HospitalInspections.org

Based on observation, interview, record review, and policy review, the hospital's Governing Body failed to:
- Ensure the Chief Executive Officer (CEO) effectively managed the hospital in order to meet applicable regulatory requirements. (A-0057)
- Ensure contracted services furnished services that permitted the hospital to comply with all applicable conditions of participation. (A-0083)
- Complete a thorough investigation and recognize failures to prevent future reoccurrences, following incidents where four discharged patients (#9, #10, #11 and #12) were transferred to Hospital B (nearby acute care hospital) for medical emergencies and were found to have fentanyl (a medication used to treat severe pain, and is a high risk drug for theft and personal use) in their system, and following incidents where contraband (items that are illegal, forbidden, or that can be used to harm self or others) was found with four discharged patients (#12, #17, #60 and #61). (A-0144 and A-0395)
- Ensure staff performed adequate body searches (visual search of the body for prohibited materials that could be used to harm themselves or others), room checks and observation of patients, when four discharged patients (#9, #10, #11 and #12) were found with fentanyl in their system after being transferred to Hospital B for medical emergencies, and when contraband was found with four discharged patients (#12, #17, #60 and #61). (A-0144 and A-0395)
- Ensure all nursing staff were educated regarding supervision and evaluation of patients, along with proper body and contraband searches after the incidents occurred. (A-0395)
- Remove ligature (anything which could be used for the purpose of hanging or strangulation) risks from one unit of six units observed. (A-0144)
- Ensure staff provided care in a safe setting when one current patient (#55) was allowed unsupervised access to contraband at one nurse's station of six nurses stations observed. (A-0144)
- Ensure that the emergency cart and Automated External Defibrillator (AED, a device that automatically analyzes the heart rhythm and treats with an electrical therapy if necessary) device were properly checked and maintained. (A-0144)
- Prevent the coercion of one patient (#18), when staff placed the patients on a 96-hour hold (court-ordered evaluation by behavioral specialists to determine if a person is safe to themselves and others) after the patients requested to be discharged against medical advice (AMA). (A-0145)
- Ensure nursing staff completed detoxification (detox, the process of removing drugs or alcohol from the body) vital signs as ordered on five current patients (#20, #47, #51, #56 and #57) of five current medical records reviewed with detox vital signs and one discharged patient (#10) of four discharged patient medical records reviewed with detox vital signs. (A-0395)
- Ensure staffing adequately met the needs of the patients, provided safety to the patients, and ensured the proper number and types of staff were available based on the patient census. (A-0392)
- Ensure that insulin (a medication that regulates the amount of sugar in the blood), a high risk medication, dosages were verified by two nurses prior to being administered to three current patients (#37, #38 and #54) of three current patients receiving insulin, and one discharged patient (#32) of one discharged patient receiving insulin. (A-0405)
These failures had the potential to adversely affect the quality of care and safety of all patients in the hospital.

The severity and cumulative effect of these systemic practices resulted in the hospital's non-compliance with 42 CFR 482.12 Condition of Participation: Governing Body and resulted in the hospital's failure to ensure quality health care and safety.

The hospital census was 98.





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Based on observation, interview, record review, and policy review, the Governing Body failed to ensure the Chief Executive Officer (CEO) was responsible for management of the entire hospital including accountability for the effective oversight of staff to comply with the requirements under 42 CFR 482.12 Condition of Participation (COP): Governing Body, 482.13 COP: Patient's Right's and 42 CFR 482.23 COP: Nursing Services. This failure had the potential to affect the quality of care and safety of all patients. The hospital census was 98.

Findings included:

1. Review of the hospital's document titled, "Amended and Restated Bylaws of CenterPointe Hospital Medical Staff," revised 11/14/17, showed that the CEO is selected by the Board of Managers of the Corporation, or by the designee of the Board of Managers and is responsible for the effective operation, organization and management of the hospital and its services, departments and subdivisions.

The CEO failed to ensure compliance with the COP of Governing Body as evidenced by failure to effectively manage the hospital in order to meet applicable regulatory requirements (A-0057), and that contracted services furnished services that permitted the hospital to comply with all applicable COPs. (A-0083)

2. The CEO failed to ensure compliance with the COP of Patient's Rights as evidenced by failure to:
- Ensure staff performed adequate body searches (visual search of a body for prohibited materials that could be used to harm themselves or others), room checks and observation of patients when four discharged patients (#9, #10, #11 and #12) were found with fentanyl in their system after being transferred to Hospital B (nearby acute care hospital) for medical emergencies and when contraband (items that are illegal, forbidden, or that can be used to harm self or others) was found with four discharged patients (#12, #17, #60 and #61). (A-0144)
- Complete a thorough investigation and recognize failures to prevent future reoccurrences following the fentanyl incidents that involved four discharged patients (#9, #10, #11 and #12) and following the contraband incidents that involved four discharged patients (#12, #17, #60 and #61). (A-0144)
- Remove ligature (anything which could be used for the purpose of hanging or strangulation) risks from one unit of six units observed. (A-0144)
- Ensure staff provided care in a safe setting when one current patient (#55) was allowed unsupervised access to contraband at one nurses station of six nurses station's observed. (A-0144)
- Ensure that the emergency cart and Automated External Defibrillator (AED, a device that automatically analyzes the heart rhythm and treats with an electrical therapy if necessary) device were properly checked and maintained. (A-0144)
- Prevent the coercion of one patient (#18), when staff placed the patient on a 96-hour hold (court-ordered evaluation by behavioral specialists to determine if a person is safe to themselves and others) after the patient requested to be discharged against medical advice (AMA). (A-0145)

3. The CEO failed to ensure compliance with the COP of Nursing Services as evidenced by failure to adequately supervise patients and provide a safe environment when:
- Seven discharged patients (#9, #10, #11, #12, #17, #60 and #61) had access to contraband (items that are illegal, forbidden, or that can be used to harm self or others). Four of those patients (#9, #10, #11, and #12) required transfer to Hospital B (nearby acute care hospital) for medical emergencies and were found to have fentanyl (a medication used to treat severe pain, and is a high risk drug for theft and personal use) in their system.
- The hospital did not implemented measures and ensure nursing staff were educated to prevent reoccurrence, including appropriate supervision of patients, proper body checks (visual search of a body for prohibited materials that could be used to harm themselves or others) and contraband searches, after the incidents occurred.
- Detoxification (detox, the process of removing drugs or alcohol from the body) vital signs (body temperature, blood pressure, heart rate, and breathing rate) were not completed as ordered on five current patients (#20, #47, #51, #56 and #57) of five current medical records reviewed with detox vital signs, and on one discharged patient (#10) of four discharged patients' medical records reviewed with detox vital signs.
- Staffing was not adequate to meet the needs of the patients, provide safety to the patients, and ensure the proper number and types of staff were available based on the patient census.
- Insulin (a high-risk medication that regulates the amount of sugar in the blood) doses were not verified by two nurses prior to being administered to patients.

During an interview on 08/03/21 at 9:35 AM, Staff Y, CEO, stated that she was responsible for the entire hospital and responsible for the oversight of regulatory compliance with the COPs for Governing Body, Patient's Rights and Nursing Services.






27727

Based on interview, record review and policy review, the hospital's Governing Body failed to ensure that contracted services furnished services that permitted the hospital to comply with all applicable conditions of participation. This failure had the potential to cause inadequate monitoring of services and poor patient outcomes. The hospital census was 98.

Findings included:

1. Review of the hospital's policy titled, "Contractual Agreements," revised 08/25/19, showed that contracts entered into, on behalf of the hospital, must be reviewed and approved by designed leaders. Contracts must only be signed by the Chief Executive Officer (CEO) or Chief Financial Officer of the hospital, or their designees who have signatory authority. After full execution of the contract, the original of signed contracts are submitted to the Risk Management Department for filing and on-going monitoring of contract expectations.

Review of the hospital's undated document titled, "Quality Assessment Performance Improvement Program (QAPI, process for reporting and/or identifying adverse events, near misses or review of high risk, problem prone areas for patient safety) 2021, showed that the program is ongoing, hospital-wide, and data-driven; and involves all hospital departments and services, including those clinical services furnished under contract or arrangement. Organization wide quality assessment and improvement activities include all key functional areas, including those serviced under contract or arrangement.

Review of the hospital's undated document titled, "Hospital Contracted Services List," showed that the hospital contracted with 24 different services.

Review of the hospital's documents titled, "Annual Contract Service Evaluation," dated 02/22/21, showed only three of the 24 contracted services (Laboratory, Radiology and Pharmacy) were evaluated for 2020.

Review of the hospital's undated document titled, "2020 Quality Indicators," showed that only three of the 24 contracted services (Dietary, Pharmacy and Radiology) were incorporated into the hospital QAPI program.

During an interview on 08/03/21 at 10:50 AM, Staff W, Risk Management Director, stated that not all contracted services were incorporated into QAPI, nor did they have an annual contract service evaluation.

During an interview on 08/03/21 at 9:35 AM, Staff Y, CEO, stated that not all contracted services were included in the hospital QAPI program.

Based on observation, interview, record review, and policy review, the hospital failed to:
- Complete a thorough investigation and recognize failures to prevent future reoccurrences, following incidents where four discharged patients (#9, #10, #11 and #12) were transferred to Hospital B (nearby acute care hospital) for medical emergencies and were found to have fentanyl (a medication used to treat severe pain, and is a high risk drug for theft and personal use) in their system, and following incidents when contraband (items that are illegal, forbidden or can be used to harm self or others) was found with four discharged patients (#12, #17, #60 and #61).
- Ensure staff performed adequate body searches (visual search of a body for prohibited materials that could be used to harm themselves or others), room checks and observation of patients, when four discharged patients (#9, #10, #11 and #12) were found with fentanyl in their system after being transferred to Hospital B for medical emergencies, and when contraband was found with four discharged patients (#12, #17, #60 and #61).
- Remove ligature (anything which could be used for the purpose of hanging or strangulation) risks from one unit of six units observed.
- Ensure staff provided care in a safe setting when one current patient (#55) was allowed unsupervised access to at one nurse's station of six nurses stations observed.
- Ensure that the emergency cart and Automated External Defibrillator (AED, a device that automatically analyzes the heart rhythm and treats with an electrical therapy if necessary) device were properly checked and maintained.
- Prevent the coercion of one patient (#18) who requested to be discharged against medical advice (AMA), when they placed the patient on a 96-hour hold (court-ordered evaluation by behavioral specialists to determine if a person is safe to themselves and others).

These practices resulted in a systemic failure and noncompliance with 42 CFR 482.13 Condition of Participation: Patient's Rights. The hospital census was 98.

The severity and cumulative effect of these practices had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ).

On 07/23/21, after the survey team informed the hospital of the IJ, the staff created educational tools, revised policies and began educating all staff, and implemented interventions to protect the patients.

As of 07/27/21, the hospital had provided an immediate action plan sufficient to remove the IJ by implementing the following:
- The body check assessment process was changed to have body checks completed in the Assessment & Referral (A&R) Exam Room prior to being admitted to the unit, prior to a patient's admission.
- The revised process includes a revised body check assessment form and requires patients to disrobe, including removing undergarments, so they could be more thoroughly checked for hidden contraband.
- A full-time equivalent staff member would be assigned to the A&R unit to perform body checks for new admissions on all shifts. The staff member would be assigned to the A&R area, and not be pulled from a nursing unit where they were scheduled and assigned patient care.
- All staff were re-educated on proper room searches which included scenarios and a mock room search.
- Nursing staff were re-educated on opioid (highly addictive narcotics) and overdose, withdrawal (symptoms that occur upon abrupt discontinuation of medications, alcohol or drugs) symptoms, and the use of Narcan (a medication used to counter the effects of narcotic overdose).
- All personal hygiene items were removed from patient rooms and the hospital developed a new system for dispensing products in paper cups.
- Patients were limited in the amount of personal clothing to be kept in their rooms.
- A new process for the inventory and the secured storage of excess patient clothing and personal items had been established.









27727

Based on observation, interview, record review and policy review, the hospital failed to:
- Complete a thorough investigation and recognize failures to prevent future reoccurrences, following incidents where four discharged patients (#9, #10, #11 and #12) were transferred to Hospital B (nearby acute care hospital) for medical emergencies and were found to have fentanyl (a medication used to treat severe pain, and is a high risk drug for theft and personal use) in their system.
- Complete a thorough investigation following incidents when contraband (items that are illegal, forbidden or can be used to harm self or others) was found with four discharged patients (#12, #17, #60 and #61).
- Ensure staff performed adequate body searches (visual search of a body for prohibited materials that could be used to harm themselves or others), room checks and observation of patients when four discharged patients (#9, #10, #11 and #12) were found with fentanyl in their system after being transferred to Hospital B for medical emergencies and when contraband was found with four discharged patients (#12, #17, #60 and #61).
- Remove ligature (anything which could be used for the purpose of hanging or strangulation) risks from one unit of six units observed.
- Ensure staff provided care in a safe setting when one current patient (#55) was allowed unsupervised access to contraband at one nurse's station of six nurses' stations observed.
- Ensure that the emergency cart and Automated External Defibrillator (AED, a device that automatically analyzes the heart rhythm and treats with an electrical therapy if necessary) device were properly checked and maintained.

The lack of oversight of patients had the potential to place all current and future patients at risk for serious harm or injury.

Findings included:

1. Review of the hospital's policy titled, "Incident Reporting," revised 07/06/21, showed that an incident report provides a detailed account of events leading up to an unforeseen circumstance. Incident reports are reviewed by the hospital to ensure proper measures are taken to provide effective patient care and reduce reoccurrences.

Review an incident report dated 07/07/21, showed that at 11:00 AM, Patient #10 was found unresponsive on the floor and incontinent of bowel and bladder. When the patient did become responsive he was not answering questions and was alert and oriented to person only. The patient was sent to Hospital B. The incident was reviewed in morning report, but did not indicate a follow-up was necessary.

Review of Patient #10's medical record showed the following:
- He was a 30-year old male admitted to the hospital on 06/30/21 for opioid (highly addictive narcotic) use withdrawal (symptoms that occur upon abrupt discontinuation of medications, alcohol or drugs).
- The patient reported using 12 to 15 capsules of fentanyl intravenous (IV, in the vein) daily since 2018.
- The patient's urine drug screen (UDS, a test that analyzes urine for the presence of certain illegal drugs and prescription medications) dated 07/02/21, obtained two days after admission, was positive for benzodiazepine (a class of psychoactive drugs that act as tranquilizers and are commonly used to treat a range of conditions, including anxiety and insomnia) and methamphetamines (a drug with more rapid and lasting effects than amphetamine, used illegally as a stimulant).
- On 07/06/21, the patient had increased shortness of breath, wheezing (a high-pitched whistling sound made while breathing) and abnormal lung sounds; he was sent to Hospital B for evaluation at 5:10 PM.
- On 07/06/21 at 11:18 PM, the patient returned from Hospital B with a diagnosis of bronchitis (inflammation of the lung passage lining) and was started on an antibiotic (medications that destroy or slow down the growth of bacteria) to take by mouth.
- No documentation of a body check or clothing check after the patient returned from Hospital B.
- On 07/07/21 at 11:30 AM, Nursing progress note documented the patient's oxygen saturation (oxygen saturation in the blood) was 84% and required oxygen. The patient was drooling and unable to take medication, a code blue (emergency situation where a patient's heart or breathing has stopped, and staff quickly respond to attempt to restore the heartbeat or breathing) was called at 10:56 AM, and the patient was transferred and admitted to Hospital B, after being found unresponsive on the floor.

Review of Patient #10's medical record from Hospital B showed that on 07/07/21 at 3:28 PM, a UDS was positive for fentanyl. The Emergency Department (ED) physician documented the suspected cause of today's episode was likely from fentanyl use, and that the patient was in the ED the day prior and could have been supplied this by a visitor.

The hospital's undated document titled, "Unit Three Investigation," showed that Patient #10 was sent out at 11:00 AM on 07/07/21. At 7:06 PM, Staff F, Chief Nursing Executive (CNE), was notified by Registered Nurse (RN) House Supervisor that Patient #10 tested positive for fentanyl. At 7:12 PM, Staff F instructed the RN House Supervisor to search Patient #10's room as well as the rest of Unit Three. No contraband was found.

During an interview on 07/26/21 at 2:30 PM, Staff F, CNE, stated that:
- Rooms were checked for contraband during walking rounds at the change of shift.
- The Mental Health Technician (MHT) "eyeball" the rooms once a shift on days and evenings, every day.
- Some of the unit patients walked through other units to go to the cafeteria, or out for smoke breaks, but they didn't mingle.
- Some of the units patients may overlap in the cafeteria area, but only for five to ten minutes.

During an interview on 07/29/21 at 2:25 PM, Staff BBB, MHT, stated that they only looked for visible (indicating that hidden items were not searched for) during room checks, and would not go through a patient's belongings unless he felt there was a need or if he was suspicious of the patient.

During an interview on 07/27/21 at 2:40 PM, Staff O, House Supervisor, stated that room checks were not completed due to the lack of staffed MHTs.

These interviews showed that there was potential for drugs or contraband to be passed not only between patients on one unit, but between units. This, in addition to MHTs not completing consistent and thorough room checks, increased the risk that drugs or contraband could be easily concealed, placing all patients at risk.

After this incident, the hospital provided no further follow-up, no interviews were conducted with patients or staff and no process changes were initiated.

Review of an incident report dated 07/08/21, showed that Patient #11 had a change in mental status and observed as responding to internal auditory hallucinations (hearing things that are not heard by others, imaginary). The patient was transferred to Hospital B. The incident report was reviewed in morning report but did not indicate a follow-up was necessary.

Review of Patient #11's medical record showed the following:
- He was a 39 year old male admitted to the hospital on 07/01/21 for opioid detoxification (the process of removing drugs or alcohol from the body).
- The patient reported he had been snorting heroin (a highly addictive drug made from morphine that is used illicitly for its euphoric effects) and Xanax (medication used especially in the treatment of mild to moderate anxiety) daily since January of 2021.
- On 07/08/21 at 11:00 AM, nursing documented that the patient had a change in level of consciousness (the state of being fully alert, aware, oriented, and responsive to the environment). The patient required prompting to know who and where he was. The patient's skin was warm, flushed and sweaty. The patient had mumbling speech and was responding to internal auditory hallucinations (hearing things that are not heard by others, imaginary), and it was difficult for him to follow simple commands.
- The patient was transferred to Hospital B for evaluation.

Review of Patient #11's medical record from Hospital B showed the following:
- He presented to the ED on 07/08/21 at 11:34 AM.
- On 07/08/21 at 3:46 PM, a urine drug screen (UDS) was positive for fentanyl and benzodiazepine.
- The patient's diagnosis was altered mental status (any change in a person's mood, behavior, psychomotor skills, and/or cognition), toxic encephalopathy (brain dysfunction caused by toxic exposure), drug induced acute dystonia (a movement disorder where muscles contract involuntarily, causing repetitive or twisting movements) and drug overdose.
- He was discharged home on 07/11/21 at 12:55 PM.

The hospital's undated document titled, "Unit Three Investigation," showed that Patient #11 was sent out on 07/08/21. At 5:42 PM, the RN Supervisor notified Staff F, CNE, that Patient #11 had tested positive for fentanyl. Staff F instructed the supervisor to search Unit Three and talk to the patients.

Review of an email correspondence dated 07/12/21 at 9:46 AM from Staff G, House Supervisor to Staff F, Staff X, Director of Nursing (DON) and Staff W, Risk Management (RM) Director regarding possible passing of drugs on Unit Three, showed that on 07/09/21, Staff G spoke with a patient on Unit Three who told him that Patient #61 was passing drugs on the unit. Patient #61 had been moved to Unit Four. When Staff G and Staff ZZ, Physician, confronted Patient #61 about this, he denied it. A fentanyl test was ordered on Patient #61 but had not been resulted.

Review of an incident report dated 07/08/21, showed that:
- Patient #61 was identified as possibly having concealed drugs on him, by another patient.
- Patient #61's room on Unit Four (Acute) was searched along with his body.
- Two pills were found on him, one pill was identified as Clozaril (an antipsychotic drug used to manage schizophrenia [a serious mental disorder that affects a person's ability to think, feel, and behave clearly]) and the second pill was unable to be identified.
- He was placed in scrubs and his observation level was changed to one to one (1:1, continuous visual contact with close physical proximity).

After the incident with Patient #11, the second patient to test positive for fentanyl, and the incident with Patient #61, the hospital initiated no new process changes or staff education.

Review of an incident report dated 07/13/21, showed that Patient #9 was noted to have mumbled speech, difficult to understand and the patient had difficulty following commands. The patient was sent to Hospital B for further evaluation. The incident was reviewed in morning report, but did not indicate a follow-up was necessary.

Review of Patient #9's medical record showed the following:
- She was admitted to the hospital on 07/08/21 for opioid detoxification, depression (extreme sadness that doesn't go away), suicidal ideations (SI, thoughts of causing one's own death) and bipolar disorder (a mental disorder that causes unusual shifts in mood by alternating periods of emotional highs and lows).
- She reported using one to one and a half grams of fentanyl daily by snorting or IV.
- Her last use of fentanyl was 30 minutes before arrival to the hospital.
- UDS dated 07/08/21 at 9:00 PM, did not include a test or result for fentanyl.
- On 07/10/21 at 2:35 PM, the patient was having visual hallucinations (seeing or hearing things which are not there).
- On 07/11/21 at 12:15 PM, a physician order was written to search the patient's room for fentanyl. (There was no documentation in the chart that this was completed)
- From 07/11/21 through 07/12/21, the patient was isolative and withdrawn to bed.
- On 07/12/21 at 1:20 PM, the patient was anxious (a feeling of fear or worry experienced intermittently), irritable and thought processes appeared tangential (a disturbance in the thought process that causes the individual to relate excessive or irrelevant detail that results in never reaching the essential point of a conversation or desired answer to a question).
- On 07/13/21 at 2:15 PM, Nursing documented that the patient was noted to be alert and oriented to person and place only. Her speech was mumbled and difficult to understand. The patient was having difficulty following commands and had a shuffled gait (a person's manner of walking). The patient would only drink if a cup was put to her lips. Staff ZZ notified and assessed the patient. Orders were received to transfer Patient #9 to Hospital B for evaluation.
- The patient was transferred to Hospital B by ambulance at 3:15 PM.

Review of Patient #9's medical record from Hospital B showed the following:
- On 07/13/21 at 3:43 PM, she arrived to the ED
- The patient presented to the ED with altered mentation and hallucinations.
- ED Nursing triage noted that the patient admitted to taking fentanyl on the morning of 07/13/21.
- UDS obtained in the ED reported to be positive for fentanyl.
- The ED physician assessment and plan was acute metabolic encephalopathy (a health condition that makes it hard for the brain to work), presumed due to drug overdose.
- On 07/14/21 at 6:43 AM, the patient vomited, and a large white pill shaped object was noted and collected in case further investigation was required.
- She was discharged home on 07/21/21.

Review of the hospital's undated document titled, "Unit Three Investigation," showed that Patient #9 was sent out on 07/13/21. The RN Supervisor notified Staff F, CNE, on 7/14/21 at 8:27 AM, that Patient #9 had tested positive for fentanyl. Staff F instructed a search of Unit three again. The RN Supervisor reported the patient's room had been searched prior to being sent to Hospital B, and no contraband was found. Staff F reached out to Hospital B to assist with interview of the patients to try to obtain more information about where the fentanyl came from or how the patients obtained it.

Review of the hospital's document titled, "Investigation of possible drugs being brought into the hospital," dated 07/14/21, showed that Staff F, received a phone call from Hospital B's ED manager, stating that unidentified pills were found on Patient #17, who was transferred (from CenterPointe Hospital) to Hospital B, a few days prior. She also reported a capsule was found in Patient #9's vomit. She reported that the patient told her it was a "red bean." The Hospital B ED manager reported that this was like the other pills that were found on Patient #17.

After the incidents with Patient #9, the third patient to test positive for fentanyl, and Patient #17, the hospital initiated no new process changes or staff education.

Review of an incident report dated 07/15/21, showed that Patient #12 was exhibiting bizarre behavior and had altered mental status. He was also positive for both visual and auditory hallucinations. The patient was transferred to Hospital B for evaluation. The incident was reviewed in morning report but did not indicate a follow-up was necessary.

Review of Patient #12's medical record showed the following:
- He was a 36 year old male admitted to the hospital on 07/10/21 at 4:00 PM for fentanyl, klonopin (medication used to control seizures), Xanax and methamphetamine detoxification.
- He used one to two grams of fentanyl a day by IV and snorting.
- The last use of fentanyl and methamphetamine was 07/10/21 at 11:00 AM and the last use of benzodiazepine was 07/09/21 at 11:00 PM.
- On 07/13/21, the patient attended groups and socialized with peers. The patient was calm and cooperative, no behavioral issues noted.
- On 07/14/21, the patient was very sedated and behaving strangely. He was responding to imagined voices.
- On 07/15/21 at 1:00 PM, a physician order was written for the patient to not go on smoke breaks or lunch breaks, limited to wearing scrubs, and for a UDS to be completed.
- On 07/15/21 at 3:00 PM, the patient's mental status had declined and the patient made delusional comments.
- On 07/15/21 at 6:00 PM the patient's UDS did not include a test or result for fentanyl.
- On 07/15/21 at 7:16 PM, the patient was sent out to Hospital B due to ongoing altered mental status. He was having both auditory and visual hallucinations.

Review of Patient #12's medical record from Hospital B showed the following:
- On 07/15/21 at 7:36 PM, the patient presented to the ED with altered mental status, hallucinations and jerking body movements. The patient was confused and disoriented.
- On 07/15/21 at 9:55 PM, the patient's UDS was positive for fentanyl.
- On 07/16/21 at 2:10 AM, the patient was discharged back to CenterPointe Hospital with a diagnosis of polysubstance (the consumption of more than one drug at once) abuse.

Review of the hospital's undated document titled, "Unit Three Investigation," showed that on 07/16/21 at 8:00 AM, information was received that Patient #12 tested positive for fentanyl.

Review of an email dated 07/16/21 showed Staff X, DON, communicated a new body check process and that all new admissions were to be placed in scrubs (not their street clothes). There was no attestation to verify if staff read the email.

During an interview on 07/22/21 at 9:30 AM, Staff J, MHT, stated that she had not received any recent education related to contraband or room checks.

During an interview on 07/22/21 at 11:00 AM, Staff L, Nurse Educator, stated that she was not asked to educate staff on any new process changes or policy changes since the incidents involving patients found with fentanyl in their system.

During an interview on 07/28/21 at 8:30 AM, Staff N, House Supervisor, stated that she had not been informed of any issues with patients and drugs until the last patient (#12) had been sent out for a medical evaluation. Staff N added that due to staffing levels, she was unable to walk through the units on her shift to ensure that room checks were completed.

During an interview on 07/22/21 at 12:25 PM and 08/03/21 at 10:50 AM, Staff W, RM Director, stated that:
- There had been four patients (#9, #10, #11, and #12) that tested positive for fentanyl in the ED when transferred to Hospital B for a change in condition.
- The hospital was made aware of the first patient who tested positive for fentanyl on 07/07/21.
- There had been no education or changes made until 07/16/21, regarding body checks and placing patients in scrubs for the first 24 hours.
- Reeducation to staff on room searches had not been started.
- Incident reports were reviewed daily in the morning meeting with senior leadership. They sometimes discussed what actions to take. It was not well documented what those actions were to be or who was responsible for any follow-up.
- The hospital had not had a meeting regarding the fentanyl issues, the processes that were put in place, or an discussions of what else could be done.

During an interview on 07/22/21 at 1:00 PM, Staff F, CNE, stated that the hospital had not interviewed nursing staff regarding possible fentanyl distribution, because she had no reason to suspect the staff were distributing.

2. Review of the hospital's policy titled, "Assessment for Contraband," dated 03/06/18, showed that:
- Routine searches would be conducted on all patients upon admission, when seclusion, restraints, or time outs had been utilized, and patient, unit, and room searches would be conducted when staff had reasonable cause to believe that the patient may possess an item that could be hazardous.
- A belongings search should include a search the patient's luggage, purse, book bag or other items carried in to the hospital by the patient and/or family.
- Items that would be considered as contraband on the adult units, would be items such as cell phones, headphones, medications, drugs, alcohol, electronics, hair tools, drug paraphernalia, pipes, cigarettes, lighters, matches, etc.
- The body search should be completed according to the "Body Check Assessment" form.

Review of the hospital's "Body Check Assessment" form dated 07/22/21 showed that:
- Staff should keep the patient in line of sight (LOS, continuous visual contact with the patient) until their body assessment had been completed.
- The assessment would be completed on the unit the patient would be admitted to.
- After inspection, the patient should be placed in scrubs.

Review of Patient #60's medical record showed that she was a 27 year old female admitted to Unit Three (Detox) on 06/26/21 for opioid detoxification. She had a history of snorting 10 fentanyl capsules daily for the last four weeks, along with using one gram of methamphetamine and two grams of marijuana a day since age 18.

Review of an incident report dated 07/01/21 at 7:00 PM, stated that Patient #60's purse had been found by her roommate on the floor between the bed and the window, her closet had been locked. Staff noted that the purse contained a cell phone, a vape pen (an electronic device shaped like a pen that is used to inhale vapor such as liquid nicotine or marijuana), a nicotine bottle, 10 chargers, two corded earphones, one cordless earphone, and one container that contained pieces of marijuana. The contraband had been previously given to Staff O, House Supervisor, and the purse had been locked in Patient #60's closet.

Review of the hospital's undated document titled, "Unit Three Investigation," showed that staff were unable to determine how long Patient #60 had the purse and contraband in her possession.

There was no indication that the hospital provided education to staff related to Patient #60's contraband, or how to prevent reoccurrence.

Review of Patient #61's medical record showed that he was a 36 year old male admitted to Unit Three (Detox) for detoxification on 07/05/21 for fentanyl and alcohol abuse. He had a history of drinking a one and a half bottles of a fifth of whiskey and one gram of fentanyl daily for the past 10 months.

Review of an incident report dated 07/08/21, showed that Patient #61 had been identified as possibly having concealed drugs on him by another patient. His room on Unit Four (Acute) had been searched, along with his body. Two pills were found on him, one pill had been identified as Clozaril (an antipsychotic drug used to manage schizophrenia [a serious mental disorder that affects a person's ability to think, feel, and behave clearly]) and the second pill was not identifiable.

Review of an incident report dated 07/11/21, showed that Patient #17 was admitted to Unit Four (Acute), and became unresponsive in the dayroom. A code blue was called, and she was transferred to Hospital B's ED.

Review of Patient #17's medical record showed that she was a 32 year old female admitted on 07/11/21 for bipolar, Post-Traumatic Stress Disorder (PTSD, a condition of persistent mental and emotional stress occurring as a result of injury or severe psychological shock) and opioid use. She had used fentanyl in the hospital's (CenterPointe) lobby bathroom and was revived with Narcan (a medication used to counter the effects of narcotic overdose). Once admitted to the hospital (CenterPointe), she overdosed on fentanyl she had hidden in her bra, and became unresponsive. She experienced periods of apnea (to intermittently, and involuntarily stop breathing) and her oxygen level dropped to 94% on six liters of supplemental oxygen, prior to her transfer to Hospital B's ED by ambulance.

Review of an incident report dated 07/16/21 at 4:54 AM, showed the following:
- During safety rounds, Patient #12 was found to have three sealed syringes without needles.
- The patient also had a metal snap button from an EKG electrode hidden in his closed hand.
- The patient had on three personal shirts.

Review of the hospital's undated document titled, "Unit Three Investigation," showed that on 07/16/21 at 7:40 AM, Staff X, DON, was notified that Patient #12 had been found with packaged syringes. At 8:00 AM, information was received that Patient #12 had tested positive for fentanyl. Staff Y, then ordered for patients on Unit Three to be locked out of their rooms, body checks performed on Unit Three patients and those patients to be placed in scrubs as well as a complete check of the unit. Searches and patient interviews began at 10:00 AM.

Incidents of a purse found with marijuana and other contraband items inside, unknown pills found on patients, and patients transferred for medical emergencies and found with fentanyl in their system began on 07/01/21. Process changes did not occur until 07/16/21, 15 days later. Staff education had not occurred until 07/23/21. These failures put all patients at risk for their health and safety.

3. Observation on 07/28/21 at 10:45 AM on Unit Seven (Silver Linings, geriatric) showed the following:
- A white board with 13 patient initials. All 13 patients were on suicide precautions.
- Medical beds with electrical cords occupied the rooms.
- Four of the beds had electrical cords that were not corded or zip tied, and measured 40 to 107 inches in length.

During an interview on 07/28/29 at 11:00 AM, Staff GG, RN, stated that electrical cords were considered a ligature risk and should not be accessible to patients.

During an interview on 08/03/21 at 4:00 PM, Staff F, CNE, stated that electrical cords should not be accessible for suicidal patients, and that she would expect the nursing units to be free from ligature risks.

4. Observation on 08/02/21 at 12:01 PM on Unit Three (Detox) showed the following:
- Patient #55 standing at the nurse's station unattended. There were no nursing staff behind the desk or visible in the vicinity.
- The nurse's station was not locked and was accessible to anyone.
- Behind the nurse's station were pens, phone cords, scissors, a metal three hole punch that could be used as a weapon and patient medical records.

During an interview on 08/02/21 at 12:10 PM, Staff KKK, RN, stated the following:
- She was the only staff person on the unit at the time.
- She was in the medication room getting Patient #55's medications.
- The MHT who worked with her, took some patients to lunch, and another staffed RN was off the unit transferring a patient to the hospital for medical evaluation.
- She and the MHT had worked the night shift and stayed over because there was not enough staff to cover the day shift. If they had not stayed over, all 15 patients on the unit would have been under the care and observation of only one RN.
- There were many shifts that she stayed late to chart, medications were sometimes not given on time, and staff were not able to give adequate attention to patients because of staffing issues.

During an interview on 08/03/21 at 3:55 PM, Staff F, CNE, stated that she considered phone cords, computer cords, staplers, charts, etc. to be items that patients should not be allowed access, and expected a staff member at the nursing desk at all times.

#5. During an interview on 07/26/21 at 2:00 PM, Staff Y, Chief Executive Officer (CEO), stated that:
- The Admissions and Referral (A&R, behavioral health intake area) Unit was staffed 24 hours a day, seven days a week.
- During the week, an RN completed Medical Screening Examinations (MSE) on the intake patients.
- A MHT, Licensed Practical Nurse (LPN) or RN was pulled from the unit they were working on, to assist the A&R Unit and perform incoming patients' body checks to look for contraband.
- She did not feel that pulling staff from the inpatient units to complete the body checks would impact the care on the unit.

During an interview on 07/26/21 at 2:30 PM, Staff F, CNE, stated that during the night, from 11:00 PM to 7:00 AM, the A&R Unit was not staffed with a RN, therefore, the House Supervisor would be responsible for filling that role, and completing the MSE and body checks.

During an interview on 07/27/21 at 2:40 PM, Staff O, House Supervisor, stated that:
- As the supervisor, she would be required to respond to any situation on the units to assist the staff as needed.
- She would be responsible for covering the A&R Unit when a body check or a MSE was needed.
- When a body check needed to be completed in A&R Unit, she called one of the inpatient units to pull an MHT in order to have two persons to complete the task.
- There was not an MHT assigned to A&R.

During an interview on 07/28/21 at 8:30 AM, Staff N, House Supervisor, stated that completion of body checks were not feasible when she had to staff a unit due to staffing shortages.

6. Review of the hospital's policy titled, "Code Blue/CPR," revised 05/22/19, showed that Unit 5/6 (Adult) would be responsible for responding to any code blue situation with the emergency cart. Once the code blue has been completed, the emergency cart supplies should be replenished, the cart re-locked, and returned to the unit for storage.

Although requested on 07/29/21, the hospital failed to provide policies specific to the contents and maintenance for the Emergency Cart or the AED machine.

Review of the hospital's undated document titled, "Emergency Cart Lock, AED Check & Oxygen Checklist," showed that:
- The first column asked the staff member to indicate yes or no if the "AED is Ready" (Green check mark is visible on the AED unit).
- The second column asked for the lock number.
- The third column asked the staff member to indicate yes or no if the "Oxygen Tank is Full."
- The fourth column asked for the staff member's signature.
- The fifth and final column was labeled, "Comments."

Review of the hospital's document titled, "Emergency Cart Lock, AED Check & Oxygen Checklist," showed that:
- For the month of July, the cart should have been checked on 07/04/21, 07/11/21, 07/18/21, and 07/25/21.
- There were no cart checks documented for those days.
- There was no list that identified the types of supplies required to be stocked in the cart, no process to ensure supplies were not outdated, and no direction for obtaining replacement supplies.

During an interview on 07/29/21 at 2:40 PM, Staff OO, RN, stated that the emergency cart would be checked by the night shift nurse on Sundays, and if the emergency cart was opened, it would be checked and re-locked.

During an interview on 07/28/21 at 8:50 AM, Staff LL, RN, stated that the hospital had only one emergency cart, and when a patient (Patient #10) became unresponsive, she was unable to find a pen light (used as part of a nursing assessment), gloves, or a stethoscope on the emergency cart.







39147

Based on interview, policy review, and record review, the hospital failed to protect one patient (#18) from emotional abuse when staff threatened to place him on a 96-hour hold (court-ordered evaluation by behavioral specialists to determine if a person is safe to themselves and others) after he requested to be discharged from the hospital. The actions of staff members had the potential to place all patients that request to be discharged from the hospital at risk for abuse. The hospital census was 98.

Findings included:

1. Review of the hospital's undated document titled, "Statement of Patient Rights," showed that the patient had the right to refuse treatment.

Review of the hospital's policy titled, "AMA Discharge and Request for Discharge by Voluntary Patient or Legal Representative," dated 08/19/19 showed that:
- When a patient or legal guardian requests to discharge, the charge nurse, social worker, and the attending or on-call physician should be notified.
- The patient, or their legal representative, should complete a written request on the Request for Discharge form.
- The patient's safety should be assessed, including whether or not they are having thoughts of or planning to harm themselves or others.
- After hours, the administrator on call should be notified.
- The case will be reviewed by the physician within four hours of completion of the Request for Discharge form.

Review of the hospital's policy titled, "Investigation of Institutional Abuse/Neglect Allegations," revised 08/21/18, showed verbal threats were considered emotional abuse.

Although request twice, on 07/22/21 at 11:25 AM and on 07/28/21 at 12:55 PM, the hospital failed to provide a policy for the initiation/completion of a 96-hour hold.

Review of Patient #18's History and Physical showed that:
- He was a 39-year old male voluntarily admitted to the hospital on 04/07/21 at 1:55 PM.
- His history of present illness consisted of having periods of time, three to five days a month, where he will be awake, not like himself, and then have no memory of those times.
- His wife reported that during these incidents, she would find him in the kitchen cabinets during the middle of the night, he seemed confused and was not making any sense.
- His past medical history included narcotic dependence (when a person is physiologically and psychologically dependent on narcotics), attention deficit hyperactive disorder (ADHD, characterized by problems with keeping attention to one thing and impulsive behaviors), anxiety (a feeling of fear or worry experienced intermittently), and depression (extreme sadness that doesn't go away).

Review of Patient #18's Request for Discharge form, dated 04/09/21 at 4:40 PM, showed that he had initially asked to be discharged on 04/07/21 at 7:47 PM. That date had been crossed out, and re-written as 04/09/21 at 4:40 PM.

Review of Patient #18's 96-hour hold paperwork, dated 04/08/21 at 3:50 PM, showed that:
- Staff O, House Supervisor, initiated the paperwork to place him on a 96-hour hold with the end date of 04/14/21 at 3:50 PM.
- Staff O documented that Patient #18 initially asked to leave AMA the evening before, but agreed to stay overnight to speak with the doctor.
- Staff O documented that Patient #18 arrived to the hospital confused, with slurred speech, mumbling, and his wife had reported he had been combative with her.
- Staff O documented that Patient #18 was speaking with a Nurse Practitioner (NP), when he demanded to be discharged and slammed his hand down on her desk.
- Staff O signed the paperwork stating these facts supported that Patient #18 needed to be involuntary (a legal process through which a person is hospitalized and treated for mental health disorders without their consent) for treatment of his mental disorder and his alcohol/drug abuse issues.
- The document listed numerous staff members as prospective witnesses to the incident.

Review of the document titled, "In the Eleventh Judicial Circuit, State of Missouri, Circuit Court Division - Petition of Writ of Habeas Corpus," dated 04/09/21, showed that:
- Patient #18's attorney filed the document on his behalf to have him released from the hospital.
- Patient #18 was voluntarily admitted to the hospital to have a psychiatric evaluation to ensure that the seizure like activity he had been experiencing was not related to a psychiatric condition.
- Patient #18 followed the suggestion for admission from his neurology NP, whom could not complete the evaluation at that hospital because the patient had not been deemed a threat to himself or others.
- He had an upcoming hearing scheduled for 06/04/21 to determine his eligibility for disability related to seizures.
- Patient #18 completed the AMA form, but was told he could not leave without being seen by a doctor for clearance.
- After he requested to leave AMA, Patient #18 and his spouse were both told that he had been placed on a 96-hour hold, and he would be held for detoxification (the process of removing drugs or alcohol from the body) treatment.
- Patient #18 took Xanax (medication used in the treatment of mild to moderate anxiety), Suboxone (medication used to treat narcotic dependency), Adderall (medication used to treat attention deficit hyperactivity disorder), and Zoloft (used to treat depression, obsessive-compulsive disorder, posttraumatic stress disorder, anxiety disorder and panic disorder) all prescribed by his provider at a local Behavioral Health clinic.
- He also took Depakote (a medication used to treat seizures [excessive activity in the brain which causes uncontrolled jerking movements]), which was prescribed by his Neurology Clinic provider.
- The document stated that Patient #18 was placed in danger by the discontinuation of all his pre-hospital medications, and placement on a different seizure medication, Gabapentin (medication used to treat nerve pain or seizures) without having been seen by a physician.

During an interview on 07/22/21 at 9:55 AM, Staff D, NP, stated that:
- Patients admitted to the detox unit usually exhibited poor judgement, had legal issues and manipulative natures.
- When a patient asked to leave AMA, the nurse should attempt to de-escalate (reduce the intensity of a conflict or potentially violent situation) the patient, remind the patient of needed treatment, and encourage them to remain until they were seen by a provider.
- Patients were routinely seen by the NPs, and the physician saw them about once a week.
- When a patient left AMA, they would not be provided discharge instructions or follow up appointments.

During an interview on 08/02/21 at 3:35 PM, Staff W, Risk Management (RM) Director, stated that she had obtained a list of staff who had been trained by the Department of Mental Health to complete the 96-hour hold paperwork, but did not have a copy of the education, and the training was not documented.

During an interview on 07/27/21 at 1:10 PM, Staff BB, Registered Nurse (RN), stated that when a voluntary patient requested to leave AMA, staff commonly told them they would be placed on a 96-hour hold, that they need to complete their treatment, and/or be seen by the physician or NP prior to leaving. If the request was made during the weekend, they would need to wait until Monday.

During an interview on 07/27/21 at 1:30 PM, Staff CC, RN, stated that when a voluntary patient requested discharge, the physician would be contacted, and staff commonly told the patient to wait to be seen by the doctor, and that insurance may not pay for their stay if they left.

During an interview on 07/27/21 at 2:40 PM, Staff O, House Supervisor, stated that:
- When a voluntary patient requested to be discharged, the NP would make them involuntary and place them on a 96-hour hold.
- Once placed on the 96-hour hold, weekends and holidays did not count for the 96 hours.
- Most patients agreed to wait until they could speak with the doctor.
- The patient could not be held against their will, but they could be made involuntary.
- She worked as the House Supervisor on the shift that Patient #18 had asked to leave the hospital.
- She filled out the paperwork for the 96-hour hold, and faxed it to the court.
- She did not personally witness his behavior toward the NP.
- A notary (person authorized to legally certify documents) was not available on that shift, so two staff members had signed the paperwork.
- She had completed a class on involuntary holds, but could not remember when or where.

During an interview on 07/27/21 at 3:15 PM, Staff DD, RN, stated that:
- On Unit 3 (Detox), patients checked in and out all the time.
- They were told that insurance may not cover their stay if they decided to leave AMA.
- When a voluntary patient asked to leave, they were told that the doctor would make them involuntary, and the staff told the patient they had to wait to be seen by the doctor.
- The doctor was supposed to be notified, along with the House Supervisor, so that the 96-hour hold paperwork could be initiated.

During an interview on 07/28/21 at 8:30 AM, Staff N, House Supervisor, stated that:
- She was not present when the 96-hour hold paperwork for Patient #18 was completed, and she had not witnessed any of Patient #18's behaviors.
- She was listed as a witness on Patient #18's paperwork.
- House Supervisors were listed as witnesses on the paperwork, even though they may have not witnessed any patient behaviors.
- The patient's behavior gave the hospital the right to place them on a 96-hour hold.

During an interview on 07/28/21 at 4:20 PM, Staff VV, Chief Medical Officer (CMO), stated that:
- Many of the detox patients asked to leave on day two since their substances were not available to them.
- The nursing staff were expected to spend time with the patient and discuss the reasons the patient wanted to leave, and tell them that the doctor would see them in the morning.
- Patients with a history of suicidal ideation (SI, thoughts of causing one's own death), homicidal ideation (HI, thoughts or attempts to cause another's death), or suicidal attempts, would be considered at risk and made involuntary.
- Staff should not threaten patients with a 96-hour hold.

Based on observation, interview, record review and policy review, the hospital failed to adequately supervise the nursing care for patients and provide a safe and theraputic environment when:
- Seven discharged patients (#9, #10, #11, #12, #17, #60 and #61) had access to contraband (items that are illegal, forbidden, or that can be used to harm self or others). Four of those patients (#9, #10, #11, and #12) required transfer to Hospital B (nearby acute care hospital) for medical emergencies and were found to have fentanyl (a medication used to treat severe pain, and is a high risk drug for theft and personal use) in their system. (A-0395)
- The hospital did not implemented measures and ensure nursing staff were educated to prevent reoccurrence, including appropriate supervision of patients, proper body checks (visual search of a body for prohibited materials that could be used to harm themselves or others) and contraband searches, after the incidents occurred. (A-0395)
- Nursing staff did not complete detoxification (detox, the process of removing drugs or alcohol from the body) vital signs (body temperature, blood pressure, heart rate, and breathing rate) as ordered on five current patients (#20, #47, #51, #56 and #57) of five current medical records reviewed with detox vital signs and one discharged patient (#10) of four discharged patient medical records reviewed with detox vital signs. (A-0395)
- Eight patients (#3, #24, #33, #34, #35, #36, #37, and #38) were not consistently provided group therapy as scheduled. (A-0392)
- Two patients (#51 and #52) engaged in sexual activity on Unit Four (Acute), and orders for continuous 1:1 monitoring of Patient #52 was decreased within hours after the event. (A-0392)
- General patient care, medication administration, physicians orders and processes to monitor the safety of patients were consistently reported by staff as unable to be carried out as expected as related to low staffing levels. (A-0392)
- Insulin (a high-risk medication that regulates the amount of sugar in the blood), dosages were not verified by two nurses prior to patient administration. (A-0405)

These practices resulted in a systemic failure and noncompliance with 42 CFR 482.23 Condition of Participation: Nursing Services. The hospital census was 98.

The severity and cumulative effect of these practices had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ).

On 07/23/21, the survey team informed the hospital of the IJ, the staff created educational tools, revised policies and began educating all staff, and implemented interventions to protect the patients.

As of 07/27/21, the hospital had provided an immediate action plan sufficient to remove the IJ by implementing the following:
- The body check assessment process was changed to complete the patient's body checks in the Assessment & Referral (A&R) Exam Room, prior to the patient's admission to the unit.
- The revised process included a revised body check assessment form and required patients to disrobe, including removing undergarments so they could be more thoroughly checked for hidden contraband.
- A full-time equivalent staff member would be assigned to the A&R unit to perform body checks for new admissions on all shifts. The staff member would be assigned to A&R area, and not be pulled from a nursing unit where they were assigned patient care.
- All staff were re-educated on proper room searches which included scenarios and a mock room search.
- Nursing staff were re-educated on opioid and overdose withdrawal symptoms, including the use of Narcan (a medication used to counter the effects of narcotic overdose).
- All personal hygiene items were removed from patient rooms and the hospital developed a new system for dispensing products in paper cups.
- Patients were limited the amount of personal clothing to be kept in their rooms.
- A new process for the inventory and the secured storage of excess patient clothing and personal items had been established.

On 08/02/21 at 5:15 PM, the survey team discovered that the hospital had continued to pull staff from the nursing units to complete body checks in the A&R area, in direct opposition to the Plan of Correction which was accepted on 07/27/21.








27727

Based on interview, policy review, and record review, the hospital failed to ensure staffing adequately met the needs of the patients, provided safety to the patients, and ensured the proper number and types of staff were available when:
- Eight patients (#3, #24, #33, #34, #35, #36, #37, and #38) were not consistently provided group therapy as scheduled.
- Two patients (#51 and #52) engaged in sexual activity on Unit Four (Acute), and orders for continuous 1:1 monitoring of Patient #52 was decreased within hours after the event.
- General patient care, medication administration, physicians orders and processes to monitor the safety of patients were consistently reported by staff as unable to be carried out as expected.
These failures had the potential to affect the safety, well-being, and therapeutic outcome of all patients admitted to the hospital. The hospital census was 98.

Findings included:

1. Review of the hospital's policy titled, "Nursing Staffing Plan," dated 10/30/19, showed that there should be a sufficient number of Registered Nurses (RNs) on duty at all times, and that an RN should supervise the nursing care of each patient.

Review of the hospital's job description titled, "House Supervisor," dated 10/01/18, showed that the House Supervisor would be responsible for the supervision of all nursing and clinical staff, they should schedule staff according to the acuity of patient population.

Review of the hospital's job description titled, "Staff Nurse (Registered Nurse, RN)," dated 10/01/18, showed that an RN should coordinate and supervise patient care, lead psycho-educational groups, educational classed and educate patients regarding their medications and possible side effects.

Review of the hospital's job description titled, "Licensed Practical Nurse (LPN)," dated 10/01/18, showed that an LPN should provide nursing care to patients under the direct supervision of an RN, and lead psycho-educational groups and education classes as assigned.

Review of the hospital's job description titled, "Mental Health Technician (MHT)," revised 12/26/16, showed that MHT's:
- Work under the general direction of a RN.
- Perform and record patient vital signs (body temperature, blood pressure, heart rate, and breathing rate) and notifies RN of any changes.
- Continuously observe patient's behavior, mental status and activities; and notifies RN of any changes or unusual occurrences.
- Assist with therapeutic groups under the direction of the RN.

Review of the hospital's "Staffing Sheets" for July 2021 showed that:
- During nine shifts, the House Supervisor was required to staff one of the nursing units along with their supervisor responsibilities.
- During one shift, the House Supervisor was required to staff two separate units at the same time, along with their supervisor responsibilities.
- On 39 separate occasions, an LPN was assigned as the only nurse on the unit.
- A total of 113 shifts on units were understaffed according to the hospital's staffing grid.

2. Review of the hospital's documents titled, "Adult Unit 5/6 Mental Health" group schedule showed that there should have been nurse led groups held three days a week at 10:30 AM, and daily MHT groups held at 11:30 AM and 1:30 PM.

Review of the hospital's documents titled, "Adult Unit 5/6 Adult Dual" group schedule showed that there should have been nurse led groups held four days a week at 10:30 AM, and daily MHT groups held at 1:30 PM and 4:30 PM.

Review of the hospital's document titled, "Adult Unit Assignment Sheet," dated 07/29/21, showed that groups were not assigned to staff members and that no topics were listed for the daytime shift.

Review of six patients (#33, #34, #35, #36, #37, and #38) medical records on 07/29/21 at 9:10 AM, showed that MHT group documentation for Unit 5/6 (Adults), between the weekend dates of 07/23/21 through 07/25/21, was inconsistent and missing at times. The group notes were not consistently completed, some of them were not dated, timed, titled, or did not have the name of the MHT that lead the group.

During an interview on 07/22/21 at 9:35 AM, Patient #3, stated that groups were not always held on the weekends due to short staffing on Unit 5/6.

3. During an interview on 07/24/21 at 4:18 PM, Staff W, Risk Management Director, reported an event that occurred in 07/24/21, which involved Patient #51 and Patient #52. The patients were engaged in a group activity with a MHT, in the day room on Unit Four (Acute). The MHT left the room and returned after a short period of time, and found Patient #52 performing oral sex on Patient #51. Staff W reported that the two patient were immediately placed on 1:1 observation and Patient #51 was moved to another unit.

Review of a physician order dated 07/24/21 at 3:50 PM, showed that Patient #52 was placed on sexual assault precautions - level 2 (indicates there has been patient concerns related to sexually inappropriate behaviors), with 1:1 observation, but at 6:20 PM, the patient's observation level was decreased to 1:1 only while awake.

Observation with concurrent interview on 07/25/21 at 1:27 PM, showed Patient #52 in her room, asleep with the door closed. Another patient was in the room changing clothes. When Staff PPP, LPN, was asked how staff knew if a patient was awake when the patient's door was closed, he replied "exactly!" When questioned about the change in observation level for Patient #52, Staff PPP stated that current, low staffing levels affected how nursing care was provided, and added that staff frequently called physicians to get patient observation orders reduced to a lower level, based on the inability to provide continuous 1:1 monitoring.

During an interview on 07/25/21 at 2:26 PM, Staff QQQ, RN, stated that the patients on Unit Four (Acute) were the sickest patients in the hospital, required the highest amount of care, and that staffing was not based on acuity and was inadequate. Staff QQQ stated there were two nurses and two MHTs currently staffed for 19 patients, and that one of those patients was ordered to be 1:1 while awake. The patients on the unit were labile and easily agitated, and she had to prioritize what had to be done, as opposed to what should be done, and added that she was "more worried about keeping the patients from killing each other or themselves, than [Patient #52] giving someone a blow job."

During an interview on 07/27/21 at 1:10 PM, Staff BB, RN, stated that:
- Staffing was a major issue with the hospital.
- Frequently she had been the only nurse on a unit, and had been responsible for all the admission, transfers, and discharges of the patients.
- She had to float between two units at one time.
- There were not enough MHT's to adequately supervise the patients for safety.
- At times, the nurses have been told by supervisors to obtain orders from the physician to decrease the level of observation for patients, usually from one to one (1:1, continuous visual contact with close physical proximity) status to 1:1 while awake (WA); there were not enough staff to accommodate the 1:1 patients.
- On Sunday, 07/25/21, day shift, there were not enough staff present. There were two RNs and one MHT for 14 patients. Four of the patients were on active detoxification (the process of removing drugs or alcohol from the body, which increases the risk of medical emergencies such as seizures and heart related events) orders (this requires frequent vital signs and assessments for possible changes in the patient's condition).
- There were no room searches or MHT groups on 07/25/21, due to staffing.
- When staff members voiced concerns to administration about staffing, nothing changed. The emphasis was on numbers and not the safety of patients or staff.

During an interview on 07/27/21 at 1:30 PM, Staff CC, RN, stated that:
- Staffing was a huge issue. On her previous shift, she had 17 patients and one MHT on Unit Three (Detox).
- She was told that there was a float nurse to assist her, but that person covered another unit at the same time.
- It was routinely difficult to take a break or go to the bathroom.
- When the MHT was pulled from the unit to do a body check, or went on break, she would be the only staff member on the unit.

During an interview on 07/27/21 at 2:40 PM, Staff O, House Supervisor, stated that:
- As the supervisor, she would be required to respond to any situation on the units and to assist the staff as needed.
- There were staffing issues in the hospital and she had been concerned not only for the patients, but the nursing staff as well.
- Administration has been aware of the staffing issue, which began about a year ago when the hospital did away with their weekend option program. They lost about 15 nurses, and have struggled ever since.
- The staff were tired of working short and won't work extra, even for bonuses.
- Staffing was a daily struggle.

During an interview on 07/27/21 at 3:15 PM, Staff DD, RN, stated that:
- The hospital has been consistently short staffed.
- Most nights, no one was available to relieve staff for their breaks.
- During an incident when two patients had engaged in a sexual act, all of the staff on the unit at that time were written up. However, administration did not address the fact that the unit was short staffed and that there had been only one MHT on the unit to safely monitor the patients.

During an interview on 07/27/21 at 4:30 PM, Staff EE, RN, stated that:
- Staffing was awful.
- Unit One (Adolescents), had been staffed with one nurse and one MHT for 13 patients.
- The kids were only able to go outside because an Activity Therapist (AT) was able to accompany the MHT outside with the children, while she (Staff EE) remained inside to monitor the three patients on unit restrictions.
- Every unit had been short staffed and the House Supervisor has, had to staff units, so the House Supervisor could not relieve staff for breaks.

During an interview on 07/28/21 at 8:30 AM, Staff N, House Supervisor, stated that:
- She was fearful (retaliation) to answer questions about staffing.
- Due to staffing levels, she had been unable to walk through the units on her shift to ensure that room checks were completed.
- Her assistance with body checks in the Admissions and Referrals (A&R) area were feasible, except for when she had to staff a unit due to staffing shortages.
- She typically ended up staffing a unit at least one or two nights a week, along with being the House Supervisor.
- She believed that if staff were forthright about staffing, they would be in jeopardy of losing their jobs.

During an interview on 07/28/21 at 8:50 AM, Staff LL, RN, stated that:
- The hospital had not been adequately staffed.
- She had been assigned 17 patients to care for on Unit 5/6 (Adults), and felt the assignment was unsafe.
- She had also worked Unit Four (Acute), and been assigned 13 patients with three discharges, and two insulin (medication that regulates the amount of sugar in the blood) dependent diabetics (a disease that affects how the body produces or uses blood sugar, and can cause poor healing).
- Caring for the diabetics had been a challenge when the assignments were so heavy.

During an interview on 07/28/21 at 9:20 AM, Staff X, Director of Nursing (DON), stated that:
- She felt staffing on the units was adequate.
- Staffing Unit Three (Detox) with one nurse and one MHT for 20 patients was acceptable, as they had the House Supervisor to support them.
- The House Supervisors had been used to staff units during the night shift, along with their routine duties.
- She was not concerned about the safety of the patients, staff would still complain even if they had five nurses and six MHT's for 36 patients.

During an interview on 07/28/21 at 10:55 AM, Patient #24, stated that she had been in the hospital for over 30 days and that groups were not held daily like the unit schedule showed, and depended on the number of people working.

During an interview on 07/28/21 at 11:30 AM, Staff OO, RN, stated that staffing the units was difficult at times and that there was never enough time to get everything done, such as charting, groups, and talking to the patients.

During an interview on 07/29/21 at 11:15 AM, Staff NN, MHT, stated that:
- She had been reluctant to discuss staffing when the surveyor viewed the unit on 07/28/21, for fear of retaliation and/or being fired.
- The documentation of vital signs was difficult to accomplish when there was only one MHT to complete charting, do rounds, do outside breaks, take patients to the cafeteria for meals and lead groups.
- There had been more staff on the unit during the survey process, which was unusual.
- Typically when she led a patient group, she had to stop every 15 minutes to round on the patients that were not attending group.
- It had been difficult to keep up with everything, and that room checks were not always completed.

During an interview on 07/29/21 at 11:40 AM, Staff WW, LPN, stated that:
- There had been occasions, about once a week, when the hospital was short staffed and she had to staff a unit as the only nurse.
-When she needed to have insulin verified, she would go to another unit to get the insulin dose verified, leaving the MHT alone on the unit.
- She has had to stay beyond her shift to complete her charting.

During an interview on 07/29/21 at 11:55 AM, Staff XX, MHT, stated that:
- There have been times when the unit was short staffed that she was not able to obtain and chart all of the detoxification vital signs that were ordered.
- The MHT's were supposed to do groups daily, but that did not always happen.
- Each group should be documented on the Patient Group Participation Notes form for every patient on the unit, whether or not they attended, the date, the time, the topic, and the MHT that lead the group.
- Groups were skipped sometimes, especially when there was only one MHT to do everything.
- She felt like she would be terminated or punished in some way because she spoke to the surveyors about the staffing issues.

During an interview on 07/29/21 at 12:15 PM, Staff TT, RN, stated that:
- There had been three patients placed on line of sight (LOS, continuous visual contact with the patient) precautions, two of them were removed because there was not enough staff to watch all three patients.
- Some days the MHT's did not have time to lead groups.
- Nurses did not lead groups.
- There had been times that an LPN was left in charge of a unit due to lack of staff.
- There were not enough staff to keep patients safe at least 25% of the time.

During an interview on 07/29/21 at 12:30 PM, Staff EE, RN, stated that:
- Staffing had been a huge issue at the hospital.
- She felt that administration would retaliate against staff members who spoke up about staffing issues.
- Nurses had to stay beyond their scheduled shift for up to four hours to complete their charting, due to the additional work load caused by the limited amount of staff.

During an interview on 07/29/21 at 12:50 PM, Staff YY, MHT, stated that:
- The limited amount of staff and additional duties assigned to her made it difficult to obtain the detoxification vital signs as they were ordered.
- Weekend shifts were the worst for staffing issues.
- The weekend MHT groups were often missed due to lack of staffing.
- She was not aware of a time that any of the nurses had held a nursing group.

During an interview on 07/29/21 at 1:00 PM, Staff JJ, MHT, stated that:
- She frequently worked short staffed on Unit 5/6.
- The short staffing on Unit 5/6 made it difficult to complete patient safety rounds on both halls and complete the detoxification vital signs.
- There were times when groups were not held due to the lack of staff and work load.

During an interview on 07/29/21 at 2:00 PM, Staff AAA, Activities Therapy Manager, stated that:
- The master group schedules for the units were created by her.
- Each unit schedule contained groups lead by social services, activities therapy, nursing, and the MHT groups.
- She was not aware of who monitors whether or not groups are held.

During an interview on 08/02/21 at 2:40 PM, Staff HHH, RN, stated that:
- Unit 5/6 was short staffed about 50% of the time.
- The lack of staff and large work load had caused her to have to stay over two hours, a couple shifts per week, to complete charting.
- Nursing staff on other units would have to leave patients unattended in order to have insulin verified by a second nurse, leaving only a MHT on the unit to supervise the patients.
- She had received training that A&R would complete the body checks on patients being admitted in the A&R unit without pulling any staff, however, two MHT's had been pulled on evening shift on 08/01/21 to the A&R to complete a body check (after the hospital had submitted the immediate jeopardy plan of correction, which was accepted on 07/27/21), which left the unit with only one MHT for 31 patients.
- Patient room checks were supposed to be completed on days and evening shifts every day. The room checks were assigned, but not completed.

During an interview on 08/02/21 at 3:10 PM, Staff III, RN, stated that:
- Staffing was horrible, the hospital did away with weekend option about one year ago, and there had been a large number of staff who left.
- He worked the evening of 08/01/21, and two MHT's had been pulled to A&R to complete body checks on a patient that was being admitted, leaving Unit 5/6 short staffed.
- He has had to remain past his scheduled shift once a week in order to complete charting due to the lack of staff.
- MHT's were supposed to hold evening groups, but due to lack of staff, no groups were held on the evening of 08/01/21.
- Room checks should be completed every day, on days and evenings, but were not done routinely.
- Nurses had contacted the provider to decrease the level of observation orders for patients when the unit did not have enough staff to watch all the patients that were ordered to have 1:1 observation.

During an interview on 08/02/21 at 3:40 PM, Staff JJJ, RN, stated that:
- MHT's had been pulled to A&R on her last evening shift, on 07/30/21, to complete a body check for a patient being admitted.
- There were staffing issues on Unit Three (Detox), where there would only be one nurse and one MHT for 15 patients.
- Due to lack of staff and the heavy workload, she had remained after her scheduled shift for up to four hours to complete charting.
- The MHT groups were sometimes missed on evenings due to lack of staff.

During an interview on 08/02/21 at 4:00 PM, Staff OO, RN, stated that:
- Staffing the units continued to be a huge issue.
- MHT's continued to be pulled from the units to complete body searches in A&R.
- Retaliation against staff for speaking about the staffing issues would most definitely occur.

During an interview on 08/02/21 at 4:50 PM, Staff F, CNE, stated that:
- There had been staff pulled from the units to A&R over the weekend to complete body checks on patients being admitted.
- They had finished education for the A&R staff today, and going forward, the body checks would be completed by the trained staff and the nurse assigned to A&R.
- Administration had re-educated the House Supervisors from the weekend and unit staff will no longer be pulled for body checks.

During an interview on 08/03/21 at 9:30 AM, Staff Y, CEO, stated that:
- The house supervisor could support the new process for body checks in A&R.
- The house supervisor would not be able to assist the A&R if they were staffing a unit.
- She did not feel that the lack of staff hindered the ability to supervise the patients.

During an interview on 08/03/21 at 1:20 PM, Staff L, Nurse Educator, stated that:
- Staffing in the hospital was a struggle.
- The MHT's struggle to complete all the tasks assigned due to the lack of staff.
- Staff members that left the hospital consistently said that they had too much responsibility and not enough staff to get everything done.

During an interview on 08/03/21 at 2:15 PM, Staff MMM, LPN, stated that:
- Staffing had been an issue, and that with decreased staff, the safety risks increased.
- He felt that the patients were not properly supervised.
- The patients knew to take advantage of the fact that the MHT had just rounded on them, and that they would have several minutes where they would not be supervised.
- It would not be unusual to only have one MHT on Unit Four (Acute).
- There have been numerous shifts, days, evenings, and nights, when he had been the only nurse on both Unit Three (Detox) and Unit Four (Acute).
- There were times when room checks had not been completed due to staffing issues.

During an interview on 08/03/21 at 2:30 PM, Staff NNN, MHT Orientee, stated that she had been assigned to Unit Four (Acute) on Saturday 07/24/21, but was moved to another unit, leaving only one MHT on the unit for 20 patients. This was the day that two patients engaged in sexual activity on Unit Four.

During an interview on 08/03/21 at 3:00 PM, Staff FF, House Supervisor, stated that:
- Staffing had been an issue, and that at times, she had to staff a unit due to staffing shortages.
- At times, she had to staff more than one unit at a time and had unlocked and opened the doors between units (which should be separate and secured) in order to watch both units at the same time.
- She had allowed access between Unit Four (Acute), Unit 5/6 (Adult), and Unit Seven (Silver Linings, geriatric), making them one large unit.
- She had also staffed Unit One (Adolescents) and left Unit Seven (Silver Linings) with two MHT's to supervise the patients.
- She had not been aware that nursing staff left units unattended to obtain insulin verification on other units.

During an interview on 08/03/21 at 3:10 PM, Staff DDD, House Supervisor, stated that:
- Staffing had been an issue, especially on the weekends.
- In the past she had been directed by the CNE to contact the doctor to change (decrease) observation levels of patients on 1:1 due to lack of staff.
- She was worried that there would be consequences as a result of speaking with surveyors about staffing issues.
- She felt that the hospital should not continue to admit patients with the limited amount of staff to supervise them.
- She was scared for the patients and the staff, as they were not safe.

During an interview on 08/03/21 at 3:20 PM, Staff YY, MHT, stated that:
- At times the room checks were completed later in the day (than expected) due to staffing constraints.
- Groups were not assigned to staff, it would just be whomever wanted to lead the group that day.
- There are times, especially on weekends when groups are skipped due to lack of staff.

During an interview on 08/03/21 at 3:55 PM, Staff F, CNE, stated that:
- She had not been aware that A&R continued to pull staff from the units for body checks after the hospital's Plan of Correction was accepted. The DON had been supervising staff at that time.
- She had not directed any staff members to get orders to change observation status for patients related to staffing issues.
- The implementation of a full time staff member in A&R for body checks had been delayed related to lack of staff availability.
- She would expect detoxification vital signs to be completed as ordered and that patient groups should be held daily.
- She felt that having one nurse staff two units would not be ideal, but patients usually slept at night.

Based on interview, record review, and policy review, the hospital failed to adequately supervise nursing care to patients and provide a safe and therapeutic environment when:
- Seven discharged patients (#9, #10, #11, #12, #17, #60 and #61) had access to contraband (items that are illegal, forbidden, or that can be used to harm self or others). Four of those patients (#9, #10, #11, and #12) required transfer to Hospital B (nearby acute care hospital) for medical emergencies and were found to have fentanyl (a medication used to treat severe pain, and is a high risk drug for theft and personal use) in their system.
- The hospital did not implemented measures and ensure nursing staff were educated to prevent reoccurrence, including appropriate supervision of patients, proper body checks (visual search of a body for prohibited materials that could be used to harm themselves or others) and contraband searches, after the incidents occurred.
- They failed to ensure that nursing staff completed detoxification (detox, the process of removing drugs or alcohol from the body) vital signs (body temperature, blood pressure, heart rate, and breathing rate) as ordered on five current patients (#20, #47, #51, #56 and #57) of five current medical records reviewed with detox vital signs and one discharged patient (#10) of four discharged patient medical records reviewed with detox vital signs.
This had the potential to affect all patients who were admitted to the hospital, and result in negative patient outcomes. The hospital census was 98.

Findings included:

1. Review of the hospital's policy titled, "Assessment for Contraband," dated 03/06/18, showed that:
- Routine searches would be conducted on all patients upon admission, and patient, unit, and room searches would be conducted when staff had reasonable cause to believe that the patient may possess an item that could be hazardous
- A belongings search should include a search the patient's luggage, purse, book bag or other items carried in to the hospital by the patient and/or family.
- Items that would be considered as contraband on the adult units, would be items such as: cell phones, headphones, medications, drugs, alcohol, electronics, hair tools, drug paraphernalia, pipes, cigarettes, lighters, matches, etc.
- The body search should be completed according to the "Body Check Assessment" form.

Review of the hospital's "Body Check Assessment" form dated 04/23/20 showed that:
- Staff should keep the patient in line of sight (LOS, continuous visual contact with the patient) until their body assessment had been completed
- The assessment would be completed on the unit the patient would be admitted to.
- Patients should remove slacks/jeans/shorts and turn them inside out, including the pockets.
- Staff should inspect the seams and check for hidden pockets, and open seams.
- The patient should pull down the waistband of their underwear, and the patient should pull their bra forward and shake it.
- After inspection, items should be returned to the patient, the patient placed in scrubs.

Review of Patient #60's medical record showed that:
- She was admitted to Unit Three (Detox) on 06/26/21 for opioid detoxification.
- On 07/01/21 she was transferred to Hospital B for jaw pain, and she returned to Unit Three later the same day.
- At 7:00 PM, staff were informed by her roommate that she had her purse hidden between the bed and the wall in her room.
- When staff located the purse, they found contraband within her purse.
- Staff were not able to determine how or why she had possession of these items.

Review of hospital's document titled, "Incident Reporting, Incident #00816" dated 07/01/21 at 7:00 PM, showed that Patient #60's purse contained a cell phone, a vape pen (an electronic device shaped like a pen that is used to inhale vapor such as liquid nicotine or cannabis), a nicotine bottle, 10 chargers, two corded earphones, one cordless earphone, and one container that contained pieces of marijuana.

Review of the hospital's undated document titled, "Unit Three Investigation," showed that staff were unable to determine how long Patient #60 had the purse and contraband in her possession. The hospital did not provide education to staff members.

Review of Patient #10's medical record showed that:
- He was a 30-year old male admitted on 06/30/21 to Unit Three for opioid (highly addictive narcotics) use withdrawal (symptoms that occur upon abrupt discontinuation of medications, alcohol or drugs).
- On 07/06/21 at 5:10 PM, he was sent to Hospital B due to increased shortness of breath, wheezing (a high-pitched whistling sound made while breathing) and abnormal lung sounds. When the patient returned from Hospital B, there was no documentation that a body or clothing search had been completed.
- On 07/07/21 at 11:30 AM, he had been found unresponsive on the floor of his room, incontinent of bowel and bladder.
- He was transferred and admitted to Hospital B for treatment where his urine drug screen (UDS, a test that analyzes urine for the presence of certain illegal drugs and prescription medications) was positive for fentanyl.

The hospital's undated document titled, "Unit Three Investigation," showed that at 7:06 PM, Staff F, Chief Nursing Executive (CNE), was notified by the House Supervisor that Patient #10 tested positive for fentanyl.

After this incident (#2), no process changes were initiated.

Review of Patient #11's medical record, showed that:
- He was a 39-year old male admitted on 07/01/21 to Unit Three for opioid detoxification.
- On 07/08/21 at 11:00 AM, the nurse documented the patient had exhibited diaphoresis (excessive, abnormal sweating), tachycardia (increased heart rate, greater than 100 beats per minute), mumbled speech, audio hallucinations (AH, hearing things that are not real), and dystonic (a movement disorder where muscles contract involuntarily, causing repetitive or twisting movements) movements.
- He was transferred to Hospital B for treatment, where his UDS showed positive for fentanyl.

The hospital's undated document titled, "Unit Three Investigation," showed that on 07/08/21 at 5:42 PM, the House Supervisor notified Staff F, CNE, that Patient #11 had tested positive for fentanyl.

After this incident (#3), no process changes were initiated.

Review of the hospital's document titled, "Incident Reporting, Incident #00816," dated 07/08/21, showed that Patient #61 had been identified as having concealed drugs. Staff completed a room and body search and two pills were found on him. One pill had been identified as Clozaril (an antipsychotic drug used to manage schizophrenia [a serious mental disorder that affects a person's ability to think, feel, and behave clearly]) and the second pill was not identified.

Review of an email correspondence dated 07/12/21 at 9:46 AM from Staff G, House Supervisor to Staff F; Staff X, Director of Nursing (DON); and Staff W, Risk Management (RM) Director, showed communication of possible drug passing on Unit Three.

After this incident (#4), no process changes were initiated.

Review of Patient #9's medical record showed that:
- On 07/08/21 she was admitted to Unit Three for opioid detoxification, depression, suicidal ideations (SI, thoughts of causing one's own death) and bipolar disorder.
- On 07/10/21 at 2:35 PM, the patient was having visual hallucinations (VH, seeing things that others cannot see, imaginary).
- On 07/11/21 at 12:15 PM, a physician order was written to search the patient's room for fentanyl (there was no documentation in the chart that this was completed).
- On 07/13/21 at 2:15 the nurse documented that the patient's mentation (mental activity) was altered, her speech mumbled and difficult to understand, a shuffled gait (a person's manner of walking), and was not eating or drinking.
- At 3:15, she was transferred to Hospital B by ambulance, and admitted.

Review of the hospital's undated document titled, "Unit Three Investigation," showed that on 7/14/21 at 8:27 AM, the House Supervisor notified Staff F, CNE, that Patient #9 had tested positive for fentanyl.

After this incident (#5), no process changes were initiated.

Review of Patient #17's medical record showed that:
- She was a 32-year old female admitted on 07/11/21 for Bipolar, Post Traumatic Stress Disorder (PTSD, a condition of persistent mental and emotional stress occurring as a result of injury or severe psychological shock) and opioid use.
- She had used fentanyl in the hospital's (CenterPointe) lobby bathroom and was revived with Narcan (a medication used to counter the effects of narcotic overdose).
- Once admitted to the hospital (CenterPointe), she overdosed on fentanyl she had hidden in her bra, and became unresponsive.
- She experienced periods of apnea (to intermittently, and involuntarily stop breathing) and her oxygen level dropped to 94% on six liters of supplemental oxygen, prior to her transfer to Hospital B's ED by ambulance.

Review of the hospital's document titled, "Investigation of possible drugs being brought into the hospital," dated 07/14/21, showed that Staff F, received a phone call from Hospital B Emergency Department (ED) manager, stating that staff had found some unidentified pills on Patient #17. She also reported that when Patient #9 was in the ED, she vomited and a capsule was found in her emesis. She reported that the patient told her it was a "red bean" (slang reference for a street drug), which was like the pills that were found on Patient #17.

After this incident (#6), no new process changes were initiated.

Review of Patient #12's medical record, showed that:
- He was admitted on 07/10/21 to Unit Three for fentanyl, Klonopin (medication used to treat seizures [excessive activity in the brain that causes uncontrolled jerking movements], panic [an episode of intense anxiety] disorders, and anxiety), Xanax (medication used especially in the treatment of mild to moderate anxiety) and methamphetamine (a drug with more rapid and lasting effects than amphetamine, used illegally as a stimulant) detoxification.
- On 07/14/21, the patient was very sedated and behaving strangely. He was responding to imaginary voices.
- On 07/15/21 he exhibited bizarre behavior, altered mental status, VH and AH.
- He was transferred to Hospital B for treatment, where his UDS showed positive for fentanyl.
- He was transferred back on 07/16/21 at 2:15 AM, and placed on Unit Four (Acute).
- On 07/16/21 at 4:54 AM, a MHT rounding on the patient found him with three sealed syringes (no needles), and a metal button from an EKG pad. All remaining EKG pads (in place on the patient since he was a patient at Hospital B) were removed.

Review of the hospital's untitled document dated, 07/16/21, signed by Staff X, DON, showed that:
- Patient #12 had returned from Hospital B (local medical hospital) at 7:40 AM, his body search had been completed, and staff found unopened syringes (barrel and plunger, no needles).
- The patients on Unit Three were locked out of patient rooms, body searches were completed, patients placed in scrubs, and re-located into a clean room.
- Staff completed thorough room searches and locked up all the patients clothing and personal belongings.
- Patients remained in scrubs for 24 hours, belongings were returned once thoroughly inspected.
- Staff discussed the process used for previous unit searches, and determined that the previous unit searches were not as comprehensive as the search completed on 07/16/21.

Review of the hospital's undated document titled, "Unit Three Investigation," showed that on 07/16/21 at 7:40 AM, Staff X, DON, was notified that Patient #12 had been found with packaged syringes. At 8:00 AM, information was received that Patient #12 had tested positive for fentanyl. Staff Y, then ordered for patients on Unit Three to be locked out of their rooms, body checks performed on Unit Three patients and those patients to be placed in scrubs as well as a complete check of the unit. Searches and patient interviews began at 10:00 AM.

The hospital had not determined where the patients had obtained the fentanyl. They failed to adequately educate staff and change processes to prevent seven patients from having access to contraband.

Review of an email dated 07/16/21 from Staff X, DON, to all staff, discussed a new body check process for contraband, and the placement of patients in scrubs upon admissions. There was no attestation to verify if staff read the email.

During an interview on 07/22/21 at 9:30 AM, Staff J, MHT, stated that she had not received any recent education related to contraband or room checks.

During an interview on 07/29/21 at 2:25 PM, Staff BBB, MHT, stated that when room checks were completed, staff looked for visible items (not items that may be hidden), and added that they would not go through belongings unless they were suspicious of the patient.

During an interview on 07/26/21 at 2:30 PM, Staff F, CNE, stated that MHTs "scanned" a patient's room for any visible contraband during room checks, during walking rounds at the change of shift.

During an interview on 07/22/21 at 11:00 AM, Staff L, Nurse Educator, stated that she was not asked to educate staff on any new process changes or policy changes since the contraband incidents.

During an interview on 07/22/21 at 12:25 PM, Staff W, RM Director, stated that:
- Until the 07/16/21 email from the DON, there were no process changes or education to prevent patient from access to contraband.
- Reeducation to staff on room searches had not been started yet.
- The hospital had not met regarding the fentanyl issues, what processes were put in place, or an overview of what else could be done.

2. Review of the hospital's document titled, "Alcohol/Benzo Detox Orders," dated 07/10/19, showed the directive for staff to document vital signs on admission, then every two hours for 24 hours, then every four hours for 24 hours, then four times a day for three days, then twice daily thereafter.

Review of the hospital's document titled, "Opiate/Narcotic Detox Orders," dated 06/22/18, showed the directive for staff to document vital signs on admission, then every two hours for 24 hours, then every four hours for 24 hours, then four times a day.

Review of Patient #10's medical record showed the following:
- He was a 30 year old male admitted to the hospital on 06/30/21 for opioid dependence.
- An order for Alcohol/Benzo Detox Orders and Opiate/Narcotic Detox Orders was written on 06/30/21 at 2:00 PM.
- The detox protocol vital sheet gave directive for staff to obtain/document vital signs every two hours starting on 06/30/21 at 2:00 PM until 07/01/21 at 2:00 PM, and vital signs every four hours starting on 07/01/21 at 2:00 PM until 07/02/21 at 2:00 PM.
- On 06/30/21, no vital signs were documented from 2:00 PM through 5:00 PM (three hours).
- On 07/01/21, no vital signs were documented from 1:30 AM through 5:00 AM (three and a half hours).
- On 07/01/21, no vital signs were documented from 9:00 PM through 9:00 AM of 07/02/21 (12 hours).

Review of Patient #20's medical record showed the following:
- She was a 52 year old female admitted to the hospital on 07/27/21 for alcohol detoxification.
- An order for Ativan (a medication that has a calming effect, used to treat anxiety or sleep difficulty) Detox Protocol was written on 07/27/21 at 7:30 PM.
- The detox protocol vital sheet gave directive for staff to obtain/document vital signs every two hours starting on 07/27/21 at 7:24 PM until 07/28/21 at 7:24 PM.
- On 07/28/21, no vital signs were documented from midnight through 4:30 AM (four and a half hours) and from 8:00 AM through 11:00 AM (three hours).

Review of Patient #47's medical record showed the following:
- She was a 39 year old female admitted to the hospital on 07/05/21 for alcohol detoxification.
- An order for Alcohol Detox Protocol was written on 07/05/21 at 11:30 PM.
- The detox protocol vital sheet gave directive for staff to obtain/document vital signs every two hours starting on 07/05/21 at 11:00 PM until 07/06/21 at 11:00 PM, and vital signs every four hours starting on 07/06/21 at 11:00 PM until 07/07/21 at 11:00 PM.
- On 07/06/21, no vital signs were documented from 11:00 AM through 8:00 PM (nine hours), or from 8:00 PM through 07/07/21 at 1:00 AM (five hours).
- On 07/07/21, no vital signs were documented from 1:00 AM through 6:00 AM (five hours) and from 8:00 AM through 4:00 PM (eight hours).

Review of Patient #51's medical record showed the following:
- He was a 19 year old male admitted to the hospital on 07/21/21 for opioid dependence.
- An order for Alcohol/Benzo Detox Orders and Opiate/Narcotic Detox Orders was written on 07/21/21 at 6:35 PM.
- The detox protocol vital sheet gave directive for staff to obtain/document vital signs every two hours starting on 07/21/21 at 6:35 PM until 07/22/21 at 6:35 PM, and vital signs every four hours starting on 07/22/21 at 6:35 PM until 07/23/21 at 6:35 PM.
- On 07/21/21, no vital signs were documented from 11:00 PM through 07/22/21 at 2:00 AM (three hours).
- On 07/22/21, no vital signs were documented from 2:00 AM through 6:30 AM (four and a half hours), and from 6:30 AM through 9:00 AM (two and a half hours).
- On 07/23/21, no vital signs were documented from 3:00 AM through 9:00 AM (six hours).

Review of Patient #56's medical record showed the following:
- He was a 67 year old male admitted to the hospital on 07/19/21 for opioid and alcohol detoxification.
- An order for Alcohol/Benzo Detox Orders and Opiate/Narcotic Detox Orders was written on 07/19/21 at 5:00 PM.
- The detox protocol vital sheet gave directive for staff to obtain/document vital signs every two hours starting on 07/19/21 at 5:00 PM until 07/20/21 at 5:00 PM, and vital signs every four hours starting on 07/20/21 at 5:00 PM until 07/21/21 at 5:00 PM.
- On 07/19/21, no vital signs were documented from 5:00 PM through 07/20/21 at 1:00 AM (eight hours).
- On 07/20/21, no vital signs were documented from 1:00 PM through 07/21/21 at 7:00 AM (18 hours).
- One set of vital signs documented on 07/21/21 at 7:00 AM on the detox protocol vital sheet. For this date, vitals should have been documented every four hours until 5:00 PM, then every six hours.

Review of Patient #57's medical record showed the following:
- She was a 42 year old female admitted to the hospital on 07/27/21 for opioid and alcohol dependency.
- An order for Alcohol/Benzo Detox Orders and Opiate/Narcotic Detox Orders was written on 07/27/21 at 4:00 PM.
- The detox protocol vital sheet gave directive for staff to obtain/document vital signs every two hours starting on 07/27/21 at 4:00 PM until 07/28/21 at 4:00 PM.
- On 07/28/21, no vital signs were documented from 9:00 AM through 3:00 PM (six hours).

During an interview on 07/28/21 at 11:00 AM, Staff II, MHT, stated that Patient #20's vital signs should have been taken at 10:00 AM, but she was behind on taking vital signs.

During an interview on 07/29/21 at 11:50 AM, Staff XX, MHT, stated that it was difficult to get detox vital signs completed on time due to low staffing levels. When she was the only MHT on the unit, she felt rushed and concerned that patients were not being watched and kept safe.

During an interview on 07/28/21 at 11:05 AM, Staff FF, House Supervisor, stated that detox vital signs should be completed every two hours for 24 hours as ordered.

During an interview on 08/03/21 at 4:00 PM, Staff F, CNE, stated that her expectation of nursing staff was to complete the detox vital signs as ordered.















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27727

Based on interview, record review and policy review, the hospital failed to ensure staff followed the insulin (medication that regulates the amount of sugar in the blood) administration policy when caring for three current patients (#37, #38 and #54) of three current patients receiving insulin, and one discharged patient (#32) of one discharged patient receiving insulin. This failure had the potential to cause harm to all patients who received insulin. The hospital census was 98.

Findings included:

1. Review of the hospital's policy titled, "Insulin Administration," revised 05/05/16, showed the directive for staff to check the insulin dose prepared with another Registered Nurse (RN)/Licensed Practical Nurse (LPN) prior to administration, and both nurses sign off on the Medication Administration Record (MAR, a list of medications ordered for the patient by the physician, also where the nurse documents administration of medications). Record on the MAR the time of the injection and the amount of insulin.

Review of Patient #32's History and Physical (H&P) dated 07/03/21, showed that she was a 60 year old female admitted to the hospital on 07/02/21 for psychiatric care, and had a past medical history of Type II diabetes (a disease that affects how the body produces or uses blood sugar).

Review of Patient #32's medical record showed the following:
- A physician order for finger stick blood sugar checks before meals and bedtime along with Humalog (a rapid acting blood glucose lowering medication) insulin sliding scale (increasing administration of the pre-meal insulin dose based on the blood sugar level before the meal) to begin 07/03/21.
- Inconsistent documentation of insulin administration on the MAR.
- Only one nurse signed off on the insulin administration for 07/03/21 at 9:30 PM; 07/06/21 at 7:30 AM; 07/07/21 at 7:30 AM, 11:30 AM and 9:30 PM; 07/08/21 at 7:30 AM and 11:30 AM; 07/10/21 at 7:30 AM, 11:30 AM and 5:20 PM; 07/12/21 at 10:00 PM; 07/13/21 at 11:00 AM; 07/14/21 at 7:30 AM and 11:30 AM; 07/15/21 at 8:30 AM; 07/16/21 (no time documented); 07/17/21 at 8:30 AM and 5:20 PM; 07/19/21 at 10:30 AM, 10:55 AM, and 11:50 AM; and 07/20/21 at 10:30 AM.
- The patient was discharged on 07/20/21.

Review of Patient #37's medical record showed the following:
- He was a 46-year old male admitted to the hospital on 07/18/21 for psychiatric care, with a past medical history of Type II diabetes.
- A physician order for finger stick blood sugar checks before meals and Humalog insulin sliding scale to begin 07/22/21 at 11:30 AM.
- Inconsistent documentation of insulin administration on the MAR.
- Only one nurse signed off on the insulin administration for 07/23/21 at 12:00 PM; 07/24/21 at 11:40 AM, (there was no documentation of a 7:30 blood sugar check or if any insulin was administered); 07/25/21 at 12:00 PM; 07/26/21 at 9:30 PM; and 07/29/21 at 8:00 AM.

Review of Patient #38's medical record showed the following:
- He was a 26-year old male admitted to the hospital on 07/22/21 for psychiatric care with a past medical history of Type I diabetes (a condition where the body produces little to no insulin (hormone) resulting in the person requiring artificial insulin injections or medication).
- A physician order for finger stick blood sugar checks before meals and bedtime, along with Novalog (a rapid-acting blood glucose lowering medication) insulin sliding scale to begin 07/23/21. There was no documentation of finger stick blood sugar checks or Novalog insulin administered on 07/23/21.
- On 07/28/21 at 5:20 PM, Novalog insulin was administered with only one nurse sign off documented on the MAR.

Review of Patient #54's medical record showed the following:
- She was a 37-year old female admitted to the hospital on 07/28/21 for psychiatric care and uncontrolled diabetes.
- An undated MAR to perform blood sugar checks before meals and at bedtime along with Humalog sliding scale insulin. Humalog insulin was administered at 8:00 PM and 10:00 PM with only one nurse sign off documented on the undated MAR.
- On 07/31/21, an order to recheck the patient's blood sugar every 2 hours and follow sliding scale until the blood sugar was below 250.
- Only one nurse signed off on the insulin administration for 07/30/21 at 1:30 PM; 07/31/21 at 5:00 PM, 7:00 PM, 9:00 PM, and 9:30 PM; and 08/01/21 at 1:00 AM.
- On 08/01/21, Humalog insulin was administered at an unknown time during the evening shift.

During an interview on 07/29/21 at 12:15 PM, Staff TT, RN, stated that it was difficult getting two signatures for insulin administration due to low staffing levels.

During an interview on 08/02/21 at 2:45 PM, Staff HHH, LPN, stated that she's had to administer insulin without a second nurse verification because of low staffing levels and lack of nurse availability.

During an interview on 08/02/21 at 4:00 PM, Staff OO, RN, stated that she has had to administer insulin without a second nurse verification in order to give the insulin on time, due to low staffing levels and lack of nurse availability.

During an interview on 07/29/21 at 1:45, Staff ZZ, Physician, stated that sometimes physician orders were not completed because of low staffing levels.

During an interview on 08/02/21 at 1:00 PM, Staff U, Pharmacist, stated that insulin was a high alert medication and required two nurses to check and sign for all insulin doses. The pharmacy did not audit the two nurse verification.

During an interview on 08/03/21 at 3:55 PM, Staff F, Chief Nursing Executive (CNE), stated that her expectation of nursing staff was to verify the insulin dosage with another nurse and each nurse sign off on the MAR before the insulin was administered.