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Based on document review and staff interviews, the hospital failed to:

a. evaluate all services provided in the hospital. See Tag A-0385 and Tag A-700; and

b. identify problems, take corrective actions, implement and monitor corrective actions to ensure compliance. See Tag A-0115 and Tag A-0263; and

c. comply with Centers for Medicare & Medicaid Services (CMS) Conditions of Participation. See Form CMS 2567 Statement of Deficiencies.

Based on hospital document review, medical record review, observation and staff interviews, the hospital failed to protect the patient from harm and ensure patient received care in a safe setting.

Findings:

1. On August 3, 2015 at 8:45 a.m., surveyors observed patient #1 drinking coffee. Surveyors observed patient # 1 with spilled coffee down the front of his gown. Patient #1's gown and socks were soaked with coffee. On August 3, 2015 at 11:00 a.m., the Chief Executive Officer (CEO) verified that patient #1's gown was coffee soaked.

2. On August 3, 2015 at 8:45 a.m., surveyors observed Staff Y perform oral care on multiple patients without changing his gloves.

3. On August 3, 2015 at 8:45 a.m., surveyors observed Staff GG administer breathing treatment to unknown male patient. Upon completion of the patient's breathing treatment, Staff GG took the Venturi Mask and portable oxygen concentrator with soiled gloves to the hand washing sink. Staff GG rinsed the patient's contaminated mask with water into the handwashing sink. Staff GG then doffed off her right hand glove holding the patient's contaminated mask and a portable oxygen concentrator with the soiled gloved (left hand). Staff GG pushed a padlock/code lock door into the medication room with her right hand that was contaminated. Staff GG placed the contaminated mask and portable oxygen concentrator on the medication counter. Staff GG left the medication room, doffed the left glove off and then used hand sanitizer. Staff GG never washed her hands and then proceeded to perform more patient care on different patients.

4. On August 6, 2015 at 10:50 a.m. surveyors toured the adolescent unit with Staff N and Staff P. The following observations were made:

~All areas of the seclusion room could not be viewed from the seclusion door window or the window looking into the seclusion room from the nursing station. Filing cabinets, racks, and charts, blocked the window in the nursing station that was used to view seclusion patients.

~Patient room 402 shower had a leak. The floor was wet in the bathroom .

~Patient room 404 had a loose baseboard and was in disrepair.

~There were brown substance/stains along the tub/wall area throughout the facility in patient bathrooms on the unit.

5. On August 6, 2015 at 11:07 a.m. surveyors toured the Adult unit with Staff N and Staff P. The following observations were made:

~There were multiple stained ceiling tiles. There were ceiling plant hooks in the ceiling tiles.

~Patient room number 300 bathroom had unsealed wood that framed the sink. The unsealed wood can't be disinfected. The wall around the sink was in disrepair.

~Patient room 301 and 302 bathroom had cabinet material that was cracked and in disrepair.

~Patient room 303 had baseboards that were loose and in disrepair.

~There were brown substance/stains along the tub/wall area throughout the facility in patient bathrooms on the unit.

6. On August 6, 2015 at 11:20 a.m. surveyors toured the Intellectually Disabled (ID) unit with Staff B and Staff P. The ID unit was for patients with intellectual disabilities. The following observations were made:

~There were brown substance/stains along the tub/wall area throughout the facility in patient bathrooms on the unit.

~There were multiple crank handles on patient beds throughout the unit. These crank handles are not anti-ligature safe hardware.

~There was a wood fenced sitting area for patients outside the ID unit. The wood fence was in disrepair in multiple locations. The wood fence had many rusty nails sticking out of the boards. The wood fence gait was in disrepair and being held together by a chain.

7. On August 6, 2015 at 1:40 p.m. surveyors toured the geriatric unit with Staff B and Staff P. The following observations were made:

~There were brown substance/stains along the tub/wall area throughout the facility in patient bathrooms on the unit. There were brown substance/stains on the stainless steel bathroom fixtures (toilet paper holder, sink faucets, hand rails).

~Multiple patient rooms had broken and chipped bathroom cabinets.

~Multiple patient bathrooms had blue tape marked on the ceiling. Surveyors asked what the blue tape was for. Staff B and Staff P said that the blue masking tape was place before painting started.

~Multiple patient bathrooms had peeled paint hanging from the ceiling. Multiple patient bathrooms had a large discolored area of the ceiling. Staff P told surveyors that the discolored area was from the leaking roof and the repair of the roof had not been approved.

~Multiple patient bathroom toilet sensors had a tape placed in front of the sensor that inhibited the toilet sensors to work as designed. The tape can't be disinfected.

~Multiple patient rooms had a larger than a dollar size chunk of unsealed wood exposed.

~Multiple patient rooms had discoloration of vinyl flooring. Staff P told surveyors the discoloration is from water.

Based on document review and staff interview, the hospital failed to:

a. involve all hospital departments that impacted patient care in the Quality Assessment Performance Improvement (QAPI) program;

b. focus QAPI indicators on improving patient heath outcomes; and

c. the governing body failed to provide adequate oversight of the QAPI program and failed to ensure the hospital's QAPI program conformed to the requirements for the Condition of Participation.

Findings:

1. On August 2, 2015 at 11:10 p.m. surveyors requested QAPI meeting minutes. Staff S provided surveyors with the QAPI meeting minutes. Surveyors reviewed QAPI meeting minutes. There was no documentation that nursing services that impacted patient care were evaluated through the QAPI program.

2. Throughout the survey, surveyors requested all QAPI meeting minutes for nursing services. Throughout the survey Staff S told surveyors that the Chief Nursing Officer (CNO) could provide clarification about nursing service QAPI data. Throughout the survey the CNO was asked multiple times for nursing service QAPI data. None was provided.

3. On August 4, 2015 at 3:10 p.m., surveyors asked the CNO if nursing documentation was reviewed and audited for consistency and accuracy. The CNO told surveyors that it was not. The CNO told surveyors that restraint/seclusion documentation was looked at to ensure physicians and Licensed Independent Practitioners (LIP) signatures were on the restraint/seclusion orders. The CNO told surveyors that she looked at complete documentation on restraint/seclusion nursing assessments/notes.

4. Surveyors reviewed 10 (patient #9, 10, 28, 29, and #30) restraint/seclusion orders for five violent patients. Eight of ten restraint/seclusion practitioner order packets (included registered nursing documentation pages 1-4) were not filled out and completed. The CNO confirmed that 8 of 10 restraint/seclusion order packets were incomplete.

5. Eight of ten restraint orders were not signed by a physician or a LIP. The Chief Executive Officer (CEO) and CNO confirmed that 8 of 10 restraint orders were not signed by a physician or LIP.

6. There was no documentation in the governing body meeting minutes that nursing services were discussed and identified opportunities for improvement. There was no documented evidence in governing body meeting minutes of restraint/seclusion order packets audited by nursing services as indicated by the CNO. This was verified at the time of review by the CEO.

7. On August 3, 2015 at 8:30 a.m. surveyors observed patient #1 strike Staff II on the chin. Surveyors did not find documented evidence that Staff II filled out an incident report. Staff members throughout the survey told surveyors unless someone (either patient or staff) was seriously hurt no incident report was documented.

8. There was no documentation the QAPI committee captured, collected, analyzed and acted on accurate incident reporting.

9. The QAPI meeting minutes included vague data. Staff S told surveyors that she was working on the QAPI process but had not made changes since the surveyors were there from the surveyors last visit (07/22/2015).

Based on medical record review, policy and procedure review, observation, and staff interview the facility failed to:

a. ensure the immediate availability of a registered nurse for bedside care of any patient; (see tag 0392)

b. ensure that each patient had a current and updated care plan; (see tag 0396)

c. ensure a registered nurse (RN) supervised and evaluated the nursing care for each patient that included continued assessment of patient care needs, patient health status, and patient's response to interventions. (see tag 0395)

Based on review of nursing staffing schedules, observation and interview, the hospital failed to ensure a Registered Nurse (RN) was immediately available for bedside care of any patient.

Findings:

1. On the evening of August 2, 2015 at 11:10 p.m. surveyors arrived at the facility. The facility consisted of 4 units; an adult unit, an adolescent unit, a geriatric unit, and an intellectual disabled (ID) unit.

2. At the time of entrance on August 2, 2015 at 11:10 p.m. The units were staffed as: one RN on the adult unit, one RN with 2 orientating RN's on the geriatric unit, one Licensed Practical Nurse (LPN) on the ID unit and one RN on the adolescent unit who was also the house supervisor for the night shift. There was not an RN who could be immediately available if needed on the ID unit. Suveyors observed the house supervisor leave the adolescent unit without an RN available for approximately 15 minutes.

3. The house supervisor told surveyors that she was scheduled as the house supervisor and also had a full patient assignment on the adolescent unit.

4. Night shift staff told surveyors that when they take a lunch break the house supervisor would come to their unit and replaced them until their break was over. Staff told surveyors that the house supervisor often took a full patient assignment. This did not make an RN available when there is only an LPN stafffed on a unit.

5. During the course of the survey the Chief Nursing Officer (CNO) told surveyors that many times the house supervisor was scheduled as house supervisor and also takes a full patient assignment. The CNO told surveyors that at times the units were only staffed with an LPN and 2 Behavioral Health Technicians (BHT).

6. On the morning of August 4, 2015, surveyors reviewed nursing staffing schedules from July 1, 2015 to August 2, 2015.

7. Review of the staffing schedules from July 1, 2015 to August 2, 2015 documented on five nights only one LPN was scheduled on a unit and the house supervisor (RN) was assigned to a different unit with a full patient assignment. This did not make an RN immediately available when there is only an LPN staffed on the unit.

8. Review of the staffing schedules documented from July 1, 2015 to August 2, 2015 documented on four nights there was an LPN assigned to a unit with an RN orientating to the unit and the house supevisor was assigned to another unit with a full patient assignment. This did not make an RN with experience immediately available on the unit staffed with the LPN.

Based on medical record review, policy and procedure review, and staff interview, the hospital failed to ensure a registered nurse (RN) supervised and evaluated the nursing care for each patient that included continued assessment of patient care needs, patient health status, and patient's response to interventions. This occured in 28 of 28 open and closed medical records reviewed.

Findings:

1. During the course of the survey August 2, 2015 to August 6, 2015, surveyors reviewed 28 open and closed medical records. All records reviewed did not contain consistent documentation of a daily RN assessment of the patient.

2. A policy titled, "Nursing Assessments/Reassessments," documented, "...Assessment and reassessment are ongoing integral parts of the nursing process. A continous evaluation of patient needs and nursing interventions to meet those needs with appropriate documentation in the nurse's notes is the expectation for all nursing staff..."

2. All records reviewed did not contain consistent documentation of patient's response to interventions that were given such as:

~pain medications given to patients with no response to the pain medication documented;
~ breathing treatments given to patients with no response to the breathing treatment documented;
~wound care given with no documentation of the response to the wound care;
~as needed medications such as, medications given for high blood pressure, and medications given for agression or behavior were given with no response documented to the medication given.

3. All records reviewed did not contain thorough and consistent skin assessments.

During the course of the survey the Chief Nursing Officer (CNO) told surveyors that thorough skin assessments were done every week on patients. The CNO told surveyors that skin assessments were done initially upon admission of the patient to the hospital by the admissions nurse.

Many medical records reviewed contained blank initial skin assessments. All records reviewed contained inconsitent documentation of skin assessment such as:

~ one week there was documentation a patient had a scar and the next week the documentation did not contain a scar noted.
~ skin assessments contained documentation of bruising on patients with no documentation of what the bruise looked like, color, shape, size, etc.
~skin assessments contained documentation of skin tears on patients with no documentation of what the skin tear looked like, color, shape, size, etc

The CNO told surveyors that brief skin assessments were done daily and documented on the nursing daily "nursing reassessment progress note."

Surveyors reviewed 28 medical records. In all medical records reviewed the daily skin assessment documented on the "Nursing Department: Daily Nursing Reassessment Progross Note" did not contain consistent and accurate documentation. The skin assessment documented was different every day.

During the course of the survey the CNO told surveyors that when a patient had a wound the nurse would document on the "wound assessment" form. In 9 ( #1, #2, #6, #9, #11, #15, #18, #27, & #30) medical records reviewed where the patient had a documented wound there was not a "wound assessment" form on any record.

Several records reviewed contained documentation by the physician's assistant of a wound and the description of the wound but contained no nursing documentation of the wound.

Several records reviewed contained no documentation of any wounds on one day and contained wounds documented on the next day. The records contained no documentation that indicated the patient received a wound.

All medical records reviewed contained Behavioral Health Technician (BHT) documentation of every 15 minute rounds on patients "Nursing Department: BHT round sheet Q-15" that were not consistently co-signed by the RN on duty.

Based on medical record review and staff interview the hospital failed to ensure every patient had a current and updated care plan as needed. This occurred in 28 of 28 open and closed medical record reviewed.

Findings:

1. During the course of the survey August 2, 2015 through August 6, 2015, surveyors reviewed 28 open and closed patient medical records.

2. Although all medical records reviewed contained care plans they did not contain any documentation that the care plans were consistently followed and/or updated as needed.

3. This was confirmed with the Chief Nursing Officer at the time of record review.

Based on observation and staff interview, the hospital failed to ensure the hospital physical environment is maintained for the safety and well being of patients.

Findings:

1. On August 6, 2015 at 10:50 a.m. surveyors toured the adolescent unit with Staff N and Staff P. The following observations were made:

~All areas of the seclusion room could not be viewed from the seclusion door window or the window looking into the seclusion room from the nursing station. Filing cabinets, racks, and charts, blocked the window in the nursing station area for viewing seclusion patients.

~Patient room 402 shower was leaking. The floor was wet in the bathroom .

~Patient room 404 had a loose baseboard and was in disrepair.

~There were brown substance/stains along the tub/wall area throughout the facility in patient bathrooms on the unit.

2. On August 6, 2015 at 11:07 a.m. surveyors toured the Adult unit with Staff N and Staff P. The following observations were made:

~There were multiple stained ceiling tiles. There were ceiling plant hooks in the ceiling tiles.

~Patient room number 300 bathroom had unsealed wood framing the sink. The unsealed wood can't be disinfected. The wall around the sink was in disrepair.

~Patient room 301 and 302 bathroom had cabinet material that was cracked and in disrepair.

~Patient room 303 had baseboards that were loose and in disrepair.

~There were brown substance/stains along the tub/wall area throughout the facility in patient bathrooms on the unit.

3. On August 6, 2015 at 11:20 a.m. surveyors toured the Intellectually Disabled (ID) unit with Staff B and Staff P. The ID unit was for patients with intellectual disabilities. The following observations were made:

~There were brown substance/stains along the tub/wall area throughout the facility in patient bathrooms on the unit.

~There were multiple crank handles on patient beds throughout the unit. These crank handles are not anti-ligature safe hardware.

~There was a wood fenced sitting area for patients outside the ID unit. The wood fence was in disrepair in multiple locations. The wood fence had many rusty nails sticking out of the boards. The wood fence gait was in disrepair and being held together by a chain.

4. On August 6, 2015 at 1:40 p.m. surveyors toured the geriatric unit with Staff B and Staff P. The following observations were made:

~There were brown substance/stains along the tub/wall area throughout the facility in patient bathrooms on the unit. There were brown substance/stains on the stainless steel bathroom fixtures (toilet paper holder, sink faucets, hand rails).

~Multiple patient rooms had broken and chipped bathroom cabinets.

~Multiple patient bathrooms had blue tape marked on the ceiling. Surveyors asked what the blue tape was for. Staff B and Staff P said that the blue masking tape was place before painting started.

~Multiple patient bathrooms had peeling paint hanging from the ceiling. Multiple patient bathrooms had a large discolored area of the ceiling. Staff P told surveyors that the discolored area was from the leaking roof and the repair of the roof had not been approved.

~Multiple patient bathroom toilet sensors had a tape placed in front of the sensor that inhibited the toilet sensors to work as designed. The tape can't be disinfected.

~Multiple patient rooms had a larger than a dollar size chunk of unsealed wood exposed.

~Multiple patient rooms had discoloration of vinyl flooring. Staff P told surveyors the discoloration is from water.