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Based on interview, record review and a review of facility documentation, the facility failed to ensure that a patient with suicidal ideations had their rights for care in a safe setting through prompt charge nurse notification of a patient's desire to strangle herself and the timely implementation of suicide prevention precautions were maintained for 1 of 5 sampled patients placed on suicide precautions (#16). As a result, Lakeside Behavioral Healthcare Hospital was not in compliance with CFR ?482.13: Condition of Participation: Patient Rights

Findings:
Cross Refer A-0144. Facility policy "Special Precautions & Special Care Levels" read, "Additionally, at any time in the CRC (Crisis Resource Center) or Inpatient Unit, staff are responsible for reporting any identified high risk client behavior or conduct that may be indicators of a need for increased levels of precaution or supervision. (1) All staff are responsible for the immediate report to the Charge RN of any reference, ideation, or attempt at suicide, elopement, assault, sexual or other inappropriate/dangerous behaviors. (2) The CRC/Unit Nurse will be responsible to assess the identified risk factors and determine if additional interventions are needed to meet the safety needs of the client....Upon identification of a client's need for increased supervision, the CRC/Unit Nurse is responsible for obtaining a physician's order as soon as possible, but no longer than one hour from identification of the need." During an interview of the Vice President of Quality and Risk Management on 6/07/13 at 9:52 AM, she stated that "immediate" refers to "within the next couple of hours" or "before the shift ends."

A progress note by a registered licensed mental health counselor intern at 11:45 AM on 6/03/13 read, "Clt (client) said... I just feel like strangling myself." There was no evidence in the record of the registered licensed mental health counselor intern having immediately reported this specific suicidal ideation, which mentioned the manner of suicide which the patient was contemplating, to the charge nurse as required in the above quoted policy. There was no evidence in the medical record of the charge nurse being aware of this statement until 6/04/13, as discussed below. A note by a registered licensed mental health counselor intern on 6/05/13 at 11:30 AM read, "Therapist met with (patient #16) to discuss the events that happened last night. Clt stated that she attempted to hang herself with her sheet from her bed."

During an interview of the registered licensed mental health counselor intern on 6/07/13 at 11:08 AM, she indicated that in cases where a patient reports suicidal ideation, she would report it to her supervisor, who is the therapist manager. Regarding the record entry of 11:45 AM on 6/03/13, quoted above, she could not state with specificity that she had reported the "strangling" statement to anyone whosoever on 6/03/13.

The failure of facility staff to implement suicide precautions with patient #16 who had voiced a suicidal ideation with a specific contemplated method meant that the patient was left without the implementation of any new protective plan.

Based on interview, record review and a review of facility documentation, the facility failed to ensure that a patient with suicidal ideations received care in a safe setting for 1 of 5 sampled patients who had been placed on suicide precautions (#16).

Findings:

A review of the medical record of patient #16 was performed. The patient was admitted to the facility on 5/31/13 under a Baker Act. The document "Lakeside Behavioral Healthcare, Inc. Admission/Transfer/Remotes", dated 5/31/13, stated the presenting symptoms as "SI (suicidal ideation) with depression." A nurses' assessment of 5/31/13 at 12:16 PM read, "Nursing diagnosis: Risk for harm to self.... Lethality assessment and safety plan: SP (Suicide precautions)." Physician orders on the Physician Admission Orders sheet of 5/31/13 at 4:55 PM read, "SP (Suicide Precautions)". Suicide Precautions were cancelled on the "Physician Post Admission Orders" sheet of 6/01/13 at 8:30 AM.

Facility policy "Special Precautions & Special Care Levels" read, "Additionally, at any time in the CRC (Crisis Resource Center) or Inpatient Unit, staff are responsible for reporting any identified high risk client behavior or conduct that may be indicators of a need for increased levels of precaution or supervision. (1) All staff are responsible for the immediate report to the Charge RN of any reference, ideation, or attempt at suicide, elopement, assault, sexual or other inappropriate/dangerous behaviors. (2) The CRC/Unit Nurse will be responsible to assess the identified risk factors and determine if additional interventions are needed to meet the safety needs of the client....Upon identification of a client's need for increased supervision, the CRC/Unit Nurse is responsible for obtaining a physician's order as soon as possible, but no longer than one hour from identification of the need." During an interview of the Vice President of Quality and Risk Management on 6/07/13 at 9:52 AM, she stated that "immediate" refers to "within the next couple of hours" or "before the shift ends."

A progress note by a registered licensed mental health counselor intern at 11:45 AM on 6/03/13 read, "Clt (client) said... I just feel like strangling myself." There was no evidence in the record of the registered licensed mental health counselor intern having immediately reported this specific suicidal ideation, which mentioned the manner of suicide which the patient was contemplating, to the charge nurse as required in the above quoted policy. There was no evidence in the medical record of the charge nurse being aware of this statement until 6/04/13, as discussed below.

During an interview of the registered licensed mental health counselor intern on 6/07/13 at 11:08 AM, she indicated that in cases where a patient reports suicidal ideation, she would report it to her supervisor, who is the therapist manager. Regarding the record entry of 11:45 AM on 6/03/13, quoted above, she could not state with specificity that she had reported the "strangling" statement to anyone whosoever on 6/03/13.

A physician's progress note of 6/03/13 at 12:03 PM read, "(+) suicidal plans using a knife." During an interview of the physician on 6/07/13 at 11:15 AM, he stated that he was not aware on 6/03/13 of the above mentioned "strangling" entry of 6/03/13 at 11:45 AM or any other report pertaining to patient #16's comment.

The failure of the registered licensed mental health counselor intern to immediately report the suicidal ideation with a specific contemplated method (strangling) to the charge nurse, in accordance with policy, meant that there was no timely reconsideration of patient #16's status and there was no immediate assessment of the newly identified risk factor on 6/03/13.

A "Multidisciplinary Integrated Summary for Treatment/Service Planning" form of 6/04/13, the next day, had the following notation by the above mentioned registered licensed mental health counselor intern: "Clt (client) expressed desire to strangle herself." An accompanying "Team Meeting Log" (which had the members of physician, charge nurse, utilization review nurse and the above mentioned mental health counselor intern) for 6/04/13 mentioned "Suicidal thought of strangling herself." These two record entries for 6/04/13, indicating an awareness of others regarding the "strangling" statement of 6/03/13, were the first mentions in the record since 6/03/13 of this concern. During an interview of the physician on 6/07/13 at 11:15 AM, he stated that the possibility of placing the patient back on suicide precautions in light of the 6/03/13 "strangling" comment by patient #16 was not discussed by the team.

The failure of facility staff to implement suicide precautions with patient #16 who had voiced a suicidal ideation with a specific contemplated method meant that the patient was left without the implementation of any new protective plan.

The "Close Observation Flow Sheet" for 6/04/13 for patient #16 made no mention of the patient having been placed on suicide precautions. This was in accordance with the physician orders as they existed at the time.

A nurse's note at 8:20 PM on 6/04/13 read, "(Patient #16) has been disruptive on unit. At 9:35 PM (patient #16) had asked to use her restroom. She was in for < (less than) 2 minutes when one of the MHTs (Mental Health Technicians) went to check on her. He knocked on the door but there was no response. He got a female tech to check on her. When the door was opened a sheet was observed tied from vent in ceiling to client's neck. Sheet had slack with no tension and sheet was tied loosely around clt's neck. No marks observed. Clt (client) assessed. Vitals stable, no acute distress, clt did not lose consciousness. Clt was slumped against shower tub wall. Supervisor + doctor notified. Clt now ordered paper scrubs, finger foods, SP, visuals, and to be more closely monitored while using bathroom. Clt was escorted to day room. She sat next to a friend where she smiled and started laughing. Will continue to monitor."

A note by a registered licensed mental health counselor intern on 6/05/13 at 11:30 AM read, "Therapist met with (patient #16) to discuss the events that happened last night. Clt stated that she attempted to hang herself with her sheet from her bed."

Based on interview, record review and a review of facility documentation, the facility failed to ensure that a patient with suicidal ideations received nursing services which included evaluations and assessments in a timely manner and superrvision in a safe manner for 1 of 5 sampled patients placed on suicide precautions (#16). As a result Lakeside Behavioral Healthcare Hospital was not in compliance with CFR ?482.23 Condition of Participation: Nursing Services.

Findings:

Cross Reference A0395. Based on interview, record review and a review of facility documentation, the facility failed to ensure that a patient with suicidal ideations was evaluated and assessed in a timely manner and superrvised in a safe manner in one of five sampled patients who had been placed on suicide precautions (#16).

Based on interview, record review and a review of facility documentation, the facility failed to ensure that a patient with suicidal ideations was evaluated and assessed in a timely manner and supervised in a safe manner for 1 of 5 sampled patients placed on suicide precautions (#16).

Findings:
A review of the medical record of patient #16 was performed. The patient was admitted to the facility on 5/31/13 as a Baker Act. The document "Lakeside Behavioral Healthcare, Inc. Admission/Transfer/Remotes", dated 5/31/13, stated the presenting symptoms as "SI (suicidal ideation) with depression." A nurse's assessment of 5/31/13 at 12:16 PM read, "Nursing diagnosis: Risk for harm to self.... Lethality assessment and safety plan: SP (Suicide precautions)." Physician orders on the Physician Admission Orders sheet of 5/31/13 at 4:55 PM read, SP (Suicide Precautions)". Suicide Precautions were canceled in the "Physician Post Admission Orders" sheet of 6/01/13 at 8:30 AM.

Facility policy "Special Precautions & Special Care Levels" read, "Additionally, at any time in the CRC (Crisis Resource Center) or Inpatient Unit, staff are responsible for reporting any identified high risk client behavior or conduct that may be indicators of a need for increased levels of precaution or supervision. (1) All staff are responsible for the immediate report to the Charge RN of any reference, ideation, or attempt at suicide, elopement, assault, sexual or other inappropriate/dangerous behaviors. (2) The CRC/Unit Nurse will be responsible to assess the identified risk factors and determine if additional interventions are needed to meet the safety needs of the client.... Upon identification of a client's need for increased supervision, the CRC/Unit Nurse is responsible for obtaining a physician's order as soon as possible, but no longer than one hour from identification of the need." During an interview of the Vice President of Quality and Risk Management on 6/07/13 at 9:52 AM, she stated that "immediate" refers to "within the next couple of hours" or "before the shift ends."

A progress note by a registered licensed mental health counselor intern at 11:45 AM on 6/03/13 read, "Clt (client) said... I just feel like strangling myself." There was no evidence in the record of the registered licensed mental health counselor intern having immediately reported this specific suicidal ideation, which mentioned the manner of suicide which the patient was contemplating, to the charge nurse as required in the above quoted policy. There was no evidence in the medical record of the charge nurse being aware of this statement until 6/04/13, as discussed below.

During an interview of the registered licensed mental health counselor intern on 6/07/13 at 11:08 AM, she indicated that in cases where a patient reports suicidal ideation, she would report it to her supervisor, who is the therapist manager. Regarding the record entry of 11:45 AM on 6/03/13, as quoted above, she could not state with specificity that she had reported the "strangling" statement to anyone whosoever on 6/03/13.

A physician's progress note of 6/03/13 at 12:03 PM read, "(+) suicidal plans using a knife." During an interview of the physician on 6/07/13 at 11:15 AM, he stated that he was not aware on 6/03/13 of the above mentioned "strangling" entry of 6/03/13 at 11:45 AM or any other report pertaining to patient #16's comment.

The failure of the registered licensed mental health counselor intern to immediately report the suicidal ideation with a specific contemplated method (strangling) to the charge nurse, in accordance with policy, meant that there was no timely reconsideration of patient #16's status and there was no immediate assessment of the newly identified risk factor on 6/03/13.

A "Multidisciplinary Integrated Summary for Treatment/Service Planning" form of 6/04/13 had the following notation by the above mentioned registered licensed mental health counselor intern: "Clt (client) expressed desire to strangle herself." An accompanying "Team Meeting Log", which included the physician, charge nurse, utilization review nurse and the above mentioned mental health counselor intern for 6/04/13 mentioned "Suicidal thought of strangling herself." These two record entries for 6/04/13, indicating an awareness of others regarding the "strangling" statement of 6/03/13, were the first mentions in the record since 6/03/13 of this concern.

During an interview of the physician on 6/07/13 at 11:15 AM, he stated that the possibility of placing the patient back on suicide precautions in light of the 6/03/13 "strangling" comment by patient #16 was not discussed by the team.

The failure of facility staff to implement suicide precautions with patient #16, who had voiced a suicidal ideation with a specific contemplated method meant that the patient was left without the implementation of any new protective plan and was not supervised in a safe manner.

The Close Observation Flow Sheet for 6/04/13 for patient #16 made no mention of the patient having been placed on suicide precautions. This was in accordance with the physician orders as they existed at the time.

A nurse's note at 8:20 PM on 6/04/13 read, "(Patient #16) has been disruptive on unit. At 9:35 PM (patient #16) had asked to use her restroom. She was in for < (less than) 2 minutes when one of the MHT's (Mental Health Technician) went to check on her. He knocked on the door but there was no response. He got a female tech to check on her. When the door was opened a sheet was observed tied from vent in ceiling to client's (patient's) neck. Sheet had slack with no tension and sheet was tied loosely around clt's neck. No marks observed. Clt (client) assessed. Vitals stable, no acute distress, clt did not lose consciousness. Clt was slumped against shower tub wall. Supervisor + doctor notified. Clt now ordered paper scrubs, finger foods, SP, visuals, and to be more closely monitored while using bathroom. Clt was escorted to day room. She sat next to a friend where she smiled and started laughing. Will continue to monitor."

A note by a registered licensed mental health counselor intern on 6/05/13 at 11:30 AM read, "Therapist met with (patient #16) to discuss the events that happened last night. Clt stated that she attempted to hang herself with her sheet from her bed."

Based on observation, interview and a review of facility documentation, the facility failed to ensure that unauthorized individuals could not gain access to patient records.

Findings:

On 6/05/13 at 3:40 PM, a four tier file cabinet was observed in a recessed area of a hallway on the third floor. The file cabinet was out of any direct, line of sight view of any nearby office and unlocked. Observation within each of the drawers revealed that they were filled with patient financial records. Documentation in these records included patient names, addresses, phone numbers, diagnoses, social security numbers and other confidential patient information. While the surveyor examined the contents of the file cabinet, no one attempted to stop him or otherwise interrupt him. The discovery was immediately brought to the attention of the Vice President of Quality and Risk Management by the surveyor.

This part of the facility contained offices in nearby rooms. Access to the hallway was obtained by going through one of two paired doors which swung open when pushed and were not locked. These doors, in turn, were easily accessible to anyone who may step off a nearby public elevator. Thus, it was possible for unauthorized individuals to gain access to this confidential patient information.

A review of facility policy "Medical Records Maintenance and Security" revealed the following: "Client records will be confidential, secure, current, authenticated, legible, and complete. Lakeside will safeguard the rights and privacy of the patients by maintaining security of client records. The information in the client record will be protected against loss, defacement, tampering, use or disclosure by unauthorized persons and maintained in a secure, locked environment."

The storage of records in the manner as described above was in violation of this policy.

During an interview of the Vice President of Quality and Risk Management on 6/06/13 at 2:11 PM, she confirmed the findings.

Based on record review and interview, the facility failed to have pharmacy policies in place related to the movement of all scheduled drugs from point of entry into the pharmacy and a policy related to medications provided to patients leaving the hospital at discharge.

Findings:

During an interview on 6/06/2013 at 2:35 p.m., the pharmacy director confirmed pharmacy policies were not in place related to the movement of all scheduled drugs from point of entry into the pharmacy and one related to medications provided to patients leaving the hospital at discharge.

Based on interview and a review of facility documentation, the facility failed to ensure that the Utilization Review committee had at least two members who were doctors of medicine and/or osteopathy.

Findings:

During a review of a meeting agenda for the Patient Safety Performance Improvement Council meeting of 5/15/13, the council responsible for Utilization Review activities, it was discovered that it only had one doctor listed as a permanent member. This doctor was a doctor of medicine.

During an interview of the contract manager, who was responsible for the Utilization Review function, on 6/05/13 at 11:37 AM, he confirmed the finding.

Based on interview and record review, the facility failed to conduct hand hygiene surveillance (A-0749); failed to update the Infection Control Program periodically (A-0749); failed to have regular infection control meetings with designated staff (A-0748); failed to have a documented log of patient and employee infections (A-0750); failed to have a policy related to pest control (A-0749) and failed to ensure patient food storage areas are provided in a sanitary manner (A-0749) resulting in the facility being out of compliance with CFR ?482.42: Condition of Participation: Infection Control Infection Control.

Findings:

1. Cross Reference A-0748. Based on interview and record review, the facility failed failed to have regular infection control meetings with designated staff.

2. Cross Reference A-0749. Based on interview and record review, the facility failed to conduct hand hygiene surveillance; failed to have a policy related to when an employee is allowed to return to work following an infection; failed to update the Infection Control Program periodically; failed to have a policy related to pest control; and failed to ensure patient food storage areas are provided in a sanitary manner.

3. Cross Reference A-0750. Based on interview and record review, the facility failed to have a documented log of patient and employee infections.

Based on interview and record review, the facility failed failed to have regular infection control meetings with designated staff.

Findings:

During an interview on 6/07/2013 at 11 a.m. the director of nursing (DON) confirmed currently she and staff #B, assistant to the DON are the only people attending the infection control meeting on a monthly basis. The DON provided documentation the last documented meeting was on 1/11/2013.

Review of the infection control policy "Infection Control Plan-Addendum G", revised last on 10/10/2011 indicated that "the Infection Control Committee has membership representing the core disciplines responsible for integrating infection control practices into overall high-quality clinical care. The committee membership includes: a. A member of the Nursing staff; b. A member of the Administrative staff; c. A member of the Facilities and Engineering staff; d. The person directly responsible for infection control practices; and e. Representation of Housekeeping and Dietary Services." The DON also said there was monthly infection control meetings since January 2013, however, there is no formal agenda or meeting minutes.

Based on interview and record review, the facility failed to conduct hand hygiene surveillance, failed to have a policy related to when an employee is allowed to return to work following an infection, failed to update the Infection Control Program periodically, failed to have a policy related to pest control, and failed to ensure patient food storage areas are provided in a sanitary manner.

Findings:

1. Review of the facility policies showed a hand hygiene policy. Review of the facility document-National Patient Safety Goals 2013 read, "Lakeside complies with current CDC hand-hygiene guidelines and provides education to these requirements at New Employee Orientation and annual competency training. Posters outlining requirements are posted in all client care areas throughout the company. The Infection Control Sub-Committee of the Consumer and Environmental Safety is responsible for setting goals and monitoring performance on an monthly basis. These results are reported quarterly in the Performance Management Report to the Performance Improvement council."
During an interview on 6/05/2013 at 1:30 p.m., staff #B and the director of nursing (DON) confirmed there was currently no monitoring/surveillance conducted related to hand washing compliance.
2. A policy review did not find a policy related to when an employee would be allowed to return to work following an event of an infectious disease.

During an interview on 6/06/2013 at 1:45 p.m., both the DON and staff #B, assistant to the DON, confirmed there was no current policy.

3. Review of the General Procedure "Infection Control Program" showed it was last revised/updated on 6/12/2008. Review of the "Infection Control Plan-Addendum G", dated as revised 10/10/2011, read, "Review and making recommendations for revision of the Infection Control Plan at least every two years."

During an interview on 6/06/2013 at 1:45 p.m., both the DON and staff #B, assistant to the DON, confirmed many of the policies require revision currently and they are in the process of reviewing.

4. Review of policy showed the facility did not have a policy related to techniques for pest control. The facility has a current contract in place dated 7/31/2000 for monthly pest control, but on 6/06/2013 at 1:03 p.m., the DON and staff #B, assistant to the DON confirmed there was no pest policy.

5. During a tour of the west dining area on 6/04/2013 at 11:35 a.m., the refrigerator used to store patient food items in the West dining area was dirty and soiled with an unknown brown substance on the middle and the bottom shelf. The DON and the nursing unit manager were present and confirmed the refrigerator was soiled.

A later observation the following day on 6/05/2013 at 3:15 p.m. showed the refrigerator used to store patient food items on the West nursing unit still dirty and soiled with an unknown brown substance on the middle and the bottom shelf and in need of cleaning. There was also a container of food. Mental health technician (MHT) #N said the one Tupperware container of food belonged to a patient. However, he confirmed it was not labeled with any patient name. There was also a red lunch box which the MHT said belonged to an employee. There was also one egg salad sandwich with a use by date of 6/03/2013. The nursing manager was present and confirmed the unlabeled item, the employee lunch bag, and the soiled areas of the refrigerator.

Review of the policy and procedures showed the facility did not have a policy currently related to food sanitation on the nursing unit patient refrigerator cleanliness and who was responsible for ensuring it was cleaned on a regular schedule. Review of the environmental safety walk completed on 5/29/2013 for the 4 West and East units showed it did not include monitoring for the cleanliness in the refrigerator. During an interview on 6/06/2013 at 1:45 p.m., DON and staff #B, assistant to the DON, confirmed there was no related policy currently.

Based on interview and record review, the facility failed to have a documented log of patient and employee infections.

Findings included:

The facility was able to provide an employee and patient log recording infections, however, the DON and staff #B, assistant to the DON, confirmed on 6/05/2013 at 1:30 p.m., they do not have a tracking system in place to identify which staff would have been exposed to patients or which patients would have been exposed to staff for review. Both said the process would require pulling all work schedules, all patient records, and other documents to determine any exposure. The DON and staff B, assistant to the DON confirmed currently the infection control plan does not include identifying staff with infections and or the patient population who may have been exposed by the infected employee.

Based on record review and interview, the facility failed to have written policies and procedures addressing its organ procurement responsibilities. The hospital's failure to ensure the specific organ, tissue, and eye procurement requirements are met, related to failure to have an agreement with an organ procurement organization (OPO), a written policy defining imminent death and timely notification, and a policy addressing the OPO's responsibility to determine medical suitability for organ donations (A-0886), failed to have an agreement with at least one tissue and one eye bank (A-0887), failed to have a process in place to notify patients of their options to donate organs, tissues, or eyes, or to decline donations (A-0888), and failed to have a designated requestor as an organ procurement representative (A-0889) resulted in the hospital being out of compliance with ?482.45: Condition of Participation: Organ Procurement Organization.

Findings:

1. Cross Reference A-0886. Based on record review and interview, the facility failed to have an agreement with an organ procurement organization, a written policy defining imminent death and timely notification, and a policy addressing the OPO's responsibility to determine medical suitability for organ donations.

2. Cross Reference A-0887. Based on record review and interview, the facility failed to have an agreement with at least one tissue and one eye bank.

3. Cross Reference A-0888. Based on record review and interview, the facility failed to have a process in place to notify patients of their options to donate organs, tissues, or eyes, or to decline donations.

4. Cross Reference A-0889. Based on record review and interview, the facility failed to have a designated requestor as an organ procurement representative.

Based on record review and interview, the facility failed to have an agreement with an organ procurement organization, a written policy defining imminent death and timely notification, and a policy addressing the OPO's responsibility to determine medical suitability for organ donations.

Findings:
During an interview on 6/7/2013 at 9:45 a.m., the risk manager stated the facility does not have any policies and procedures related to a written policy defining imminent death and timely notification, and a policy addressing the OPO's responsibility to determine medical suitability for organ donations, contracts with an OPO, or Verification of membership in Organ Procurement and Transplantation Network related to organ procurement.

Based on record review and interview, the facility failed to have an agreement with at least one tissue and one eye bank.

Findings:
During an interview on 6/7/2013 at 9:45 a.m. , the risk manager stated the facility does not have an agreement with at least one tissue and one eye bank.

Based on record review and interview, the facility failed to have a process in place to notify patients of their options to donate organs, tissues, or eyes, or to decline donations.

Findings:

During an interview on 6/07/2013 at 9:45 a.m., the risk manager stated the facility did not have any policies and procedures related to notifying patients of their options to donate organs, tissues, or eyes, or to decline donations.

Based on record review and interview, the facility failed to have a designated requestor as an organ procurement representative.

Findings:

During an interview on 6/07/2013 at 9:45 a.m., the risk manager stated the facility did not have a designated requestor as an organ procurement representative.