats and other [high] calorie foods." A review of the medical record did not reveal a nutrition care plan with these recommendations. There was no documentation that other members of the healthcare team encouraged the patient to make healthy food choices.


During an interview with the RD on 6/15/12 at 11:15 AM, she stated that she did not write a nutrition care plan with her recommendations. She stated that she put her assessment in the chart and did not communicate her recommendations to the other members of the healthcare team. She verified that it was not likely her recommendations were noted by all the other members of the healthcare team who would be instrumental in encouraging the patient to make healthy food choices.

e. A review of the medical record for Patient 31 revealed that the patient was admitted to the hospital on 6/6/12 with medical diagnoses which included eating disorder, bulimia. Bulimia is an eating disorder characterized by binge eating and purging, or consuming a large amount of food in a short amount of time, followed by an attempt to rid oneself of the food consumed (purging), typically by vomiting, taking a laxative or diuretic and/or excessive exercise, and commonly accompanied with fasting over an extended period of time. A physician order for a dietary consult for eating disorder was noted on 6/7/12.

A review of the RD Nutrition Assessment dated 6/10/12 revealed goals that included "no purging after meals." It also showed recommendations to "Monitor activity after meals." A review of the medical record did not reveal a nutrition care plan with these goals or recommendations. There was no documentation that other members of the healthcare team were monitoring the patient's activities after meals to prevent purging.

During an interview with the RD on 6/15/12 at 11:15 AM, she stated that she did not write a nutrition care plan with her goals or recommendations. She stated that she put her assessment in the chart and did not communicate her recommendations to the other members of the healthcare team. She verified that it was not likely her recommendations were noted by all the other members of the healthcare team who would be instrumental in monitoring the patient's purging behavior after meals. She further stated that she did not reassess the patient and her goals to determine if the recommendations were effective. She stated that she does not reassess patients once a consult has been completed.

During an interview with the CEO and the Director of Support Services (DSS) on 6/14/12 at 2:30 PM, they verified that the current system of determining which patients need to have a nutritional assessment "needs some work." They verified that patients who would benefit from nutrition assessment and follow up were not being assessed by the RD.

2. During an interview with the Registered Dietitian (RD) on 6/15/12 at 11:15 AM she stated that the hospital does not have a nutrition analysis of the patient menus. She stated that she determined that the menus were nutritionally appropriate based on Vitamin C and protein. She stated that she made sure that the menus contained a Vitamin C rich food daily. She stated that she ensured that each meal had protein rich food: 1 ounce at breakfast, 2 - 3 ounces at lunch, and 3 - 4 ounces at dinner. The therapeutic diet menus were based on general guidelines but not a nutritional analysis. She was unable to state if the menus met the recommended dietary allowances for all the vitamins and minerals, calories, protein, fats and fiber. She verified that there could be no way to ensure the current Recommended Dietary Allowances (RDA) or the Dietary Reference Intakes (DRI) of the Food and Nutrition Board of the National Research Council were met without a nutritional analysis of the menus. These are the current national standards for evaluating adequacy of diets.

A review of the hospital policy titled, "Hospital Diet Manual" dated 2/11 revealed that "The recommended dietary allowances of the National Research Council is the guide used in developing the standards of adequacy of the diets in this [diet] manual."

Based on observation, record review and interview, the hospital failed to ensure, for a universe of 87 patients, that the physical environment was maintained in a manner that the safety and well-being of the patients were assured. This increased the risk of harm to the patients due to the facility's failure to maintain the physical environment.

Findings:

1. On 6/12/12 at 3:25 PM, the table on Unit 1 in Lounge A was observed moving from side to side (unsteady). At the time of the observation there were several patients at the table as well as a Mental Health Worker (MHW) 1.

MHW 1 confirmed that the table was unsteady and potentially unsafe for patient use. He stated that the female patients used the table during daily activities and at meal times. When he was asked the facility's practice for reporting broken equipment, the MHW stated that the table had been fixed several times in the past, but continues to be unstable.

This failure created the risk for injury to all patients that used the table for activities and/or meal times.

2. On 6/12/12 at 10:30 AM, an observation of the standing weight scale on Unit 2 B was conducted. The scale had a maintenance sticker that indicated that the scale was last checked in 2010 and that the preventative maintenance check was due in 8/2011. The Chief Nursing Officer confirmed the finding. She stated the Maintenance Supervisor (MS) kept a current record of all preventative maintenance checks for the hospital's equipment.

On 6/12 12 at 4 PM, the MS stated that the standing weight scales throughout the hospital were not checked in 8/2011. The MS confirmed that the preventative maintenance checks were overdue.

This failure created the risk for all patient weights to be inaccurately measured and recorded.



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3. A review of the hospital's disaster food plan dated 2/11 revealed that the plan was that "Food Service personnel shall prepare food in sufficient quantities for all patients and personnel."

During an interview with the Director of Support Services (DSS) on 6/12/12 at 3:20 PM, he stated that the hospital's plan was to feed 100 people in the event of a disaster. He verified that this was not enough to feed all patients and personnel.

During an observation and concurrent review of the hospital's disaster food plan and supplies on 6/12/12 at 3:20 PM, the following was noted:

· The plan required 100 servings of ravioli, there was none.
· The plan required 100 servings of beef stew, there was none.
· The plan required 900 servings of milk, there were 840 servings.
· The plan required 300 servings of soup, there were 174 servings.

During the continued interview with the DSS (same date and time), he stated that the hospital needed to improve the disaster food plan and ensure that they maintained adequate supplies to meet the plan for patients and staff.

Based on observation, interview and record review:

A. the hospital failed to ensure that the infection control officer developed a system for monitoring staff for the effectiveness of their sanitation. This failure had the potential to result in a spread of infection due to improper use of sanitizing agents; and

B. The hospital failed to ensure that there were infection control measures in place to prevent the development of food borne illness and cross contamination with regards food service when:

1. A lack of system for monitoring the safe cooling of cooked potentially hazardous foods;
2. A lack of effective system for sanitizing the ice storage bin of the ice machine;
3. A lack of system for monitoring the expiration date of perishable refrigerated juices; and,
4. A lack of an effective system for monitoring the safety and sanitation of the Patient Food Refrigerators on the Nursing Units.

The hospital failed to have a thorough infection control surveillance system that monitored the conditions and practices of the dietetics services staff. By not having these measures and a thorough surveillance system, potentially hazardous foods had been stored, prepared and distributed under unsafe and unsanitary conditions and there was potential for such continuation in the absence of identification and remediation.

Findings:

A1. An observation was conducted on 6/12/12 at 10:30 AM on Unit 2. A Mental Health Worker (MHW 1) was cleaning a patient bed, after the patient had been discharged. The MHW sprayed the bed with a sanitizing spray labeled as "Tuberculocidal Spray" and immediately wiped off the bed.

An interview was conducted with MHW 1 during the observation. He stated that was how he always disinfected the beds after a patient was discharged. He sprayed the solution on and wiped it off.

The label on the spray can was read and the label directed the product's user to leave the product on the surface for at least three (3) minutes for proper sanitization.

The Director of Program Services was present during the observation and confirmed that the MHW did not follow the manufactures direction.

2. An observation was conducted on 6/13/12 at 11 AM on Unit 1. A housekeeper (HK 1) was observed cleaning the sink in a patient room. HK 1 sprayed on a solution, Morning Mist, and wiped the solution off with a cloth.

HK 1 was interviewed, during the observation, she stated that she cleans the sinks with the same solution and always just sprays it on and wipes it off. She stated that if there was visible grime present on the surface, she would scrub the surface.

The information on the bottle was reviewed and the manufacturer's recommendations directed the product's user to saturate the area/surface, scrub as necessary, rinse with potable water then dry the area/surface.

The HK confirmed that she did not follow the manufacturer's directions for the use of the product.

3. An observation was conducted on Unit 2 on 6/12/12 at 10 AM, accompanied by the Chief Nursing Officer (CNO) and one of the licensed vocational nurses (LVN 1).

An oxygen tank was observed in a clean room. The oxygen tank had an open nasal canula hanging off the tank.

The CNO asked LVN 1 why there was an open nasal cannula on the tank and LVN 1 stated that a patient had used the oxygen the previous night. LVN 1 stated that the night shift must have put the oxygen away with the used nasal canula still on.

The CNO confirmed that a used nasal canula should not be left open and in a clean room.



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B1. During a tour of the kitchen on 6/12/12 at 3:00 PM, leftover cooked breakfast sausages (a potentially hazardous food) were observed in the reach-in refrigerator. The temperature of the sausage links was observed to be 39 degrees Fahrenheit (F).

During a concurrent interview with the Food Service Supervisor (FSS), he stated that the sausage was leftover from breakfast and was placed in the refrigerator at 10:00 AM that day. He stated that it was the dietary staff's usual practice to save leftovers. The staff did not monitor the safe cool down of the sausage. It was not the practice of the staff to monitor the cool down of leftovers to ensure the leftovers reached appropriate temperatures within safe timeframes.

According to the 2009 FDA Food Code, cooked, potentially hazardous food (PHF) shall be cooled within 2 hours from 135 degrees F to 70 degrees F, and within a total of 6 hours from 135 degrees F to 41 degrees F. It further states that if food is not cooled in accordance to this Code requirement, pathogens may grow to sufficient numbers to cause foodborne illness.

During further interview with the FSS (same date and time), he stated that he understood that PHF should be cooled to 70 degrees F within 4 hour and to 40 degrees F within an additional 2 hours. He stated that he had attended a food safety course in September of 2009. He did not recall that in order to ensure PHF remained safe during cooling; it needed to reach 70 degrees F within 2 hours, not 4 hours.

Also according to the 2009 Food Code, the initial 2-hour cool is a critical element of this cooling process to slow the rapid growth of pathogens that can cause foodborne illness.

A review of the hospital's policy and procedure manual revealed no policy for monitoring the safe cooling of PHF.

During an interview with the Registered Dietitian (RD) on 6/15/12 at 11:15 AM, she stated that she was aware that the kitchen staff saved leftovers of previously cooked PHF. She stated that she had not in serviced the FSS or staff on safe cooling and had not developed a policy for it.

2. During an observation of the ice machine in the cafeteria on 6/14/12 at 11:30 AM, a clean white paper towel swipe of the interior of the ice storage bin produced a moderate amount of a black/brown residue. The ice machine and storage bin were part of a unit that also dispenses beverages. The finding was concurrently verified by the Director of Support Services (DSS).

During a concurrent interview with FSS, he stated that the kitchen staff only clean the nozzles of the beverage dispenser and do not clean the ice machine or storage bin. He stated that the ice machine was the only one in the hospital and it served patients, staff and visitors.

During an interview with the Maintenance Coordinator (MC) on 6/15/12 at 11:30 AM, he stated that the maintenance staff performs quarterly preventive maintenance (PM) on the ice machine. The PM did not include cleaning and sanitizing the ice storage bin. He stated that the ice machine and storage bin were cleaned and sanitized every 6 months by an outside contractor.

A review of the PM record showed that the last quarterly PM was completed on 5/16/12. The last semiannual cleaning and sanitizing by the contractor was completed on 6/4/12.

The MC and the DSS were unable to explain why there was a moderate amount of black/brown residue on the interior of the ice storage bin. They both verified that the residue should not be present and likely contaminated the ice.

The 2009 Food Code states that in equipment such as ice bins and enclosed components of equipment such as ice machines, surfaces shall be cleaned at a frequency necessary to preclude accumulation of soil or mold.

3. During an observation in the walk-in refrigerator in the kitchen on 6/12/12 at 4:00 PM, four ounce cartons of various juices were labeled "Keep Frozen," and "use within 10 days of thawing." The juices were not dated.

During a concurrent interview with the FSS, he stated that they don't date the juices because they are generally used before the 10 days. He was unable to state how he monitors the expiration date for juices once they leave the kitchen. He verified that the juices are stored in the Patient Refrigerators on the Nursing Units and when not dated, there was no system for monitoring when they expire. He validated that in order to ensure juices were not retained and consumed past their expiration date; they would need to be dated.

A review of the hospital's policy and procedures for food and nutrition services did not reveal a policy for monitoring of the expiration date for the juices.

4. The Patient Food Refrigerators on the Nursing Units were observed on 6/14/12 between 11:45 AM and 12:10 PM. The refrigerator on Unit 2B was not locked. It had an accumulation of an orange residue on the bottom interior. The refrigerator on Unit 2A was also not locked. It had an accumulation of a brown dry crusty residue on the shelf. There was no thermometer inside the refrigerator. And it contained a disposable container of food that was not labeled or dated. The refrigerator on Unit 3 was noted to have an accumulation of a brown dry crusty and a sticky residue on the shelves. All refrigerators contained individual cartons of juice that were labeled for use within 10 days of thawing, but were not dated.

A review of the temperature log for the refrigerator for Unit 2B showed that for the month of June, only 2 temperatures were recorded. The temperature log for the refrigerator for Unit 2A showed that for the month of June, only 3 temperatures were recorded.

During an interview with the Nursing House Supervisor on 6/14/12 at 12:00 PM, she stated that the refrigerators should remain locked so that the patients who are on restricted diets cannot take food that is not a part of their diets. She stated that all patient food that is stored in the refrigerators should be labeled with the patient's name and the date so it can be monitored for safety. She verified that since the refrigerator was not locked in Unit 2B, any patient could have eaten the unlabeled food which may not be safe to eat or may not be consistent with the patient's diet order. She verified the food container from Unit 2A was not labeled with a name or time. She also stated that it was the hospital policy to record the refrigerator temperatures daily on the Patient Refrigerator log. She verified that this was not done for Units 2A and 2B.

During an interview with Mental Health Worker X on 6/14/12 at 12:10 PM, he stated that he usually wipes the refrigerators out daily, but he had been too busy this week to do it.

A review of the hospital's policy titled, "Care of Refrigerators, Infection Control, Nursing Services, Support Service," dated 2/12 revealed that the "temperature of all patient care refrigerators will be checked and recorded daily." It stated that any untagged or undated food items were to be discarded. It also stated that the housekeeping staff were to clean the refrigerators once a month and as needed

During an interview with the DSS on 6/14/12 at 12:10 PM, he stated that housekeeping should clean the refrigerators. He was unable to state why the refrigerators were dirty. He verified that the food in the refrigerators was exposed to cross contamination from the accumulation of debris. He verified that the juices should be dated with an expiration date to monitor when they should be discarded and to avoid patients drinking spoiled juice. He was unable to state how the hospital could ensure the food in the refrigerators was safely stored at appropriate temperatures without consistent monitoring of the temperatures.

Based on interview and record review, the hospital failed to ensure that they had in effect a discharge planning process that applied to all patients.

1. For Patient 41, the hospital failed to ensure that the discharge plan was reassessed to include his allegation of abuse by his parents, his assessment of being an "unresolved risk of self-harm", his unpredictable assaultive behaviors, his loss of hope, and his "overall poor behavior." (Refer to A 821)

2. For Patient 28, the hospital failed to ensure that the discharge plan was reassessed to include the patient's allegation that she was bullied at school.(Refer to A 821)

3. For Patient 36, the hospital failed to ensure that the discharge plan was reassessed to include the patient's report of physical abuse by his mother. (Refer to A 821)

4. For Patient 2, the hospital failed to arrange for the initial implementation of the patient's discharge plan because it did not ensure that living quarters had been arranged for the patient, and did not ensure that the patient was free of access to firearms, creating the risk of a poor health outcome for the patient. (Refer to A 820)

5. For Patient 1, the hospital failed to ensure that case management performed discharge planning for health related conditions, such as eating and substance abuse disorders. The hospital also failed to ensure that case management followed up with out-patient providers. (Refer A 818)

6. The hospital failed to ensure that patients and family members or interested persons were counseled to prepare them for post-hospital care by failing to ensure that all patients received discharge instructions on monitoring their weight as it relates to their medications and as instructed by the physician. (Refer to A 822)

7. The hospital failed to evaluate the discharge planning process on an on-going basis to help ensure that they were responsive to the patient's discharge needs. The hospital failed to include in their discharge policy the requirement to conduct a reassessment of the discharge plan when care needs change for the patient. (Refer to A 843)

The cumulative effect of these systemic problems resulted in the hospital's inability to provide a safe discharge planning process for all patients.

Based on interview and record review, for 1 of 35 sampled patients (Patient 1), the facility failed to perform discharge planning for health related conditions such as eating disorders and substance abuse disorders, and failed to follow up with outpatient providers for Patient 1, creating a risk of a poor health outcome for that patients. The hospital also failed to follow-up on patient complaints of bullying that threatened the well being for 1 of 35 sampled patients (Patient 3), creating the risk of a poor health outcome for that patient.

Findings:

1. The medical record of Patient 1 was reviewed and the admission assessment recorded that the patient reported anorexia, bulimia, and a recent 20 pound weight loss. She also reported abuse of several substances, including the use of heroin the day prior to admission. The patient's discharge plan was reviewed and a referral to outpatient psychiatric services was noted in the plan. The patient stated that she was unable to comply with this referral in the near future. There were no referrals for chemical dependency or eating disorders noted on review.

In an interview with the Medical Director on 6/15/12 at 10:10 AM, he stated that if a patient had an eating disorder, the facility would try to refer the patient for assistance with that condition upon discharge. He also believed that the facility would follow up with the patients' outpatient mental health providers after discharge, if the patient consented.

During an interview with the Director of Case Management (DCM) on 6/14/12 at 2:45 PM, she reviewed the medical record of Patient 1 and stated that she would have expected documentation of an eating disorder and substance abuse disorder on the discharge forms, and referrals to appropriate programs on the forms, but these were not there.

2. The medical records of Patient 3 from April, 2012 and June, 2012 admissions were reviewed on 6/15/12. The Psychiatric Progress Note completed upon admission to the facility on 4/24/12 included the chief complaint, " I was depressed and suicidal because the kids were bullying me at school ". Patient 3 was discharged from the facility and readmitted in June, 2012, with the same complaint of suicidality related to bullying.

During an interview with the Medical Director on 6/15/12 at 10:10 AM, he reviewed the medical record of Patient 3, who complained of bullying by peers. The Medical Director reviewed the medical record from the April, 2012 admission and stated that the staff would intervene on behalf of a child who complained of bullying. However, he was not able to find evidence of such an intervention in the medical record. He stated that the staff might not have documented the intervention.

In an interview with the DCM on 6/14/12 at 2:45 PM and 3:10 PM, she stated that the subject of bullying should have been addressed in a family meeting prior to discharge. She reviewed the progress notes and concurred that there was no documentation that the issue was addressed. She stated that the case manger should call the school or make additional reports regarding bullying if needed, but there was no evidence that this was done for Patient 3 during the April, 2012 admission.

3. After reviewing the medical record of Patient 1 on 6/14/12 at 2:45 PM, the DCM stated that it would have been a good idea to contact the outpatient provider for Patient 1, who did not agree to her discharge plan, and who had an outpatient counselor and psychiatrist. She stated there was no evidence that the patient refused to give consent to have the outpatient healthcare providers contacted. She stated that she was not sure if there was anything in facility policy regarding contacting outpatient providers.

The facility policy, Discharge Planning (date effective 12/01), read in part, "The case management staff shall assess discharge planning needs and aftercare plan when completing psychosocial evaluations. This shall include identification of the patient's initial discharge plan.", and "Once the assessment is completed and initial discharge plans are developed, the case management staff shall prepare referrals and complete the Case Management Discharge Plan forms and the Psychiatric Discharge/Aftercare Plan."

Based on interview and record review for 1 of 35 patients (Patient 2), the facility failed to arrange for the initial implementation of the patient's discharge plan because it did not ensure that living quarters had been arranged for the patient, and did not ensure that the patient was free of access to firearms, creating the risk of a poor health outcome for the patient.

Findings:

The medical record of Patient 2 was reviewed. The record contained a form, Psychiatric Discharge/Aftercare Plan, dated 4/5/12, that indicated that the patient was discharged to "home." However, the psychosocial assessment dated 3/23/12, completed by the social work intern, indicated that the patient stated that he was recently evicted from his residence and was homeless. Progress notes from 4/3/12 indicated that the patient was willing to go to a board and care, but there was no documentation that a board and care was found for him.

In an interview with the Medical Director on 6/15/12 at 10:10 AM, he stated that discharge planning staff would ensure that a patient who was homeless and wants a home would receive help needed to obtain it prior to discharge from the facility.

In an interview with the Director of Case Management (DCM) on 6/14/12 at 3:10 PM, she reviewed the medical record of Patient 2 and stated that the information regarding the board and care that the patient was to be discharged to had not been documented. She stated that the case manager in charge of his case should have found a board and care for the patient and that where he was being discharged to should have been documented in the medical record. She concurred that no follow-up phone call to the patient had been placed per facility policy as there was no number to call.

Patient 2's Discharge Safety Plan dated 3/23/12 was reviewed and indicated that the patient had access to firearms. However, the subsequent portions of the "Firearms Safety Plan", regarding how the patient would be safeguarded from accessing the firearms, was not completed.

The facility policy, Discharge Planning (date effective 12/01), read in part, "The case management staff shall assess discharge planning needs and aftercare planned when completing psychosocial evaluations. This shall include identification of the patient's initial discharge plan." Additionally, "Once the assessment is completed and initial discharge plans are developed, the case management staff shall prepare referrals and complete the Case Management Discharge Plan forms and the Psychiatric Discharge/Aftercare Plan."

Based on interview and record review, the hospital failed to ensure that they had a process to reassess the patient's discharge plan when factors were identified that could affect the patient's continuing care needs or the appropriateness of the discharge plan for 3 of 35 patients sampled by nursing (Patients 41, 28, and 36) and potentially for any patient discharged from the hospital.

For Patient 41, the hospital failed to ensure that the discharge plan was reassessed to include his allegation of abuse by his parents, "unresolved risk of self-harm", unpredictable assaultive behaviors, loss of hope, and "overall poor behavior." This failure had the potential for the patient to be discharged to an unsafe environment in an unstable condition and had the potential for the patient to cause harm to him-self or to others.

For Patient 28, the hospital failed to ensure that the discharge plan was reassessed to include the patient's allegation that she was bullied at school. This failure had the potential to cause the patient to be discharged back to an unsafe environment and had the potential for the patient to be placed at risk of harm.

For Patient 36, the hospital failed to ensure that the discharge plan was reassessed to include the patient's report of physical abuse by his mother.
This failure had the potential to cause the patient to be discharged back to an unsafe environment and had the potential for the patient to be placed at risk of harm. Patient 36 had a suicide attempt before hospitalization and was diagnosed with alcohol dependance. The hospital discharged him with no instructions for who to contact for follow-up psychiatric and chemical dependency care. This failure had the potential to contribute to the patient dying from suicide.

Findings:

1. A review of the medical record for Patient 41 was conducted on 6/14/12. The review revealed that the patient was a 16 year old who was admitted to the hospital on 2/26/12 with diagnoses that included bipolar disorder and depression.

A review of the intake information, dated 2/26/12 at 4:32 PM, revealed that the patient stated "My mom started cussing me out for no reason...then they (mom & stepdad) started hitting me." Further review revealed that the patient stated, "he wanted to shoot himself in the shoulders and bleed to death in front of his family."

A review of the physician's psychiatric evaluation, dated 2/26/12 at 6:30 PM, revealed that the patient stated, "I don't want to go home. I don't want to be there. I don't want to be beaten up. Both my mother and father are physically beating me up."

A review of the medical record revealed that there was no documentation of a report made to Child Protective Services (CPS) on 2/26/12, 2/27/12, or 2/28/12.

A review of the physician's progress notes, dated 2/28/12, revealed that the patient was reporting being physically beaten up by his parents and a CPS evaluation would be obtained.

Further review of the medical record revealed that a report was filed on 2/29/12 (3 days after the patient reported the abuse to the hospital).

A review of the physician's orders revealed that the patient had an order to discharge home (to his mother and father) on 3/2/12.

A review of the medical record revealed that there was no contact with CPS regarding the patient's safety in being discharged home to his parents.

A review of the discharge instructions, dated 3/12/12, revealed that the patient did not discharge home until 10 days after his order for discharge.

A review of the case management notes, dated 3/6/12, revealed that the patient's parents would take him home, so he was waiting for placement in a group home.

A review of all of the physician's orders from 3/2/12 until discharge on 3/12/12 revealed that there was no updated physician's order for the patient to discharge to placement in a group home on 3/12/12.

A review of the physician's progress notes, dated 3/11/12, revealed that the physician documented that the patient, "continues to make treats for self-harm." The physician also documented, "Unresolved risk of self-harm."

Further review of the medical record revealed that there was no follow up on the day of discharge, by the physician, regarding the patient's unresolved risk of self-harm.

A review of the nurse's notes, dated 3/12/12 (the day of discharge) revealed that the nurse documented that the patient's "Assault" assessment was "unpredictable". The nurse also documented, "Pt (patient) anxious, restless, uncooperative, disruptive and overall poor behavior. Pt cursing staff and inciting poor behaviors in peers. Pt depressed and appearing to lose hope. Pt ready for placement to leave hospital." There was no documentation of notification to the physician regarding the patient's behaviors, mood, unpredictable assault assessment, or the assessment that the patient was appearing to lose hope.

A review of the physician's notes, nursing notes, therapy notes, and the case management notes, for the entire stay, revealed that there was no further mention of the patient's allegation of abuse by his family in relation to his discharge. There was no mention of the physician's failure to document regarding the risk of self-harm.

A review of the hospital policy titled "Discharge Planning", dated 6/11, revealed that there was no requirement for a reassessment of the discharge plan when factors are identified that may affect the patient's continuing care needs or the appropriateness of the discharge plan.

An interview was conducted with the Chief Nursing Officer (CNO) and the Director of Case Management (DCM) on 6/18/12 at 9 AM. They confirmed that the patient had reported abuse to several members of the treatment team and that the first discharge plan was to send him home to his parents (the alleged abusers). The DCM confirmed that the case management staff do not necessarily document if they contacted CPS, when a report of alleged abuse was reported, to discuss the patient's safety in the home. They confirmed that the reason that the patient did not get sent home to his parents on 3/2/12 was that the parents refused to take him home.

In the same interview, the CNO stated the physician did not do a second discharge to placement and did not document a reassessment of the patient's suicide or homicidal risk prior to discharge. The CNO confirmed that the physician had documented a risk of self-harm on the day prior to discharge and did not document a follow up to that risk. The CON confirmed that the nurse documented patient risk behaviors and that there was no documented evidence that the risk had been communicated to the physician prior to the patient's discharge. The CNO confirmed that the discharge plan did not take into consideration the patient's allegation of abuse, the patient's risk of self-harm, unpredictable assaultive behaviors, loss of hope, and "overall poor behavior." The DCM confirmed that the patient had problem identified that could affect his continuing care needs and that the discharge plan was not reassessed to include these problems.

2. A review of the medical record for Patient 28 was conducted on 6/13/12. The review revealed that the patient was a 13 year old who was admitted to the hospital on 4/19/12 with diagnoses that included depression.

A review of the intake information, dated 4/19/12, revealed that the patient "reported being bullied."

A review of the "Adolescent Psychosocial Assessment", dated 4/19/12, revealed, "Pt (patient) reported being bullied at school and is unresolved." The report further documented, "Pt is unable to connect with peers at school and is bullied."

A review of the case management notes, dated 4/20/12, documented, "Pt indicated being bullied at school and is still unresolved."

A review of the physician's notes, nursing notes, therapy notes, and the case management notes revealed that there was no further mention of the patient's allegation of being bullied.

A review of the discharge plan, dated 4/27/12, revealed that the patient was discharged to the same living arrangement she had prior. There was no documented evidence that the allegation of the patient being bullied was investigated or that the home was notified that the patient complained of being bullied at school.

An interview was conducted with the Director of Program Services (DPS) on 6/13/12 at 2:45 PM. She confirmed the documentation that the patient stated she was being bullied at school and acknowledged that being bullied can lead to serious injury for the patient. She confirmed that there was no follow up on the allegation made by the patient and stated that the staff should have followed up. She stated that there was no documentation of a conversation with the patient's home to see if they had already worked with the school and no documentation to show that the staff had contacted the home regarding the allegation.





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3. Patient 36's record was chosen for review due to an entry in the hospital incident log that indicated that the patient had committed suicide a few weeks after being discharged from the hospital.

A review on 6/14/12 of Patient 36's record shows that the patient was admitted to the hospital on 11/25/11 with diagnoses that included major depressive disorder, suicide attempt and alcohol abuse. He was admitted as a 5150 hold (a law that allows for a 72 hour hold in the hospital due to the patient being a danger to himself or others). The patient was discharged home on 11/27/11.

A review of a form titled "Section I -- Point of Contact -- Assessment dated 11/25/11 indicated that Patient 36 reported that his mother physically abused him. Patient 36 also stated that he felt that his mother and ex-wife were conspiring against him.

A review of Patient 36's personal history shows that his parents are supporting him financially as he is unemployed.

There was no indication in the record that the hospital did a follow up to ensure that the patient would be safe from abuse upon discharge.

A review of the Psychiatric Discharge/Aftercare Plan indicated that Patient 36 was discharged home with his mother.

In an interview on 6/14/12 at 4:00 PM with a RN (Registered Nurse) case manager, she acknowledged that the patient's statement that he was abused by his mother was not followed up and should have been before the patient was discharged. The RN case manager stated that there should have been documentation that the patient felt safe to go home with his mother.

A review of Patient 36's Psychiatric Discharge/Aftercare Plan dated 11/27/12 showed the documentation of the patient's discharge instructions. Under the section "After Care Referral, Appointment Plan", the instructions for medical follow-up documented "May call case worker if (you) have questions."

There was no information on where the patient could go, or should go for follow-up treatment of his psychological and addiction problems.

In an interview on 6/14/12 at 4:00 PM with a RN case manager, she acknowledged that the patient should have been given the information on where to go for follow-up treatment.

Based on interview and record review, the hospital failed to ensure that patients and family members or interested persons were counseled to prepare them for post-hospital care by failing to ensure that all patients received discharge instructions on monitoring their weight as it relates to their medications and as instructed by the physician. This failure had the potential for all patients who were discharged from the hospital to have a problem with weight gain or weight loss related to a medication and not be aware of the source of the problem and not seek help for the weight change.

Findings:

1. A review of the medical record for Patient 41 was conducted on 6/14/12. The review revealed that the patient was a 16 year old who was admitted to the hospital on 2/26/12 with diagnoses that included bipolar disorder and depression.

A review of the physician's discharge summary, dated 3/15/12, revealed "Aftercare Instructions" that stated "weight monitoring" (many antipsychotic medications cause problems with a patient's weight).

A review of the patient's discharge plan, dated 3/12/12, revealed no instructions for the patient to conduct weight monitoring.

2. A review of the medical record for Patient 28 was conducted on 6/13/12. The review revealed that the patient was a 13 year old who was admitted to the hospital on 4/19/12 with diagnoses that included depression.

A review of the physician's discharge summary, dated 5/3/12, revealed "Aftercare Instructions" that stated "weight monitoring."

A review of the patient's discharge plan, dated 4/27/12, revealed no instructions for the patient to conduct weight monitoring.

3. A review of the medical record for Patient 29 revealed that she was admitted to the hospital on 3/28/12 with diagnoses that included major depression.

A review of the physician's discharge summary, dated 4/4/12, revealed "Aftercare Instructions" that stated "weight monitoring."

A review of the patient's discharge plan, dated 3/30/12, revealed no instructions for the patient to conduct weight monitoring.

An interview was conducted with the Director of Program Services (DPS) on 6/13/12 at 10 AM. She confirmed that the physician's discharge instructions did not match the information that the patient was given on discharge. She stated that the weight monitoring was important for most patients due to the medication they were prescribed. The DPS stated that the discharge summaries are a template that the clinician just fills in certain areas, so all discharge summaries would have the same information. She confirmed that most of the discharge instructions would not contain that information. The DPS stated that the patient should be given the information and be counseled regarding weight monitoring.










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4. A review on 6/13/12 of the medical record for Patient 26 revealed that she was admitted to the hospital on 3/22/12 with diagnoses that included Bi-Polar disorder, recently manic {a major mental disorder characterized by episodes of mania (hyperactivity, agitation and excitability), depression or mixed mood}.

A review of the physician's discharge summary, dated 4/3/12, revealed "Aftercare Instructions" that stated "weight monitoring."

A review of the patient's discharge plan, dated 3/26/12, revealed no instructions for the patient to conduct weight monitoring.

An interview was conducted with the Director of Program Services (DPS) on 6/13/12 at 10 AM. She confirmed that the physician's discharge instructions did not match the information that the patient was given on discharge. She stated that the weight monitoring was important for most patients due to the medication they were prescribed. The DPS stated that the discharge summaries are a template that the clinician just fills in certain areas, so all discharge summaries would have the same information. She confirmed that most of the discharge instructions would not contain that information. The DPS stated that the patient should be given the information and be counseled regarding weight monitoring.

Based on interview and record review, the hospital failed to evaluate the discharge planning process on an on-going basis to help ensure that they are responsive to the patient's discharge needs. The hospital failed to include in their discharge policy the requirement to conduct a reassessment of the discharge plan when care needs change for the patient. This failure had the potential to result in a negative outcome for a universe of 87 patients, by allowing for no reassessment of the discharge plan when circumstances change for patient.

Findings:

A review of several of the discharge patient medical records revealed that there were factors identified, such as allegations of abuse and being bullied at school that were not reassessed and addressed at the time of discharge. (Refer to A 821)

A review of the hospital policy titled "Discharge Planning", dated 6/11, revealed that there was no requirement for a reassessment of the discharge plan when factors are identified that may affect the patient's continuing care needs or the appropriateness of the discharge plan.

An interview was conducted with the Director of Case Management (DCM) on 6/15/12 at 11 AM. She confirmed that the policy does allow the discharge planning forms to be updated at anytime; however, did not direct discharge planning staff to reassess the discharge plan when the factors were identified that could affect the patient's continuing care needs or the appropriateness of the discharge plan.

In the same interview, with the DCM and the Director of Performance Improvement (DPI), they were asked if the hospital had conducted a quality review of the discharge planning process. The DCM stated that they had reviewed some elements of discharge planning; however, it would not constitute a reassessment of the discharge planning process. The DPI stated that the discharge planning process was not a scheduled item on the quality roster and confirmed that the quality review was not being done on an on-going basis.

Based on interview and record review, the hospital failed to promote the right of the patients to formulate a Healthcare Advance Directive (AD, a written instruction, such as a living will or durable power of attorney for health care, relating to the provision of health care when the individual is incapacitated) for 3 of 35 sampled patients (Patients 23, 1 and 2), and failed to accurately present information to all patients, due to incomplete statements in the facility's pre-printed Advance Directive Acknowledgement form. This failure increased the risk of patients to not have their rights to have Advance Directive healthcare wishes to be known and honored by outside healthcare professionals in the event of an emergency transfer from the hospital.

Findings:

1. On 6/13/12, a review of the hospital's policy titled, "Psychiatric and Medical Advance Directives," dated 2/12, indicated that the hospital's policy was to provide information of Advance Directives and to assess if the patient has a current Medical or Psychiatric Advance Directive. The Purpose statement showed, "To protects the patient's rights to self-determination regarding specific aspects of care planning at end of life and treat the patient/family with discretion and sensitivity."The Procedure section include, "If the patient would like more information, the request is forwarded to the Case Manager. This individual will record in the patient's medical record any information given to the patient to assist with this procedure.

On 6/13/12, a review of Patient 23's medical record was conducted.

A review of the face sheet indicated that Patient 23 was admitted to the facility on 9/11/11, with diagnoses that included depression.

A review of the facility's Advance Directive Acknowledgement (ADA) document was conducted and revealed that the patient did not submit an executed a Health Care (Advance Directive) on admission. The ADA document section that indicated whether the patient wished to execute a Healthcare Advance Directive was blank. There were no hospital staff signatures on the document to indicate that the hospital's AD policy was followed.

On 6/15/12 at 2:10 PM, an interview was conducted with the Chief Nursing Officer (CNO). The CNO reviewed the patient's Advance Directive Acknowledgement document and confirmed that the documentation was incomplete. She stated that the hospital was in the process of revising the document to ensure that patients' right to formulate an advance directive was promoted.




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2. The medical record of Patient 1 was reviewed, and contained a form, Advance Directive Acknowledgement. The top section of the pre-printed form contained instruction, "Place your initials after each statement.", with six statements regarding the patient's wishes and a line to the left of each statement for the patient to initial. However, for Patient 1, only one set of initials was provided, in the margin opposite statement 4. The bottom portion of the pre-printed form contained a series of incomplete statements, such as, "I have not executed a health care."

In an interview with the Director of Program Services (DPS) on 6/13/12 at 8:40 AM, she reviewed the Advanced Directives Acknowledgement pre-printed form in the medical record of Patient 1. The DPS stated that the six questions should have been bracketed as she believed that the initials were intended to apply to all six statements. She also concurred that some of the pre-printed statements on the form, such as, "I have not executed a health care" were incomplete. She stated that she had not previously noted that the form contained incomplete statements.

3. The medical record of Patient 2 was reviewed, and contained the form, Advance Directive Acknowledgement. The top section of the pre-printed form contained the six statements and the instructions to "Place your initials after each statement". However, Patient 1 had initialed only one statement, "I understand that (Hospital name) does not provide advance cardiac life support." Other statements such as, "I have been given material about my right to accept or refuse medical treatments", had not been acknowledged by the patients with his initials.

During an interview with the DPS on 6/13/12 at 8:40 AM, she stated that each of the statements on the top of the form were to have been initialed by the patient, to document that the patient received the information.

Based on interview and record review the facility failed to ensure that 5 of 35 sampled patients (Patient 21, 3, 41, 28 and 36) were protected from all forms of abuse.

1. For Patient 21, the hospital failed to ensure that the patient was not assaulted (a violent physical attack) on 6/11/12 by Patient 24 who had exhibited aggressive behavior two days (on 6/9/12) prior to the physical attack. The facility's failure to implement measures to prevent Patient 24's progressive escalation in behaviors contributed to harm for Patient 21 and Patient 24.

2. For Patient 3, the hospital failed to ensure that the patient's allegation of bullying at school was investigated and his safety promoted prior to the patient being discharged back to the same environment. This resulted in Patient 3 returning to the facility with recurrent suicidality related to bullying.

3. For Patient 41, the hospital failed to ensure prompt reporting of an allegation of abuse by the patient's parents to child protective services (CPS). The hospital also failed to follow up with CPS prior to attempting to discharge the patient home to his parents. This failure had the potential for the patient to suffer continuing abuse and continuing harm including death.

4. For Patient 28, the hospital failed to ensure that the patient's allegation of being bullied at school was investigated and reported to her group home prior to her discharge back to the same environment. This failure had the potential for the patient to continue to suffer abuse.

5. For Patient 36, the hospital failed to ensure that patient's allegation of abuse by his mother was investigated. The hospital discharged Patient 36 without ensuring that he was not going back to an abusive environment. This failure had the potential to contribute to harm to the patient.

These failures contributed to the Patient to Patient abuse for Patient 21 and created the risk for all patients that received care and/or services in the hospital to experience different forms of abuse.

Findings:

1. A review of the facility's policy, "Patient Abuse or Neglect," dated 3/12, did not address Patient to Patient abuse.

A review of the facility's Nursing policy, "Assault/Aggression/Homicidal Ideation Precautions," dated 1/2012 was conducted and revealed the following:

Policy: Patients assessed to be at heightened risk of assault, aggression towards others or destruction of property as determined in the conclusion of core assessments such as Assessments and Referral, Nursing Assessment, Psychiatric Evaluation, or based upon patient statements and or behaviors, may be placed on Assault/Aggression Precautions commensurate with the assessed level of risk, homicidal ideation. Staff responsible for monitoring patients on assault precautions shall maintain the patient in a safe environment and take measures to protect the patient and others from harm.

Definitions: 15-minute checks - staff may make contact with the patient and confirm that the patient is safe and in no physical distress at frequent intervals not to exceed 15 minutes apart. Whenever possible, verbally interact with patient to assess safety and well-being.

1 to 1 - a dedicated staff member is assigned to remain within arm ' s reach of the patient at all times.

Limit Setting - offering the patient reasonable choices and consequences in response to threatening or unsafe behavior.

Procedure: A Registered Nurse (RN) may immediately increase the level of observation based upon assessment/reassessment without a physician order.

The observation flow sheet shall clearly indicate if a patient is on Assault/Aggression precautions.

Treatment Planning (TP) and Documentation: Routine Observation Sheets should indicate that the patient is on Assault/Aggression Precautions.

The TP should indicate separate problems and/or goals which address aggressive behaviors, and interventions to be used by staff in response.

Any individual behavior plans should be included in the TP.

Nursing progress notes should reflect re-assessment of aggressive behaviors, response to as necessary medication and effectiveness of de-escalation techniques.

On 6/15/12, a review of Patient 21's medical record was conducted with RN 2 and the Director of Program Services (DPS).

A review of Patient 21's medical record face sheet showed that the patient was admitted to the hospital on 5/19/12, with diagnoses that included paranoid schizophrenia (psychiatric disorder).

A review of the "Daily Treatment Plan Update/RN Assessment," dated 6/11/12, showed that Patient 21 was involved in an altercation with a peer (Patient 24). Patient 21 was punched on the face and swelling was noted. The plan of care section showed, "continue to monitor for safety, ice pack to swelling."

A review of Patient 21's physician order (PO), dated 6/11/12, revealed an order for an ice compress to right forehead and left hand swelling every 2 hours for 24 hours as tolerated, and Motrin (pain medication) 400 milligrams (mg) orally every 4 hours as necessary for pain.

A review of Patient 21's Medication Administration Record, dated 6/11/12, revealed that the patient required an ice compress for face swelling.

A review of the "Progress Note Documentation," dated 6/11/12 at 2 PM, revealed that the patient stated, "I was in my room lying down and a peer came and punched me on my face." The physical assessment section revealed that the patient acquired swelling to his face. The nursing actions/interventions section noted ice compress was applied to the patients face swelling. The document noted that the patient's TP was updated.

A review of patient's TP did not reflect an update to address the assault as the Progress Note Documentation indicated.

On 6/15/12 at 11 AM, an interview was conducted with RN 1 and the DPS regarding the incident. RN 1 verified that she was on duty on the day and at the time of the Patient to Patient altercation, and that she observed the patient's injuries. When asked what measures the facility took to protect Patient 21 from further harm and others from harm, RN 1 and the DPS stated that the aggressor (Patient 24) had been discharged from the facility. The DPS suggested that the surveyor speak with the facility's Risk Manager (RM) who was responsible for conducting the investigation.

On 6/15/12, a review of Patient 24's (aggressor) medical record was conducted and revealed that the patient was admitted to the facility on 6/9/12 with diagnoses that included depression. The patient was on a 72 hour detention (involuntary hold) related to being a danger to self. The patient was discharged from the facility on 6/14/12.

A review of the initial Interdisciplinary Treatment Plan (TP), dated 6/9/12, showed that the patient's problem list addressed self harm and depression.

A review of the "Daily Treatment Plan Update/RN Assessment," dated 6/9/12, showed that Patient 24 was agitated and threw a chair at a window. The patient stated that he wanted to harm others.

A review of the PO, dated 6/9/12 at 1:10 PM, revealed an order to administer Benadryl (antihistamine) 50 mg orally now, "patient agitated, threw chair against window, threatening peer."

A review of the "Patient Observation/Rounds Precautions," dated 6/9/12, was conducted and revealed that after the incident the patient remained on the every 15 minute observation monitoring by staff. The documentation failed to show that the patient was placed on Assault/Aggression Precautions (included - to tell nurse ''now" of increased agitation, paranoia, anger, hallucinations, homicidal ideations; 5 feet separation from "at risk" peers; document all acting our behavior/add to shift report).

A review of the "Progress Note Documentation", dated 6/9/12 at 1:10 PM, revealed that the patient got in an argument with a peer. Patient 24 picked up a chair and threw it at a window. The documentation indicated that the patient's treatment plan was updated on 6/9/12.

A review of the patient's medical record failed to show documented evidence that a TP was implemented to address the aggressive behaviors.

A review of the "Daily Treatment Plan Update/RN Assessment," dated 6/11/12, showed tha

Based on interview and record review the hospital failed to measure, analyze, and track quality indicators that assessed the processes of care and hospital services, creating the risk for a poor health outcome for all patients receiving care from the hospital.

1. The hospital failed to ensure that the Quality Program evaluated the discharge planning process on an on-going basis to help ensure that they are responsive to the patient's discharge needs.

2. The hospital failed to ensure that the Quality Program evaluated the contracted services provided by the Pharmacist.

3. The hospital failed to ensure that the Quality Program evaluated the patient classification system for validity and for nursing knowledge of the system. The hospital also failed to ensure that each patient was assigned a primary nurse responsible for his or her care.

4. The hospital failed to ensure that the Quality Program evaluated nursing services to ensure that all nursing staff had the competencies required to provide safe patient care.

5. The hospital failed to ensure that the Quality Program evaluated medical records to ensure that patient records were accessible at all times.

6. The hospital failed to ensure that the Quality Program evaluated the process of the development and implementation of a patient's plan of care.

7. The hospital's food service department failed to measure, analyze and track quality indicators related to the provision of nutrition services.

These failures had the potential to result in substandard care provided by the facility for a universe of 87 patients and created the possibility of missed opportunities for improvement in care provided to the patients.

Findings:

1a. A review of several of the discharge patient medical records revealed that there were factors identified, such as allegations of abuse and being bullied at school that were not reassessed and addressed at the time of discharge. (Refer to A 821)

A review of the hospital policy titled "Discharge Planning", dated 6/11, revealed that there was no requirement for a reassessment of the discharge plan when factors are identified that may affect the patient's continuing care needs or the appropriateness of the discharge plan.

An interview was conducted with the Director of Case Management (DCM) on 6/15/12 at 11 AM. She confirmed that the policy does allow the discharge planning forms to be updated at anytime; however, the policy did not direct discharge planning staff to reassess the discharge plan when the factors were identified that could affect the patient's continuing care needs or the appropriateness of the discharge plan.

In the same interview, with the DCM and the Director of Performance Improvement (DPI), they were asked if the hospital had conducted a quality review of the discharge planning process. The DCM stated that they had reviewed some elements of discharge planning; however, it would not constitute a reassessment of the discharge planning process. The DPI stated that the discharge planning process was not a scheduled item on the quality roster and confirmed that the quality review was not being done on an on-going basis.

b. The medical records were reviewed for Patients 1, 2 and 3. The facility failed to perform discharge planning for health related conditions such as eating disorders and substance abuse disorders and failed to follow-up on patient complaints of conditions that threatened their well-being, creating a risk of a poor health outcome for those patients (see A818). For one of 1 of 35 sampled patients (Patient 2) the facility failed to ensure that the patient was discharged to a home and that he was safe from access to firearms (see A820).

During an interview with the DPI on 6/13/12 at 2 PM, she stated that the facility reviewed discharge planning only for elements of family contact, a single referral, and a discharge safety plan. She stated that referrals for secondary problems and whether the patient had a home to be discharged to, had not been the subject of quality assurance review.

2a. A review of the list of "Users" for the hospital's automated drug delivery system, PIXIS, was reviewed and compared with a list of active employees on 6/15/12.

The comparison revealed that there were several employees who were active on the PIXIS list that were not on the active employee list.

An interview was conducted with the hospital's Pharmacist on 6/14/12 at 10:15 AM. He stated that there was no updated list and that the pharmacy had not reviewed the employees that were terminated from the hospital, so that their PIXIS access could be removed, since July 2011. He stated that there was no process for Human Resources (HR) to notify pharmacy regarding previous staff members who no longer worked in the hospital. The Pharmacist confirmed that it was his responsibility to ensure the security of medications, especially controlled medications. He acknowledged that the security of medications was an important part of his supervision of pharmaceutical services.

An interview was conducted with the DPI on 6/15/12 at 11 AM. She stated that the hospital had not conducted a review of the contracted pharmacy services.

b. An interview was conducted with Registered Nurse (RN) 2, on Unit 1, on 6/12/12 at 2 PM. She stated that if a medication order was received from a physician for a patient on hours that the pharmacy was not open, the nurse would give the medication if it was available in the PYXIS (automated drug delivery system). She stated that the only time the nurse would call the pharmacist was if the medication was not available.

An interview was conducted with RN 3, on Unit 2, on 6/12/12 at 2:30 PM. She stated that if the physician ordered a medication for a patient when the pharmacy was closed, the nurse gave the medication if it was available. She stated that they would call the Pharmacist, only if the medication was not available. RN 3 was asked if the nurse faxed the order to the Pharmacist for review prior to administration, if it was a first time dose for the patient. She replied "no". She stated that a copy of the order was placed in the medication room and the pharmacy picked up the order the next day.

A review of the hospital's pharmacy policy and procedure manual was conducted on 6/13/12. There was no policy found outlining the process for the Pharmacist to review the first dose of a medication before the medication was given to the patient, except in the event of an emergency.

An interview was conducted with the Pharmacist of the hospital on 6/14/12 at 9 AM. He stated that he did not have a process for the nursing staff to notify him, on hours when the pharmacy was closed (the pharmacy hours are Monday through Friday 6:30 AM to 2 PM and on the weekend, 9 AM to 1 PM), of new medication orders so that he could review the medications prior to the first dose being administered to the patient. He stated that the medication could be held and not given until the next day. The Pharmacist acknowledged that some medications are scheduled to be given at night, so the patient would have to wait over 24 hours before the first dose. The Pharmacist confirmed that supervision of the pharmaceutical services included reviewing a medication prior to the first dose being administered and that making the patient wait for the first dose could be a patient safety concern.

An interview was conducted with the DPI on 6/15/12 at 11 AM. She stated that the hospital had not conducted a review of the contracted pharmacy services.

c. A review of the employee file for the hospital Pharmacist was conducted on 6/18/12. The review revealed that the last performance evaluation of the Pharmacist was conducted on 1/9/09.

An interview was conducted with the Human Resource Director on 6/18/12 at 11 AM. She confirmed that a performance evaluation had not been conducted on the Pharmacist, who provided a contracted service, since 1/9/09.

An interview was conducted with the DPI on 6/15/12 at 11 AM. She stated that the hospital had not conducted a review of the contracted pharmacy services.

3a. A review of the hospital's patient classification system was conduct

Based on interview and record review the hospital failed to measure, analyze, and track quality indicators that assessed the processes of care and hospital services, creating the risk for a poor health outcome for all patients receiving care from the hospital.

1. The hospital failed to ensure that the Quality Program evaluated the discharge planning process on an on-going basis to help ensure that they are responsive to the patient's discharge needs.

2. The hospital failed to ensure that the Quality Program evaluated the contracted services provided by the Pharmacist.

3. The hospital failed to ensure that the Quality Program evaluated the patient classification system for validity and for nursing knowledge of the system. The hospital also failed to ensure that each patient was assigned a primary nurse responsible for his or her care.

4. The hospital failed to ensure that the Quality Program evaluated nursing services to ensure that all nursing staff had the competencies required to provide safe patient care.

5. The hospital failed to ensure that the Quality Program evaluated medical records to ensure that patient records were accessible at all times.

6. The hospital failed to ensure that the Quality Program evaluated the process of the development and implementation of a patient's plan of care.

7. The hospital's food service department failed to measure, analyze and track quality indicators related to the provision of nutrition services.

These failures had the potential to result in substandard care provided by the facility for a universe of 87 patients and created the possibility of missed opportunities for improvement in care provided to the patients.

Findings:

1a. A review of several of the discharge patient medical records revealed that there were factors identified, such as allegations of abuse and being bullied at school that were not reassessed and addressed at the time of discharge. (Refer to A 821)

A review of the hospital policy titled "Discharge Planning", dated 6/11, revealed that there was no requirement for a reassessment of the discharge plan when factors are identified that may affect the patient's continuing care needs or the appropriateness of the discharge plan.

An interview was conducted with the Director of Case Management (DCM) on 6/15/12 at 11 AM. She confirmed that the policy does allow the discharge planning forms to be updated at anytime; however, the policy did not direct discharge planning staff to reassess the discharge plan when the factors were identified that could affect the patient's continuing care needs or the appropriateness of the discharge plan.

In the same interview, with the DCM and the Director of Performance Improvement (DPI), they were asked if the hospital had conducted a quality review of the discharge planning process. The DCM stated that they had reviewed some elements of discharge planning; however, it would not constitute a reassessment of the discharge planning process. The DPI stated that the discharge planning process was not a scheduled item on the quality roster and confirmed that the quality review was not being done on an on-going basis.

b. The medical records were reviewed for Patients 1, 2 and 3. The facility failed to perform discharge planning for health related conditions such as eating disorders and substance abuse disorders and failed to follow-up on patient complaints of conditions that threatened their well-being, creating a risk of a poor health outcome for those patients (see A818). For one of 1 of 35 sampled patients (Patient 2) the facility failed to ensure that the patient was discharged to a home and that he was safe from access to firearms (see A820).

During an interview with the DPI on 6/13/12 at 2 PM, she stated that the facility reviewed discharge planning only for elements of family contact, a single referral, and a discharge safety plan. She stated that referrals for secondary problems and whether the patient had a home to be discharged to, had not been the subject of quality assurance review.

2a. A review of the list of "Users" for the hospital's automated drug delivery system, PIXIS, was reviewed and compared with a list of active employees on 6/15/12.

The comparison revealed that there were several employees who were active on the PIXIS list that were not on the active employee list.

An interview was conducted with the hospital's Pharmacist on 6/14/12 at 10:15 AM. He stated that there was no updated list and that the pharmacy had not reviewed the employees that were terminated from the hospital, so that their PIXIS access could be removed, since July 2011. He stated that there was no process for Human Resources (HR) to notify pharmacy regarding previous staff members who no longer worked in the hospital. The Pharmacist confirmed that it was his responsibility to ensure the security of medications, especially controlled medications. He acknowledged that the security of medications was an important part of his supervision of pharmaceutical services.

An interview was conducted with the DPI on 6/15/12 at 11 AM. She stated that the hospital had not conducted a review of the contracted pharmacy services.

b. An interview was conducted with Registered Nurse (RN) 2, on Unit 1, on 6/12/12 at 2 PM. She stated that if a medication order was received from a physician for a patient on hours that the pharmacy was not open, the nurse would give the medication if it was available in the PYXIS (automated drug delivery system). She stated that the only time the nurse would call the pharmacist was if the medication was not available.

An interview was conducted with RN 3, on Unit 2, on 6/12/12 at 2:30 PM. She stated that if the physician ordered a medication for a patient when the pharmacy was closed, the nurse gave the medication if it was available. She stated that they would call the Pharmacist, only if the medication was not available. RN 3 was asked if the nurse faxed the order to the Pharmacist for review prior to administration, if it was a first time dose for the patient. She replied "no". She stated that a copy of the order was placed in the medication room and the pharmacy picked up the order the next day.

A review of the hospital's pharmacy policy and procedure manual was conducted on 6/13/12. There was no policy found outlining the process for the Pharmacist to review the first dose of a medication before the medication was given to the patient, except in the event of an emergency.

An interview was conducted with the Pharmacist of the hospital on 6/14/12 at 9 AM. He stated that he did not have a process for the nursing staff to notify him, on hours when the pharmacy was closed (the pharmacy hours are Monday through Friday 6:30 AM to 2 PM and on the weekend, 9 AM to 1 PM), of new medication orders so that he could review the medications prior to the first dose being administered to the patient. He stated that the medication could be held and not given until the next day. The Pharmacist acknowledged that some medications are scheduled to be given at night, so the patient would have to wait over 24 hours before the first dose. The Pharmacist confirmed that supervision of the pharmaceutical services included reviewing a medication prior to the first dose being administered and that making the patient wait for the first dose could be a patient safety concern.

An interview was conducted with the DPI on 6/15/12 at 11 AM. She stated that the hospital had not conducted a review of the contracted pharmacy services.

c. A review of the employee file for the hospital Pharmacist was conducted on 6/18/12. The review revealed that the last performance evaluation of the Pharmacist was conducted on 1/9/09.

An interview was conducted with the Human Resource Director on 6/18/12 at 11 AM. She confirmed that a performance evaluation had not been conducted on the Pharmacist, who provided a contracted service, since 1/9/09.

An interview was conducted with the DPI on 6/15/12 at 11 AM. She stated that the hospital had not conducted a review of the contracted pharmacy services.

3a. A review of the hospital's patient classification system was conduct

Based on interview and record review, the medical staff failed to follow the Medical Staff Bylaws for 6 of 35 sampled patients (Patients 1, 12, 2, 5, 41, and 22) because:

1. For Patients 1 and 12, the discharge summaries were not completed by the medical staff, and the discharge summaries were incomplete, creating the risk of substandard healthcare for all patients discharged from the facility due to the possibility of inaccurate and incomplete discharge summaries.

2. For Patient 2, the medical staff did not follow-up on an abnormal lab test result, creating the risk of a poor health outcome for Patient 2.

3. For Patient 5, the physician omitted significant information from the medical records of that patient, creating the risk of a poor health outcome for Patients 5.

4. For Patient 1, the physicians omitted information from the psychiatric evaluation, history and physical examination, contributing to the risk of untreated conditions.

5. For Patient 41, the medical staff failed to ensure that the physician responsible for Patient 41 documented that he had evaluated the patient on the day of patient discharge to determine if the patient was still a danger to himself. Patient 41 was on a 14 day hold for being a danger to himself. This failure had the potential for the patient to be discharged from the hospital and cause himself harm including death.

6. For Patient 22, the hospital failed to ensure that the Medical Staff complied with the Bylaws. Patient 22's history and physical (H&P) evaluation was incomplete. This failure created the risk for the patient's history and physical evaluation to not be communicated to all authorized persons involved in the patient's care to ensure continuity of care.

Findings:

1. During an interview with the Medical Director on 6/15/12 at 10:10 AM, he stated that other staff members were completing the discharge summaries for patients leaving the facility, and that the physicians were signing the summaries.

In an interview with the Director of Case Management (DCM) on 6/14/12 at 2:45 PM, she stated that one of the Director of Program Services's (DPS) employees was completing the discharge summary, which was then signed by the physician. She stated that if the physician left information off of the handwritten discharge information form, it was not included on the typed discharge summary.

The discharge summary of Patient 12 was reviewed with the DCM on 6/14/12 at 3:10 PM. She stated that the physician had not included all information regarding patient discharge conditions on the handwritten discharge order, and hence it had not been included on the discharge summary.

During a interview with the Medical Director on 6/15/12 at 10:10 AM, he stated that the discharge summary should include all relevant medical diagnoses, including drug abuse.
He stated that the omissions on the discharge summaries were the physician's responsibility.

The Medical Staff Rules and Regulations, chapter 2, was reviewed, and included the requirement that the medical staff were to complete a discharge summary on each patient.

2. The medical record of Patient 2 was reviewed on 6/13/12 and showed that the patient reported in the admission assessment on 3/22/12 that he was feeling out of control and very anxious. The admitting clinician recorded that he was agitated and irritable. Upon testing at the psychiatrist's order, on 3/23/12, Patient 2 had a lab result of TSH (thyroid stimulating hormone) 0.011 mIU/L (milli-international units per liter) (this value is abnormally low, and suggestive of an abnormally elevated thyroid hormone level). There was no evidence of confirmatory testing or treatment for an elevated thyroid hormone level prior to discharge on 4/5/12.

According to the Medline Plus reference of the National Institute of Health, symptoms of elevated thyroid level (hyperthyroidism) include nervousness, restlessness and difficulty concentrating.

During an interview with the Medical Director on 6/15/12 at 12 PM, he stated that he was unable to find evidence of follow-up of a low TSH for Patient 2 in the medical record, and that the lab value should have been followed up by the physician.

3a. The medical record of Patient 1 was reviewed and her Discharge Summary dated 4/11/12 included a list of "Admitting Diagnoses" from her 4/7/12 admission including major depression with anxiety and suicidal ideation, anorexia and bulimia nervosa, marijuana abuse and alcohol abuse. The "Discharge Diagnoses" included only that of major depression. A review of the medical record did not show evidence that her eating disorders or chemical dependency problems had been resolved during the admission.

b. The medical record of Patient 5 was reviewed and showed an admitting diagnosis of bipolar NOS (not otherwise specified) with psychotic features. The discharge diagnosis was listed as schizoaffective disorder on the discharge summary. The progress notes during the patient's stay indicated that the diagnosis was "unchanged from treatment plan", which indicated bipolar disorder.

The discharge summary of Patient 5 was reviewed with the DPS on 6/15/12 at 9:35 AM, and she stated that the typed discharge summary was dictated by a social worker who culled information from the medical record that the physician then signed.

During an interview with the Medical Director on 6/15/12 at 12 PM, he concurred that there was a discrepancy between the admitting and discharge diagnoses, and stated that the physician should have clarified the change in diagnosis in his chart documentation, but he did not see such clarification in the record.

During a interview with the Medical Director on 6/15/12 at 10:10 AM, he stated that the discharge summary should include all relevant medical diagnoses, including drug abuse.
He stated that the omissions on the discharge summaries were the physician's responsibility.

4. The medical record of Patient 1 was reviewed and showed a pre-printed Psychiatric Evaluation form in which there was a list of possible reasons for admission. However, none of the reasons were indicted for Patient 1, the section was left blank.

Patient 1's History and Physical Evaluation form had a section to record the patient's medical history, but the section was left blank, despite the patient's report of anorexia and bulimia. The section for illegal drugs used indicated only THC (marijuana), while elsewhere in the record multiple substances were listed, including the use of heroin the day prior to admission. The section for Family Medical History contained the note, N/C (noncontributory), despite the fact that elsewhere in the record a history of depression and suicidally in the grandmother were reported.

Further review of Patient 1's medical record showed that she did not receive inpatient treatment or outpatient referrals for anorexia or bulmia, and she did not receive a referral for substance abuse/chemical dependency upon discharge.

The Medical Staff Rules and Regulations section 2.8 specified that the psychiatric evaluation should include, "reason for hospitalization". Section 2.7 specified that the History and Physical Evaluation should include, "sufficient information necessary to provide the care and services required to address the patient's present conditions and needs", and was to include "substance abuse history", and "family medical history".


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5. A review of the medical record for Patient 41 was conducted on 6/14/12. The review revealed that the patient was admitted to the hospital on 2/26/12 with diagnoses that included bipolar disorder and depression.

A review of the physician's psychiatric evaluation, dated 2/26/12 at 6:30 PM, revealed that the patient stated that he, "reported feeling extremely depressed and wanted to commit suicide. He stated that he wanted to shoot himself in the shoulders and bleed to death in front of his family."

A review of the hearing officer's determination regarding the patient's 14 day hold, dated 3/1/12, revealed that the hospital had probable cause to keep the patient because he was a danger to himself.

A review of the physician's progress notes, dated 3/11/12,

Based on interview and record review the hospital failed to have an organized nursing service as evidenced by:

1. The hospital's failure to develop a policy regarding a current facility practice pertaining to patients who were at a risk for harming themselves. This practice was called "Contracting for Safety" by the facility.

2. The hospital's failure to ensure that the nursing staff had competency evaluations for the tasks that were needed for patient care.

For a universe of 87 patients, these failures had the potential to contribute to the increase risk of patient harm related to patients who verbally agree to not harm themselves and still have the intent to do otherwise as well as patients who receive care from a nursing staff that may not be adept in providing the necessary care required by the patients.

Findings:

1. On 6/12/12 through 6/14/12 several patient medical records were reviewed. On the nursing "Suicide Risk Assessment" a number for the patient's risk was assigned. On many of the record a hand written note was observed that stated "Contract for Safety." A review of the medical records revealed that there was no document that discussed further the contract for safety.

An interview was conducted with the Chief Nursing Officer (CNO) on 6/15/12 at 10 AM. When the CNO was asked to define/explain what was "Contract for Safety". She responded that contract for safety was when the patient gives the nurse a verbal agreement that they will not attempt to hurt themselves. Given this agreement, even if the patient's suicide risk assessment number was high, the patient was assessed to require less monitoring. The CNO stated that the nurse asked for the verbal contract from the patient upon admission, during the patient's suicide risk assessment; however, the CNO stated that often the patients have repeated their story to the police, the staff in the emergency room and the intake staff at the hospital. She stated that the patient may be tired at that time and may just agree to contract for safety, so they can get some sleep.

During the same interview, the CNO was asked if the hospital had a policy related to the "Contract for Safety" and she stated that they did not have a policy to direct staff on how and when to ask the patient regarding contracting for safety.



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2. A review of three (3) nursing employee files was conducted on 6/18/12. The three nursing files did not contain complete competency evaluations. There were tests taken by the staff to indicate an understanding of the competency, but there were no recorded observations of the staff performing the tasks to ensure that they were competent of the required care tasks.

In an interview on 6/12/12 at 3:15 PM with LPT (Licensed Psychiatric Technician) 1, LPT 1 stated that the nurses administer hand-held nebulizer (a device that delivers medication in a mist form to be inhaled) medications, as there were no respiratory therapists in the hospital. LPT 1 stated that a staff member trained her on how to use the hand-held nebulizer but that she never received an official in-service training for the hand-held nebulizer.

In an interview on 6/18/12 at 5:45 PM with the CNO, she stated that the nursing staff needed to be competent in the following areas: De-escalation (calming an agitated patient), Medical emergencies and Suicide risk assessment. The CNO stated that there had been no training conducted for the use of hand-held nebulizers. The CNO acknowledged that the competency evaluations for the staff were not complete.

Based on interview and record review the hospital failed to ensure that an RN supervised and evaluated the nursing care for 10 of 35 sampled patients (Patient 36, 40, 41, 28, 29, 43, 1, 30, 32, 34).

For Patients 36, 40, 41, 28, 29 and 43 the hospital failed to ensure that the treatment plan goals were documented and met. The hospital further failed to ensure that the patients' suicide risk assessments were accurate. These failures had the potential (1) to contribute to substandard nursing care provided to the patients, (2) for patients to be discharged from the facility without meeting their treatment goals and (3) for patients to not have the care necessary for safety related to their suicide risk.

For Patient 40 the hospital failed to ensure that the patient was monitored after a new medication was administered to the patient to ensure that the patient was protected from a potential injury due to a potential fall. This may have contributed to the patient hitting his forehead on the floor.

For Patient 28, the hospital failed to ensure that the nurse notified the physician that the patient was "verbally threatening assault" prior to discharge. This failure had the potential to result in harm to the patient or to others after the patient's discharge

For Patients 1, 32 and 34, the hospital failed to ensure that the nursing staff accurately completed the Nutrition Risk Screens.

For Patients 32 and 30, the hospital failed to ensure that the physician was informed of the patients' significant weight changes.

Findings:

1. A review of Patient 36's record on 6/14/12 showed that the patient was admitted to the hospital on 11/25/11 with diagnoses that included recurrent depression, alcohol dependency and suicide attempt. The patient was discharged from the hospital on 11/27/11.

A review of the treatment plan showed the following goals:

Patient will develop aftercare plan for finding assistance for self-harm feelings/impulses. Date resolved: 11/27/11
Patient will learn two coping skills. Date resolved: 11/27/11
Patient will identify trigger to self-harm. Date resolved: 11/27/11

There was no clear documentation in the patient's record of how Patient 36 met the treatment plan goals.

In an interview on 6/15/12 at 10:00 AM with the Chief Nursing Officer (CNO), she acknowledged that there should be documentation in the record of how the patient met the treatment plan goals.

2. A review of Patient 40's record on 6/15/12 showed that the patient was admitted to the hospital on 3/18/12 with a diagnosis of schizophrenia, chronic, paranoid type (a psychiatric condition characterized by gross distortion of reality, disturbances of language and communication, withdrawal from social interaction and disorganization and fragmentation of thought, perception and emotional reaction). The patient was discharged from the hospital on 3/27/12.

A review of the treatment plan showed the following goals for a fall risk:

Patient will follow medical recommendations. Date resolved: 3/27/12.
Patient will verbalize identified hazards in living environment. Date resolved: 3/27/12

There was no clear documentation in the record of how Patient 40 met the treatment plan goals.

In an interview on 6/15/12 at 10:00 AM with the CNO, she acknowledged that there should be documentation in the record of how the patient met the treatment plan goals.

3. A review of Patient 36's record on 6/14/12 showed that the patient was admitted to the hospital on 11/25/11 with diagnoses that included recurrent depression, alcohol dependant and suicide attempt. The patient was discharged from the hospital on 11/27/11.

A review of the Suicide Risk Assessment showed that if the score was 0-7 the suicide risk was low and that the patient may be placed on routine every 15 minute observations and monitored for any change of status. If the score was 8-14 the suicide risk was moderate and the patient was to be monitored every 15 minutes for safety and initiate the risk for self harm treatment plan. If the score was 15-29 the suicide risk was high and the patient was to be evaluated for 1 on 1 monitoring (a staff member would be continuously watching the patient) and initiate the suicide precautions treatment plan.

Further review of the Suicide Risk Assessment showed that Patient 36 was scored by the nurse as a "7" which indicated that the patient was a low suicide risk. Even though the reason the patient was hospitalized was due to a suicide attempt.

In an interview on 6/15/12 at 9:00 AM with the Chief Nursing Officer, she acknowledged that the patient's suicide attempt should have been taken into account when assessing the patient for suicide risk.

4a. A review of Patient 40's record on 6/15/12 showed that the patient was admitted to the hospital on 3/18/12 with diagnosis that included schizophrenia, chronic, paranoid type (a psychiatric condition characterized by gross distortion of reality, disturbances of language and communication, withdrawal from social interaction and disorganization and fragmentation of thought, perception and emotional reaction) and a suicide attempt. The patient was discharged from the hospital on 3/27/12.

A review of the Suicide Risk Assessment showed that if the score was 0-7 the suicide risk was low and that the patient may be placed on routine every 15 minute observations and monitored for any change of status. If the score was 8-14 the suicide risk was moderate and the patient was to be monitored every 15 minutes for safety and initiate the risk for self harm treatment plan. If the score was 15-29 the suicide risk was high and the patient was to be evaluated for 1 on 1 monitoring (a staff member would be continuously watching the patient) and initiate the suicide precautions treatment plan.

Further review of the Suicide Risk Assessment showed that Patient 40 was scored by the nurse as a "1" which indicated that the patient was a low suicide risk. Even though the reason the patient was hospitalized was due to a suicide attempt.

In an interview on 6/15/12 at 1:45 PM with the Chief Nursing Officer, she acknowledged the suicide risk assessment did not take into account the reason for the patient's admission and recent past behavior and should be considered when assessing for suicide risk.

b. A review of Patient 40's record on 6/15/12 showed that the patient was admitted to the hospital on 3/18/12 with a diagnosis of schizophrenia, chronic, paranoid type (a psychiatric condition characterized by gross distortion of reality, disturbances of language and communication, withdrawal from social interaction and disorganization and fragmentation of thought, perception and emotional reaction).

A review of a Patient Fall Progress Note, dated 3/20/12 and timed 9:00 PM, indicated that Patient 40 was found on the floor in the hallway asleep. The Patient Fall Progress Note further indicated that the patient was easily awakened, appeared drowsy and was able to follow directions. There was no apparent injury.

A treatment plan for Fall Risk was initiated on 3/20/12, the night that the patient was found on the floor. The documented reason for the fall risk was "Drugs that alter LOC (level of consciousness) or behavior - Seroquel (an antipsychotic medication that can cause drowsiness) increased to 800 mg (milligrams)." Under the short-term goals was the instruction to "Monitor patient after administration of new medication."

A review of a Patient Fall Progress Note dated 3/23/12 and timed 9:15 PM indicated that Patient 40 was "asleep on chair and fell forward, according to peer." The patient had "pink to red small area on forehead."

The two falls occurred during the same time in the evening, approximately half (1/2) an hour after Seroquel was given to the patient.

There were no new interventions to prevent falls on the treatment plan or evidence that the treatment plan was evaluated for effectiveness in preventing patient falls.

In an interview on 6/15/12 at 1:45 PM with the CNO (Chief Nursing Officer), the CNO acknowledged that the treatment plan for Patient 40 should have been evaluated and updated to reflect the second fall.



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5. A review of the medi

Based on interview and record review the hospital failed to keep current a treatment plan for 4 of 35 sampled patients (Patients 40, 1, 2 and 8). When Patient 40 sustained a second fall, there were no new interventions or an evaluation of the treatment plan to prevent further patient falls. The facility did not ensure that care plans were initiated for Patient 1 who had an eating disorder. For Patients 1 and 2, there were no care plans initiated for the substance abuse disorders. Care plans were not initiated for falls and seizure precautions for Patient 2. For Patient 8, not all of the elements of the care plan were reassessed, creating the risk of poor health outcomes for those patients due to untreated health problems.

Findings:

1. A review of Patient 40's record on 6/15/12 showed that the patient was admitted to the hospital on 3/18/12 with a diagnosis of schizophrenia, chronic, paranoid type (a psychiatric condition characterized by gross distortion of reality, disturbances of language and communication, withdrawal from social interaction and disorganization and fragmentation of thought, perception and emotional reaction).

A review of a Patient Fall Progress Note dated 3/20/12 and timed 9:00 PM indicated that Patient 40 was found on the floor in the hallway, asleep. The Patient Fall Progress Note further indicated that the patient was easily awakened, appeared drowsy and was able to follow directions. There was no apparent injury.

A treatment plan for Fall Risk was initiated on 3/20/12 the night the patient was found on the floor. The documented reason for the fall risk was "Drugs that alter LOC (level of consciousness) or behavior-Seroquel (an antipsychotic medication that can cause drowsiness) increased to 800 mg (milligrams)."

A review of a Patient Fall Progress Note dated 3/23/12 and timed 9:15 PM indicated that Patient 40 was "asleep on chair and fell forward, according to peer." The patient had "pink to red small area on forehead."

There were no new interventions to prevent falls on the treatment plan or evidence that the treatment plan was evaluated for effectiveness in preventing falls.

In an interview on 6/15/12 at 1:45 PM with the CNO (Chief Nursing Officer), the CNO acknowledged that the treatment plan for Patient 40 should have been evaluated and updated to reflect the second fall.

A review of a hospital policy titled, "Treatment Plan Protocol" and with a revision date of 5/11 showed the following: "Daily team collaboration may be documented on the Daily Treatment Plan/Assessment form. The RN (Registered Nurse) will complete the Plan/Assessment and coordinating disciplines will record update(d) information, as applicable."



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2. The medical record of Patient 1 was reviewed on 6/13/12. The initial assessment included a history of polysubstance abuse (abuse of multiple substances), with heroin use the day prior to admission by Patient 1 and a report of anorexia and bulimia (eating disorders) with a 20 pound weight loss in the two months prior to admission. The nursing assessment for Patient 1 was reviewed, and did not identify Patient 1 as having an eating disorder or substance abuse problem.

During an interview with the Director of Program Services (DPS) on 6/13/12 at 8:40 AM, she concurred that Patient 1 had not been identified by the nurse as having an eating and substance abuse disorders.

3. The medical record of Patient 2 was reviewed on 6/13/12, and showed that the patient had a history of chemical dependency. The care plans were reviewed, and there was no care plan for chemical dependency for Patient 2. The medical record also showed that the patient had a history of seizures and falls. The patient flow sheet for Patient 2 was reviewed and there was no indication on the flow sheets that the patient needed to be observed for risk of falls or seizures.

During an interview with the DPS on 6/13/12 at 2 PM, she reviewed the record of Patient 2 and stated that she would have expected a treatment plan for chemical dependency. She also stated that she would have expected the categories for falls and seizure precautions to be circled on the flow sheets. She stated that circling of the conditions for which the patient was at risk for was part of the hospital's policy for preventing falls and seizures.

4. The medical record of Patient 8 was reviewed on 6/14/12 and showed that the patient had a significant substance abuse problem. A care plan goal included that the patient be able to identify triggers to chemical dependency/substance abuse. The goal was marked "resolved 3/23/12", the date that the patient left against medical advice. The progress and treatment notes were reviewed, and there was no documentation that the patient identified triggers prior to leaving the facility.

The Director of Performance Improvement (DPI) reviewed the medical record of Patient 8 on 6/14/12 at 11:30 AM and concurred that there was no documentation that the care plan goal regarding identifying triggers had been met, and she did not know why it was listed as "resolved". She stated that follow-up of care plans was done at the time of the interdisciplinary treatment plan meeting, which was held weekly by the physician. She concurred that since the average length of stay was 3-5 days, and the treatment team did not always meet to follow-up on the care plans prior to the patients leaving the facility.

Based on observation, interview and record review, the hospital failed to ensure that the nursing care of each patient was assigned in accordance with the patient's needs and the specialized qualifications of the nursing staff. The hospital failed to ensure that each patient was assigned to a member of the nursing staff on each shift, that the hospital's patient classification system provided accurate information that was used to ensure assignments were made to meet each patient's needs, that mental health workers (MHW) were assigned so they had the ability to complete the every 15 minute patient safety checks and that specific staff members were assigned to respond to emergency health crisis situations. These failures had the potential to result in patient's needs not being met and potential to contribute to patient harm.

Findings:

1a. An observation was conducted on 6/12/12 at 10 AM on Unit 1. The census of the unit was 35 patients.

A review of the patient assignment sheets was conducted. The assignment sheet revealed that 14 of the patients were assigned a nurse.

An interview was conducted with the charge nurse RN 2 on 6/12/12 at 10 AM. She stated that she only assigned the patients who required an assessment on her shift. RN 2 stated that both RNs take care of all of the patients.

b. An observation was conducted on 6/12/12 at 10:20 AM on Unit 2B. The census of the unit was 19 patients.

A review of the patient assignment sheets was conducted. The patients were not assigned to any specific nurse.

An interview was conducted with the charge nurse of the unit, Registered Nurse (RN) 3 on 6/12/12 at 10:45 AM. She stated that there was one RN assigned to the unit and one RN assigned as a float between Unit 2B and Unit 2A. She was asked how they determined who was responsible for the care of any given patient and she responded, "we both take care of any patient". She confirmed that there was no documented evidence of which nurse was assigned to which patient.

c. An observation of the care provided in Unit 3 was conducted on 6/12/12 at 10:45 AM. The census of the unit was 24 patients.

A review of the patient assignment sheets was conducted. The assignment sheet revealed that 8 of the patients were assigned a nurse.

An interview was conducted with the Director of Program Services (DPS) on 6/12/12 at 11 AM. She stated that there were 2 RNs on the unit. She stated that the nurses only assign patients who are due for an assessment that shift. The DPS stated that all of the nurses help to take care of all of the patients. She confirmed that all patients needed to be assigned a specific nurse who takes the responsibility for each patient. She acknowledged that the assignment of nurses to be responsible for the care of patients helps ensure patient safety.

2a. An observation was conducted on 6/12/12 at 10:20 AM on Unit 2B. The census of the unit was 19 patients.

A review of the patient assignment sheets was conducted. There was one mental health worker (MHW) to cover the needs of the 19 patients.

A review of the assignments for the MHW included rounds (every 15 minute checks on patients for location, activity, behavior, and if sleeping required observation for breathing), goals/closure groups/concern log, supply/snack ordering, contraband checks, and assistance with visitors.

An observation was conducted of MHW 1 on 6/12/12 at 10:25 AM. The MHW was cleaning a patient bed. He was asked what were his responsibilities in the unit. MHW 1 stated that he was responsible for every 15 minute checks, doing daily contraband checks which included checking all belonging and patient areas, doing group in the morning, cleaning beds and rooms of patients that have been discharged, monitoring patient behaviors and monitoring patients during patio smoking breaks. He was asked what the process was when he could not complete the every 15 minute rounds and he stated "someone else does it." He confirmed that there was no standardized method for observations to be conducted while he performed other duties. He confirmed that the every 15 minute checks of patients takes up most of his time.

b. An observation was conducted on 6/12/12 at 10:20 AM on Unit 2A. The census of the unit was 13 patients.

A review of the patient assignment sheets was conducted. There was one mental health worker (MHW) to cover the needs of the 13 patients.

A review of the assignments for the MHW included rounds (every 15 minute checks on patients for location, activity, behavior, and if sleeping required observation for breathing), activity of daily living forms, goals/closure groups/concern log, supply/snack ordering, patient fridge checks, contraband checks, assistance with visitors, patient meals, and taking patients blood pressures.

An observation was conducted at the same time. The survey team was in the nurse's station for 25 minutes and the MHW for Unit 2A was sitting with a new patient and assisting to the new patient's needs for the 25 minute period of time.

c. An observation was conducted on 6/12/12 at 10:20 AM on Unit 2A. The census of the unit was 13 patients.

A review of the patient assignment sheets was conducted. There was one mental health worker (MHW) and a licensed phychiatric technician (LPT) on duty. The MHW was assigned to a patient for 1 to 1 observation. The LPT was assigned to the every 15 minute rounds, activity of daily living forms, goals/closure groups/concern log, supply/snack ordering, contraband checks, assistance with visitors, patient meals, and taking patients blood pressures.

d. A review of the last 2 weeks of patient care assignments was conducted on 6/13/12. The review revealed a similar pattern of assignments for each day of the two (2) weeks.

e. On 6/13/12 from 10:35 AM to 11 AM an observation was conducted on Unit 1 in hallway B. Two (2) survey team members were either at the desk or in the hallway for the period of time. There were patients in 2 rooms, asleep, within hallway B. The observation revealed that there were no staff members that went into the patient's rooms during the 25 minute period of time.

An interview was conducted with the Chief Nursing Officer (CNO) on 6/13/12 at 2 PM. She stated that if a patient was asleep in the room, the person doing the every 15 minute checks would have to go into the room and observe the patient at arms length, to ensure that the patient was breathing. She acknowledged that the assignment sheets did not provide for coverage for the every 15 minute checks when the MHWs were busy doing other tasks.

In a follow up interview with the CNO on 6/14/12 at 2:30 PM. The CNO stated that the person doing every 15 minute checks should not have other duties. She stated that the every 15 minute checks take all of the staff's time.

3. A review of the hospital's patient classification system was conducted on 6/12/12. The classification system gives patient care needs a numerical value to assist in assigning nursing personnel in accordance with the patient's needs and the specialized qualifications and competence of the nursing staff.

An observation was conducted on 6/12/12 at 10:20 AM on Unit 2A. The census of the unit was 13 patients. The patient care assignment sheets were reviewed along with the patient classification sheets.

The patient care assignment sheets revealed that under the area for patient assignments the word "all" was written.

An interview was conducted with the charge nurse of the unit, RN 4, on 6/12/12 at 10:30 AM. She stated that there was another RN on the unit that was a float RN between Unit 2A and 2B. She stated that she did not assign patients to this RN. RN 4 was not able to explain why she assigned all of the patients to herself. She was asked about the patient classification system that was used by the hospital and she stated "All the patients on this floor are a 2." She was asked how she did the patient classification system to help ensure that patient care was assigned according to patient need. She stated that most patients were a 2 if they required minimal assistance and they would be a 3 if they required more help. RN 4 was asked if she used the hospital

Based on observation, interview and record review the hospital failed to ensure that all drugs were given in accordance with a physician's order for a medication for 2 of 35 sampled patients (Patients 34 and 35).

1. For Patient 34, the hospital failed to ensure the correct insulin dose was administered. Patient 34 was administered incorrect insulin doses on 3 occasions according to the physician order. This failure had the potential to cause the patient to experience altered blood sugar control including elevated blood sugar levels which could lead to coma.

2. For Patient 35, nursing failed to clarify the physician's order before giving a medication. This failure had the potential to contribute to the patient receiving the wrong medication or the wrong dose of a medication.

Findings:

1. A review of the medical record for Patient 34 revealed that the patient was admitted to the hospital on 6/8/12 with medical diagnoses which included Type 1 Diabetes (a lifelong disease in which there are high levels of sugar in the blood) maintained on insulin (a medicine to help control levels of sugar in the blood). A review of the physician orders included a sliding scale insulin order as follows:

Accucheck (blood sugar testing method) 2 hours after each meal, cover with [insulin] sliding scale as follows:

[if blood sugar level is:]
0-70 give juice and call MD (Medical Doctor)
70-139 = 0 units [of insulin]
140-180 = 1 unit [of insulin]
181-221 = 2 units [of insulin]
222-262 = 3 units [of insulin]
263-303 = 4 units [of insulin]
304-344 = 5 units [of insulin]
345-305 = 6 units [of insulin]
306-426 = 7 units [of insulin]
If greater than 426 call MD.

A review of the patients Insulin and Diabetic Flow Sheet showed that on 6/9/12 at 2:30 PM the blood sugar level was 268 and 6 units of insulin were given when 4 units should have been given. On 6/11/12 at 11:30 AM the blood sugar level was 307 and 4 units of insulin were given when 7 units should have been given. On 6/12/12 at 2:30 PM the blood sugar level was 329 and 4 units of insulin were given when 5 units should have been given.

During an interview with the Chef Nursing Officer on 6/15/12 at 9:45 AM, she verified that the physician orders were not followed on the 3 occasions and the wrong insulin doses were given to Patient 34.




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2. During an observation of a medication pass on 6/14/12 at 8:30 AM, it was observed that the nurse administered lisinopril 10 mg (milligrams) 1 tablet and 1 tablet of hydrochlorothiazide (HCTZ) 12.5 mg (medications for blood pressure) to Patient 35.

A review of Patient 35's physician orders dated 6/11/12 for lisinopril-HCTZ 10 mg-12.5 mg 1 tablet by mouth daily. First dose when available.

In an interview with LPT (Licensed Psychiatric Technician) 2 on 6/14/12 at 9:40 AM, LPT 2 stated that the combination tablet was not available so she gave the two separate tablets.

In an interview on 6/14/12 at 10:00 AM with RN 3, RN 3 acknowledged that the medication order should have been clarified with the physician to see if it was acceptable to give the lisinopril and HCTZ separately as the combination tablet was not available before the medications were given.

Based on observation, interview and record review, the hospital failed to ensure that medications and biologicals were controlled and distributed in accordance with standards of practice.

1. The hospital failed to ensure that the pharmacist reviewed each medication for appropriateness before the first dose was dispensed.

2. The pharmacy failed to supply the medication Narcan (a narcotic reversal agent) for emergency use. The hospital did administer narcotics, so a commonly used reversal agent should be available to the nursing staff.

3. The pharmacy failed to exercise control over all medications when injectable medications Haldol (an antipsychotic medication), cogentin (a medication used to treat side effects of other medications) and benadryl (an antihistamine that may causes drowsiness) were found on an open shelf with oral house supply medications.

4. The the hospital failed to ensure that that the pharmacy followed their policy for "Medications Brought Into the Facility", when a patient's own medications, brought from outside of the facility, were found in the "use area" without prior clearance for use by the pharmacist.

5. The hospital failed to ensure that a multi-use medication vial was dated when opened, creating the increased risk of infection for patients receiving medication from the undated vial.

These failures had the potential to result in a negative outcome due to a medication error for all patients admitted to the acute care unit of the hospital.

Findings:

1. An interview was conducted with RN 2, on Unit 1, on 6/12/12 at 2 PM. She stated that if a medication order was received from a physician for a patient during hours that the pharmacy was not open, the nurse would give the medication if it was available in the PYXIS (automated drug delivery system). She stated that the only time the nurse would call the pharmacist was if the medication was not available.

An interview was conducted with RN 3, on Unit 2, on 6/12/12 at 2:30 PM. She stated that if the physician ordered a medication for a patient when the pharmacy was closed, the nurse gave the medication if it was available. She stated that they would call the Pharmacist, only if the medication was not available. RN 3 was asked if the nurse faxed the order to the Pharmacist for review prior to administration, if it was a first time dose for the patient. She stated "no". She stated that a copy of the order was placed in the medication room and the pharmacy picked up the order the next day.

A review of the hospital's pharmacy policy and procedure manual was conducted on 6/13/12. There was no policy found outlining the process for the Pharmacist to review the first dose of a medication before the medication was given to the patient, except in the event of an emergency.

An interview was conducted with the Pharmacist of the hospital on 6/14/12 at 9 AM. He stated that he did not have a process for the nursing staff to notify him of new medication orders so that he could review the medications prior to the first dose when the pharmacy was closed (pharmacy hours, Monday through Friday 6:30 AM to 2 PM and weekend 9 AM to 1 PM). He stated that the medication could be held and not given until the next day. The Pharmacist acknowledged that some medications are scheduled to be given at night, so the patient would have to wait over 24 hours before the first dose. The Pharmacist confirmed that supervision of the pharmaceutical services included reviewing a medication prior to the first dose and that making the patient wait for the first dose could be a patient safety concern.

2. An observation of the hospital Units 1, 2, and 3 was conducted on 6/12/12 at 2 PM through 3:30 PM.

On each unit the medication nurses (Licensed Vocational Nurse 1, Licensed Psychiatric Technician 1 and 2) were asked if the patients on the unit received narcotic pain medications. The medication nurses stated that some patients did receive narcotics. The nurses were asked if the unit had a supply of Narcan to reverse the effects of a possible overdose or reaction to narcotics. On each unit the medication nurses stated that there was no Narcan available.

An interview was conducted with the hospital's Pharmacist on 6/14/12 at 9 AM. He stated that there was no Narcan within the hospital; however, since the hospital administered narcotics and there was always a potential for a patient to have a problem requiring reversal of the narcotic, the hospital should have Narcan on, at least, one of the units.

3. An observation was conducted on Unit 3 of the hospital on 6/12/12 at 3:15 PM. On a shelf that contained oral house supply medications, there were 5 vials of injectable medications found. The medications were 3 vials of Haldol and 1 vial each of Cogentin and Benadryl.

An interview was conducted with the medication nurse Licensed Psychiatric Technician (LPT 2). She confirmed the finding and stated that the medications should be secured and not just sitting on a shelf for patient use.

4. An observation was conducted on Unit 1 on 6/12/12 at 2:30 PM. On a shelf there were 2 boxes of medications that had a patient label; however, no initials by the Pharmacist were recorded on the label. The medications were over-the-counter medications, Midol (used for relief of menstrual symptoms) and Dramamine (used for motion sickness).

A review of the hospital policy tilted "Medications Brought Into the Facility, dated 6/12, revealed that "The Pharmacist must make a positive identification of the drug...then sign and date the container signifying that the drug has been checked by pharmacy." The policy further stated that the medication must be kept in the patient cassette during the hospital stay."

An interview was conducted with LPT 1, during the policy review. She stated that the medications were brought in by a patient and that they had a label on the box indicating which patient the medications belonged to. She stated that they were on the shelf where the patient's own medications were stored until the patient needed the medications. LPT 1 was asked if the pharmacist had reviewed the medications and she stated no, because there were no initials of the pharmacist that were recorded on the label. She stated that the medications should have been sent to the pharmacy prior to being available for patient use.






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5. During a tour of the medication room on unit 1 on 6/12/12 at 9:20 AM, the refrigerator contained an opened vial of Lantus insulin 100 units. The vial was not labeled with the date it was opened.

During a concurrent interview with LPT 1, she concurred that the vial was undated, and that it should have been dated when opened.

The facility policy, Expiration Dating, effective 12/01, read in part, "Multiple dose vials are given a 28-day expiration date once first used."

Based on record reviews and interviews:

1. The hospital failed to ensure that the nutrition needs were met for 5 of 7 patients whose records were reviewed for nutrition care (Patients 1, 32, 34, 37 and 31) when:

a. Patient 1 was admitted with a recent history of an eating disorder that was out of control, a recent severe weight loss and there was no facility conducted nutrition assessment of the patient;

b. Patient 32 had a five pound weight increase in five days and there was no facility conducted nutrition assessment of the weight gain;

c. Patient 34 was an adolescent with Type 1 Diabetes with poorly controlled blood sugars. There was no facility conducted nutrition assessment;

d. Patient 37 had nutrition recommendations from the Registered Dietitian to encourage healthy food choices that were not communicated to the other members of the health care team;

e. Patient 31 had nutrition recommendations from the Registered Dietitian to monitor purging activity after meals that were not communicated to the other members of the health care team.

2. The hospital failed to ensure that the patient menus met the nutritional needs of the patients in accordance with recognized dietary practices when they failed to do a nutritional analysis of the menus.

These failures resulted in the nutrition needs of the patients either not being met or not being monitored and had the potential to further compromise their nutritional and medical status. They also had the potential to contribute in nutrition needs of the patients not being met in accordance with physician's orders and/or current national standards for recommended dietary allowances.

Findings:

1. a. A review of the medical record for Patient 1 revealed that the patient was admitted to the hospital on 4/7/12 with a history of eating disorder. A review of the psychiatric evaluation dated 4/7/12 stated, "The patient stated that her eating disorder is out of control." A review of the Point of Contact Assessment dated 4/7/12 stated, "appetite - eating disorder; reduced weight 15 - 20 pounds in 2 months." A review of the Nutritional Risk Screen on the initial Nursing Assessment form showed that no nutrition risk factors were identified on the screen.

Further review of the medical record showed that the patient was not referred to the Registered Dietitian for a nutrition assessment or follow up. The record did not contain a nutrition assessment despite reports of recent severe weight loss and patient reports of an eating disorder out of control.

A review of the hospital's policy titled, "Multidisciplinary Admission Assessment Procedure" date 2/11 revealed that the policy was to obtain a full and accurate multidisciplinary database on every patient. It stated that the purpose was to provide guidelines for assessment and referral. For the Nutrition Risk Assessment, it stated that the Registered Nurse will identify and document patients at nutritional risk by utilizing the Nutrition Risk Screen. It stated that if any risk factors were checked, including eating binges/purges/anorexia or weight loss/gain, the patient was to be referred to the physician for a potential nutritional consult.

During an interview with the Chief Nursing Officer (CNO) on 6/15/12 at 9:30 AM, she stated that the patient should have been referred for a nutritional consult. She was unable to explain why the Nutritional Risk Screen on the Nursing Assessment did not identify that the patient was at nutrition risk related to the recent weight loss and reports of eating disorder out of control. She verified that there was no nutrition assessment for Patient 1.

During an interview with the Registered Dietitian (RD) on 6/15/12 at 11:15 AM, she stated that she does not have a system for identifying patients who are at nutrition risk. She stated she only completes a nutrition assessment on patients who have a physician order for a consult. She stated that although the hospital admitted an average of 400 - 500 patients a month, she receives only 10 - 12 nutrition consult orders a month. She stated that she hasn't done any evaluation or studies of the hospital's process to determine if patients were appropriately referred for nutrition care. She stated that the nutrition consults she receives was "just scratching the surface of the patients who are at nutrition risk," and that she "would like to be more involved in the nutrition care of the patients".

b. A review of the medical record for Patient 32 revealed that the patient was admitted to the hospital on 6/4/12. A review of the patient's Vital Signs record showed the patient's admit weight on 6/4/12 was 153 pounds. Five days later, on 6/9/12, the patient's weight was recorded as 158 pounds. There was no documentation in the medical record that the physician or the RD were informed of the 5 pound weight gain in 5 days.

During an interview with the Charge Nurse for Patient 32 on 6/13/12 at 11:15 AM, he stated that the physician should have been notified of the patient's significant weight gain. He verified that there was no documentation that the physician was notified. At 11:30 AM the Charge Nurse stated that the patient had been re-weighed and remained at 158 pounds.

During an interview with the RD on 6/13/12 at 11:25 AM, she stated that she did not receive a nutritional consult order and that there was no nutrition assessment of the patient to address the significant weight gain. She agreed that the weight gain should have triggered an RD consult for a nutrition assessment to help prevent further undesirable weight gain.

c. A review of the medical record for Patient 34 revealed that the patient was admitted to the hospital on 6/8/12 with medical diagnoses which included Type 1 Diabetes (a lifelong disease in which there are high levels of sugar in the blood) maintained on insulin (a medicine to help control levels of sugar in the blood). A review of the Nutrition Risk Screen on the Nursing Assessment indicated only that the patient was on a "special diet". The boxes labeled "Diabetes" and "on insulin" were not checked. The boxes should have been checked to indicate nutrition risk factors requiring a referral to the physician for a potential nutritional consult. The referral to the physician was not made and a nutritional consult was not ordered.

During an interview with the CNO on 6/15/12 at 9:30 AM, she verified that the Nutrition Risk Screen was not accurate and a referral to the physician and the RD were not made. She verified that the physician should have been asked for a nutritional consult for Patient 34 due to her diagnosis.

Further review of Patient 34's medical record revealed blood sugars ranging from 69 to 458 with all but one over 200. The National Institute of Health states blood sugar levels of 70 - 130 before meals and less than 180 after meals is normal. Blood sugars greater than 180 are considered too high. There was no nutrition consult ordered based on the patient's elevated blood sugars over the 7 day admission.

During an interview with the RD on 6/13/12 at 11:25 AM, she stated that she did not received a nutritional consult and there was no nutrition assessment of the patient to address the elevated blood sugars. She was unable to explain why the patient was not referred to the physician for a nutritional consult order. The RD verified that diet has an important role in the management of Type 1 Diabetes.

d. A review of the medical record for Patient 37 revealed that the patient was admitted to the hospital on 6/11/12 with diagnoses which included a history of fatty liver. A physician order was noted, dated 6/12/12, for a nutrition consult for elevated triglycerides (one of the types of fats transported in the bloodstream). Elevated triglyceride levels are considered to be a risk factor for developing hardening of the arteries.

A nutrition assessment dated 6/13/12 was reviewed. The recommendations on the RD assessment stated, "Motivate [the] patient to eat healthy foods and avoid fats and other [high] calorie foods." A review of the medical record did not reveal a nutrition care plan with these recomme

Based on observation, record review and interview, the hospital failed to ensure, for a universe of 87 patients, that the physical environment was maintained in a manner that the safety and well-being of the patients were assured. This increased the risk of harm to the patients due to the facility's failure to maintain the physical environment.

Findings:

1. On 6/12/12 at 3:25 PM, the table on Unit 1 in Lounge A was observed moving from side to side (unsteady). At the time of the observation there were several patients at the table as well as a Mental Health Worker (MHW) 1.

MHW 1 confirmed that the table was unsteady and potentially unsafe for patient use. He stated that the female patients used the table during daily activities and at meal times. When he was asked the facility's practice for reporting broken equipment, the MHW stated that the table had been fixed several times in the past, but continues to be unstable.

This failure created the risk for injury to all patients that used the table for activities and/or meal times.

2. On 6/12/12 at 10:30 AM, an observation of the standing weight scale on Unit 2 B was conducted. The scale had a maintenance sticker that indicated that the scale was last checked in 2010 and that the preventative maintenance check was due in 8/2011. The Chief Nursing Officer confirmed the finding. She stated the Maintenance Supervisor (MS) kept a current record of all preventative maintenance checks for the hospital's equipment.

On 6/12 12 at 4 PM, the MS stated that the standing weight scales throughout the hospital were not checked in 8/2011. The MS confirmed that the preventative maintenance checks were overdue.

This failure created the risk for all patient weights to be inaccurately measured and recorded.



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3. A review of the hospital's disaster food plan dated 2/11 revealed that the plan was that "Food Service personnel shall prepare food in sufficient quantities for all patients and personnel."

During an interview with the Director of Support Services (DSS) on 6/12/12 at 3:20 PM, he stated that the hospital's plan was to feed 100 people in the event of a disaster. He verified that this was not enough to feed all patients and personnel.

During an observation and concurrent review of the hospital's disaster food plan and supplies on 6/12/12 at 3:20 PM, the following was noted:

· The plan required 100 servings of ravioli, there was none.
· The plan required 100 servings of beef stew, there was none.
· The plan required 900 servings of milk, there were 840 servings.
· The plan required 300 servings of soup, there were 174 servings.

During the continued interview with the DSS (same date and time), he stated that the hospital needed to improve the disaster food plan and ensure that they maintained adequate supplies to meet the plan for patients and staff.

Based on observation, interview and record review:

A. the hospital failed to ensure that the infection control officer developed a system for monitoring staff for the effectiveness of their sanitation. This failure had the potential to result in a spread of infection due to improper use of sanitizing agents; and

B. The hospital failed to ensure that there were infection control measures in place to prevent the development of food borne illness and cross contamination with regards food service when:

1. A lack of system for monitoring the safe cooling of cooked potentially hazardous foods;
2. A lack of effective system for sanitizing the ice storage bin of the ice machine;
3. A lack of system for monitoring the expiration date of perishable refrigerated juices; and,
4. A lack of an effective system for monitoring the safety and sanitation of the Patient Food Refrigerators on the Nursing Units.

The hospital failed to have a thorough infection control surveillance system that monitored the conditions and practices of the dietetics services staff. By not having these measures and a thorough surveillance system, potentially hazardous foods had been stored, prepared and distributed under unsafe and unsanitary conditions and there was potential for such continuation in the absence of identification and remediation.

Findings:

A1. An observation was conducted on 6/12/12 at 10:30 AM on Unit 2. A Mental Health Worker (MHW 1) was cleaning a patient bed, after the patient had been discharged. The MHW sprayed the bed with a sanitizing spray labeled as "Tuberculocidal Spray" and immediately wiped off the bed.

An interview was conducted with MHW 1 during the observation. He stated that was how he always disinfected the beds after a patient was discharged. He sprayed the solution on and wiped it off.

The label on the spray can was read and the label directed the product's user to leave the product on the surface for at least three (3) minutes for proper sanitization.

The Director of Program Services was present during the observation and confirmed that the MHW did not follow the manufactures direction.

2. An observation was conducted on 6/13/12 at 11 AM on Unit 1. A housekeeper (HK 1) was observed cleaning the sink in a patient room. HK 1 sprayed on a solution, Morning Mist, and wiped the solution off with a cloth.

HK 1 was interviewed, during the observation, she stated that she cleans the sinks with the same solution and always just sprays it on and wipes it off. She stated that if there was visible grime present on the surface, she would scrub the surface.

The information on the bottle was reviewed and the manufacturer's recommendations directed the product's user to saturate the area/surface, scrub as necessary, rinse with potable water then dry the area/surface.

The HK confirmed that she did not follow the manufacturer's directions for the use of the product.

3. An observation was conducted on Unit 2 on 6/12/12 at 10 AM, accompanied by the Chief Nursing Officer (CNO) and one of the licensed vocational nurses (LVN 1).

An oxygen tank was observed in a clean room. The oxygen tank had an open nasal canula hanging off the tank.

The CNO asked LVN 1 why there was an open nasal cannula on the tank and LVN 1 stated that a patient had used the oxygen the previous night. LVN 1 stated that the night shift must have put the oxygen away with the used nasal canula still on.

The CNO confirmed that a used nasal canula should not be left open and in a clean room.



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B1. During a tour of the kitchen on 6/12/12 at 3:00 PM, leftover cooked breakfast sausages (a potentially hazardous food) were observed in the reach-in refrigerator. The temperature of the sausage links was observed to be 39 degrees Fahrenheit (F).

During a concurrent interview with the Food Service Supervisor (FSS), he stated that the sausage was leftover from breakfast and was placed in the refrigerator at 10:00 AM that day. He stated that it was the dietary staff's usual practice to save leftovers. The staff did not monitor the safe cool down of the sausage. It was not the practice of the staff to monitor the cool down of leftovers to ensure the leftovers reached appropriate temperatures within safe timeframes.

According to the 2009 FDA Food Code, cooked, potentially hazardous food (PHF) shall be cooled within 2 hours from 135 degrees F to 70 degrees F, and within a total of 6 hours from 135 degrees F to 41 degrees F. It further states that if food is not cooled in accordance to this Code requirement, pathogens may grow to sufficient numbers to cause foodborne illness.

During further interview with the FSS (same date and time), he stated that he understood that PHF should be cooled to 70 degrees F within 4 hour and to 40 degrees F within an additional 2 hours. He stated that he had attended a food safety course in September of 2009. He did not recall that in order to ensure PHF remained safe during cooling; it needed to reach 70 degrees F within 2 hours, not 4 hours.

Also according to the 2009 Food Code, the initial 2-hour cool is a critical element of this cooling process to slow the rapid growth of pathogens that can cause foodborne illness.

A review of the hospital's policy and procedure manual revealed no policy for monitoring the safe cooling of PHF.

During an interview with the Registered Dietitian (RD) on 6/15/12 at 11:15 AM, she stated that she was aware that the kitchen staff saved leftovers of previously cooked PHF. She stated that she had not in serviced the FSS or staff on safe cooling and had not developed a policy for it.

2. During an observation of the ice machine in the cafeteria on 6/14/12 at 11:30 AM, a clean white paper towel swipe of the interior of the ice storage bin produced a moderate amount of a black/brown residue. The ice machine and storage bin were part of a unit that also dispenses beverages. The finding was concurrently verified by the Director of Support Services (DSS).

During a concurrent interview with FSS, he stated that the kitchen staff only clean the nozzles of the beverage dispenser and do not clean the ice machine or storage bin. He stated that the ice machine was the only one in the hospital and it served patients, staff and visitors.

During an interview with the Maintenance Coordinator (MC) on 6/15/12 at 11:30 AM, he stated that the maintenance staff performs quarterly preventive maintenance (PM) on the ice machine. The PM did not include cleaning and sanitizing the ice storage bin. He stated that the ice machine and storage bin were cleaned and sanitized every 6 months by an outside contractor.

A review of the PM record showed that the last quarterly PM was completed on 5/16/12. The last semiannual cleaning and sanitizing by the contractor was completed on 6/4/12.

The MC and the DSS were unable to explain why there was a moderate amount of black/brown residue on the interior of the ice storage bin. They both verified that the residue should not be present and likely contaminated the ice.

The 2009 Food Code states that in equipment such as ice bins and enclosed components of equipment such as ice machines, surfaces shall be cleaned at a frequency necessary to preclude accumulation of soil or mold.

3. During an observation in the walk-in refrigerator in the kitchen on 6/12/12 at 4:00 PM, four ounce cartons of various juices were labeled "Keep Frozen," and "use within 10 days of thawing." The juices were not dated.

During a concurrent interview with the FSS, he stated that they don't date the juices because they are generally used before the 10 days. He was unable to state how he monitors the expiration date for juices once they leave the kitchen. He verified that the juices are stored in the Patient Refrigerators on the Nursing Units and when not dated, there was no system for monitoring when they expire. He validated that in order to ensure juices were not retained and consumed past their expiration date; they would need to be dated.

A review of the hospital's policy and procedures for food and nutrition services did not reveal a policy for monitoring of the expiration date for the j

Based on interview and record review, the hospital failed to ensure that they had a process to reassess the patient's discharge plan when factors were identified that could affect the patient's continuing care needs or the appropriateness of the discharge plan for 3 of 35 patients sampled by nursing (Patients 41, 28, and 36) and potentially for any patient discharged from the hospital.

For Patient 41, the hospital failed to ensure that the discharge plan was reassessed to include his allegation of abuse by his parents, "unresolved risk of self-harm", unpredictable assaultive behaviors, loss of hope, and "overall poor behavior." This failure had the potential for the patient to be discharged to an unsafe environment in an unstable condition and had the potential for the patient to cause harm to him-self or to others.

For Patient 28, the hospital failed to ensure that the discharge plan was reassessed to include the patient's allegation that she was bullied at school. This failure had the potential to cause the patient to be discharged back to an unsafe environment and had the potential for the patient to be placed at risk of harm.

For Patient 36, the hospital failed to ensure that the discharge plan was reassessed to include the patient's report of physical abuse by his mother.
This failure had the potential to cause the patient to be discharged back to an unsafe environment and had the potential for the patient to be placed at risk of harm. Patient 36 had a suicide attempt before hospitalization and was diagnosed with alcohol dependance. The hospital discharged him with no instructions for who to contact for follow-up psychiatric and chemical dependency care. This failure had the potential to contribute to the patient dying from suicide.

Findings:

1. A review of the medical record for Patient 41 was conducted on 6/14/12. The review revealed that the patient was a 16 year old who was admitted to the hospital on 2/26/12 with diagnoses that included bipolar disorder and depression.

A review of the intake information, dated 2/26/12 at 4:32 PM, revealed that the patient stated "My mom started cussing me out for no reason...then they (mom & stepdad) started hitting me." Further review revealed that the patient stated, "he wanted to shoot himself in the shoulders and bleed to death in front of his family."

A review of the physician's psychiatric evaluation, dated 2/26/12 at 6:30 PM, revealed that the patient stated, "I don't want to go home. I don't want to be there. I don't want to be beaten up. Both my mother and father are physically beating me up."

A review of the medical record revealed that there was no documentation of a report made to Child Protective Services (CPS) on 2/26/12, 2/27/12, or 2/28/12.

A review of the physician's progress notes, dated 2/28/12, revealed that the patient was reporting being physically beaten up by his parents and a CPS evaluation would be obtained.

Further review of the medical record revealed that a report was filed on 2/29/12 (3 days after the patient reported the abuse to the hospital).

A review of the physician's orders revealed that the patient had an order to discharge home (to his mother and father) on 3/2/12.

A review of the medical record revealed that there was no contact with CPS regarding the patient's safety in being discharged home to his parents.

A review of the discharge instructions, dated 3/12/12, revealed that the patient did not discharge home until 10 days after his order for discharge.

A review of the case management notes, dated 3/6/12, revealed that the patient's parents would take him home, so he was waiting for placement in a group home.

A review of all of the physician's orders from 3/2/12 until discharge on 3/12/12 revealed that there was no updated physician's order for the patient to discharge to placement in a group home on 3/12/12.

A review of the physician's progress notes, dated 3/11/12, revealed that the physician documented that the patient, "continues to make treats for self-harm." The physician also documented, "Unresolved risk of self-harm."

Further review of the medical record revealed that there was no follow up on the day of discharge, by the physician, regarding the patient's unresolved risk of self-harm.

A review of the nurse's notes, dated 3/12/12 (the day of discharge) revealed that the nurse documented that the patient's "Assault" assessment was "unpredictable". The nurse also documented, "Pt (patient) anxious, restless, uncooperative, disruptive and overall poor behavior. Pt cursing staff and inciting poor behaviors in peers. Pt depressed and appearing to lose hope. Pt ready for placement to leave hospital." There was no documentation of notification to the physician regarding the patient's behaviors, mood, unpredictable assault assessment, or the assessment that the patient was appearing to lose hope.

A review of the physician's notes, nursing notes, therapy notes, and the case management notes, for the entire stay, revealed that there was no further mention of the patient's allegation of abuse by his family in relation to his discharge. There was no mention of the physician's failure to document regarding the risk of self-harm.

A review of the hospital policy titled "Discharge Planning", dated 6/11, revealed that there was no requirement for a reassessment of the discharge plan when factors are identified that may affect the patient's continuing care needs or the appropriateness of the discharge plan.

An interview was conducted with the Chief Nursing Officer (CNO) and the Director of Case Management (DCM) on 6/18/12 at 9 AM. They confirmed that the patient had reported abuse to several members of the treatment team and that the first discharge plan was to send him home to his parents (the alleged abusers). The DCM confirmed that the case management staff do not necessarily document if they contacted CPS, when a report of alleged abuse was reported, to discuss the patient's safety in the home. They confirmed that the reason that the patient did not get sent home to his parents on 3/2/12 was that the parents refused to take him home.

In the same interview, the CNO stated the physician did not do a second discharge to placement and did not document a reassessment of the patient's suicide or homicidal risk prior to discharge. The CNO confirmed that the physician had documented a risk of self-harm on the day prior to discharge and did not document a follow up to that risk. The CON confirmed that the nurse documented patient risk behaviors and that there was no documented evidence that the risk had been communicated to the physician prior to the patient's discharge. The CNO confirmed that the discharge plan did not take into consideration the patient's allegation of abuse, the patient's risk of self-harm, unpredictable assaultive behaviors, loss of hope, and "overall poor behavior." The DCM confirmed that the patient had problem identified that could affect his continuing care needs and that the discharge plan was not reassessed to include these problems.

2. A review of the medical record for Patient 28 was conducted on 6/13/12. The review revealed that the patient was a 13 year old who was admitted to the hospital on 4/19/12 with diagnoses that included depression.

A review of the intake information, dated 4/19/12, revealed that the patient "reported being bullied."

A review of the "Adolescent Psychosocial Assessment", dated 4/19/12, revealed, "Pt (patient) reported being bullied at school and is unresolved." The report further documented, "Pt is unable to connect with peers at school and is bullied."

A review of the case management notes, dated 4/20/12, documented, "Pt indicated being bullied at school and is still unresolved."

A review of the physician's notes, nursing notes, therapy notes, and the case management notes revealed that there was no further mention of the patient's allegation of being bullied.

A review of the discharge plan, dated 4/27/12, revealed that the patient was discharged to the same living arrangement she had prior. There was no documented evidence that the allegation of the patient being bullied wa

Based on interview and record review, the hospital failed to ensure that patients and family members or interested persons were counseled to prepare them for post-hospital care by failing to ensure that all patients received discharge instructions on monitoring their weight as it relates to their medications and as instructed by the physician. This failure had the potential for all patients who were discharged from the hospital to have a problem with weight gain or weight loss related to a medication and not be aware of the source of the problem and not seek help for the weight change.

Findings:

1. A review of the medical record for Patient 41 was conducted on 6/14/12. The review revealed that the patient was a 16 year old who was admitted to the hospital on 2/26/12 with diagnoses that included bipolar disorder and depression.

A review of the physician's discharge summary, dated 3/15/12, revealed "Aftercare Instructions" that stated "weight monitoring" (many antipsychotic medications cause problems with a patient's weight).

A review of the patient's discharge plan, dated 3/12/12, revealed no instructions for the patient to conduct weight monitoring.

2. A review of the medical record for Patient 28 was conducted on 6/13/12. The review revealed that the patient was a 13 year old who was admitted to the hospital on 4/19/12 with diagnoses that included depression.

A review of the physician's discharge summary, dated 5/3/12, revealed "Aftercare Instructions" that stated "weight monitoring."

A review of the patient's discharge plan, dated 4/27/12, revealed no instructions for the patient to conduct weight monitoring.

3. A review of the medical record for Patient 29 revealed that she was admitted to the hospital on 3/28/12 with diagnoses that included major depression.

A review of the physician's discharge summary, dated 4/4/12, revealed "Aftercare Instructions" that stated "weight monitoring."

A review of the patient's discharge plan, dated 3/30/12, revealed no instructions for the patient to conduct weight monitoring.

An interview was conducted with the Director of Program Services (DPS) on 6/13/12 at 10 AM. She confirmed that the physician's discharge instructions did not match the information that the patient was given on discharge. She stated that the weight monitoring was important for most patients due to the medication they were prescribed. The DPS stated that the discharge summaries are a template that the clinician just fills in certain areas, so all discharge summaries would have the same information. She confirmed that most of the discharge instructions would not contain that information. The DPS stated that the patient should be given the information and be counseled regarding weight monitoring.










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4. A review on 6/13/12 of the medical record for Patient 26 revealed that she was admitted to the hospital on 3/22/12 with diagnoses that included Bi-Polar disorder, recently manic {a major mental disorder characterized by episodes of mania (hyperactivity, agitation and excitability), depression or mixed mood}.

A review of the physician's discharge summary, dated 4/3/12, revealed "Aftercare Instructions" that stated "weight monitoring."

A review of the patient's discharge plan, dated 3/26/12, revealed no instructions for the patient to conduct weight monitoring.

An interview was conducted with the Director of Program Services (DPS) on 6/13/12 at 10 AM. She confirmed that the physician's discharge instructions did not match the information that the patient was given on discharge. She stated that the weight monitoring was important for most patients due to the medication they were prescribed. The DPS stated that the discharge summaries are a template that the clinician just fills in certain areas, so all discharge summaries would have the same information. She confirmed that most of the discharge instructions would not contain that information. The DPS stated that the patient should be given the information and be counseled regarding weight monitoring.