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Based on record reviews, observations, and interviews, the hospital failed to ensure its Governing Body and CEO was effective in ensuring the hospital was compliant with the Condition of Participation as evidenced by:

1) Failing to ensure the requirements of the Condition of Participation of Patient Rights were met as evidenced by failing to ensure patients received care in a safe setting. This deficient practice was evidenced by failing to ensure patients admitted for being a harm to themselves and/or others had not had access to contraband items in the inpatient care units for 4 (#FR12, #FR14, #FR15, #FR17) of 4 sampled patients reviewed for contraband item possession from a total patient sample of 13 and a random patient sample of 21 (See findings at tag A-0144).

2) Failing to ensure the requirements of the Condition of Participation for Nursing Services were met as evidenced by:
a) failure of the RN to ensure patients admitted with thoughts of self-harm, who subsequently attempted suicide, had been observed at the ordered level of observation (Level II- Line of Sight) for 2 (#F12 and #F13) of 2 sampled patients reviewed for suicide attempts made in the hospital (See findings at tag A-0395); and
b) failure of the RN to obtain patient admission orders from a licensed independent practitioner for 1 (#FR18) of 1 patient sampled for the admission process (see findings tag A-0395).

3) Failing to ensure the requirements for the Condition of Participation of Food and Dietary Services were met as evidenced by:
a) Failure to have an employee appointed that served as director of food and dietetic services who was responsible for the daily management of the dietary services, and was qualified by experience or training. (See Findings in A-0620)
b) Failure to have a qualified dietitian. (See Findings in A-0621),
c) Failure to ensure administrative and technical personnel were competent in their respective duties. (See Findings in A-0622),
d) Failure to ensure menus met the needs of patients. (See Findings in A-0629), and
e)Failure to ensure a current therapeutic diet manual, approved by the dietitian and medical staff was readily available to all medical, nursing, and food service personnel. (See Findings in A-0631).

Based on record reviews, observations, and interviews, the CEO failed to effectively manage the hospital as evidenced by:

1) Failing to ensure the requirements of the Condition of Participation of Patient Rights were met as evidenced by failing to ensure patients received care in a safe setting. This deficient practice was evidenced by failing to ensure patients admitted for being a harm to themselves and/or others did not have access to contraband items in the inpatient care units for 4 (#FR12, #FR14, #FR15, #FR17) of 4 sampled patients reviewed for contraband item possession from a total patient sample of 13 and a random patient sample of 21 (See findings at tag A-0144).

2) Failing to ensure the requirements of the Condition of Participation for Nursing Services were met as evidenced by:
a) failure of the RN to ensure patients admitted with thoughts of self-harm, who subsequently attempted suicide, had been observed at the ordered level of observation (Level II- Line of Sight) for 2 (#F12 and #F13) of 2 sampled patients reviewed for suicide attempts made in the hospital (See findings at tag A-0395); and
b) failure of the RN to obtain patient admission orders from a licensed independent practitioner for 1 (#FR18) of 1 patient sampled for the admission process (see findings tag A-0395).

3) Failing to ensure the requirements for the Condition of Participation of Food and Dietary Services were met as evidenced by:
a) Failure to have an employee appointed that served as director of food and dietetic services who was responsible for the daily management of the dietary services, and was qualified by experience or training. (See Findings in A-0620); and
b) Failure to have a qualified dietitian. (See Findings in A-0621); and
c) Failure to ensure administrative and technical personnel were competent in their respective duties. (See Findings in A-0622); and
d) Failure to ensure menus met the needs of patients. (See Findings in A-0629); and
e)Failure to ensure a current therapeutic diet manual, approved by the dietitian and medical staff was readily available to all medical, nursing, and food service personnel. (See Findings in A-0631).

In an interview on 3/22/18 at 5:45 p.m. with SF1Adm, he indicated patient access to contraband items was an issue. He confirmed the plan to conduct contraband searches in intake, prior to the patient being brought back to the inpatient unit, and placing patient belongings in lockers outside of the inpatient unit had not been initiated yet. SF1Adm indicated one of the patients who had attempted suicide on the unit had only been on the unit briefly when he had attempted suicide. SF1Adm was informed the patient had been on Level II- line of sight when he had attempted suicide and it had been confirmed in staff interviews that the patient had not been maintained in line of staff sight as ordered. He reported he had not been aware a patient had been smoking in the gym bathroom. SF1Adm confirmed he had not been aware nurses were documenting that they had called the physician for admission orders and had not actually called the physician. SF1Adm reported the question had been asked whether the nursing staff was actually calling for verbal/telephone orders and they didn't have a definitive answer. He said he knew the dietician/dietary manager leaving presented an issue for them to meet the dietary needs for the hospital.

Based on record review and interview, the hospital failed to ensure the institution had an overall institutional plan that included a projection of capital expenditures for at least a 3 year period. This deficient practice was evidenced by the hospital having a budget for the year 2018 only.

Findings:

Review of the hospital's requested budget information, provided by SF20Controller as current, revealed the budget was for the year 2018 only.

In an interview on 3/20/18 at 10:50 a.m. with SF20Controller, she reported the hospital had not projected capital expenditures for at least the next 3 years because healthcare was so unpredictable. She confirmed the budget she brought was for 2018 only.

In an interview on 3/22/18 at 6:30 p.m. with SF14CFO, he confirmed the hospital's overall institutional plan did not include a projection of capital expenditures for at least a 3 year period due to the unpredictability of healthcare.

Based on record review and interview, the governing body failed to ensure all services furnished in the hospital, including contracted services, were performed in a safe and effective manner. This deficient practice was evidenced by failing to ensure all services, including contracted services, were included in the quality assurance and performance improvement (QAPI) program.

Findings:

Review of the list of the hospital's current contracted services, presented by SF4QA, revealed the following services were provided via contract: Radiology Services, Lab Services, Laundry Services, Stericycle Services, and Interpreter Services.

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In an interview on 3/22/18 at 6:18 p.m. with SF4QA, she confirmed the following services were not included in the hospital's QA plan: Radiology, Lab, Respiratory Services (provided directly), Laundry Services, Stericycle Services, and Interpreter Services.

Based on record review and interview, the hospital failed to meet the requirements of the Condition of Participation for Patient Rights by failing to ensure patients received care in a safe setting. This deficient practice was evidenced by failing to ensure patients admitted for being a harm to themselves and/or others had not had access to contraband items in the inpatient care units for 4 (#FR12, #FR14, #FR15, #FR17) of 4 sampled patients reviewed for contraband item possession from a total patient sample of 13 and a random patient sample of 21 (See findings tag A-0144).

Based on record review and interview the hospitial failed to ensure grievenace resolution letters to patients included the steps taken on behalf of the patient to investigate the greivance, the results of the grieveance process, and the date of completion. This deficient practice was evidenced by Grievance response letters that did not include the steps taken on behalf of the patient (to investigate the grievance), or the results of the grievance process for 2 of 2 (#FR19, #FR20) patient grievance notices reviewed.

Findings:

Review of hospital policy No: RM-038 titled "Grievance, Patient"(original Date of Issue: 9/2017), provided 3/22/18 as current by SF4QA, revealed in part, The Patient Advocate (or CEO designee) would ...report to the patient should contian the name of the hospital contact person, steps taken on behalf of the patient to investigate the grievance, results of the grievance, and date of completion. Tell the patient what has been done. Mail a written report if the complainant is not the patient or the patient has been discharged."

Patient #FR19
Review of a copy of a written Grievance letter, written in response to a grievance filed by Patient #FR19 revealed no documentation relaying what measures had been taken to investigate the grievance, or the results of the gievance process. The letter stated the grievance was resolved, but offered no information of it was resolved or if it was substantiated.

Patient #FR20
Review of a copy of a written Grievance letter, written in respons to a grievance filed by Patient #FR20 revealed no documentation relaying what measures had been taken to investigate the grievance, or the results of the gievance process. The letter stated the grievance was resolved, but offered no information of how it was resolved or if it was substantiated.

In an interview 3/22/18 at 8:45 a.m. SF4QA confirmed the Grievance response letters did not include the steps taken to investigate the grievances or the results of or actions taken in response to the grievance investigation findings.

Based on observation, record review, and interview, the hospital failed to ensure patients received care in a safe setting. This deficient practice was evidenced by:
1) failing to mitigate a known elopement risk as evidenced by having a patient elope by jumping a fence surrounding an exterior patient area for 1 (#F11) of 1 total patient reviewed for elopements. Deficient practice was previously cited on a complaint survey at the hospital on 12/19/17 for 7 psychiatric patient elopements since 1/24/17 resulting from patients jumping exterior fences. Deficient practice was also cited on another complaint survey on 1/31/18 for 1 psychiatric patient elopement since the survey conducted on 12/19/17; and

2) failing to ensure patients admitted for being a harm to themselves and/or others had not had access to contraband items in the inpatient care units for 4 (#FR12, #FR14, #FR15, #FR17) of 4 random sampled patients reviewed for contraband item possession; and

3) failing to maintain a safe environment for patients admitted for being at risk for harm to self and/or others by allowing psychiatric inpatients to use bathrooms that contained ligature risks without supervision.

Findings:

1)Failing to mitigate a known elopement risk as evidenced by having a patient elope by jumping a fence surrounding an exterior patient area.

Observation beginning on 3/18/18 at 2:30 p.m. of the exterior patient area of the hospital's Detox Unit- B revealed the following: The outside area was surrounded by a 6-foot wooden fence on 1 side and chain link fence on the other 3 sides. The chain link section had 2 gates with bars across the middle which could facilitate climbing. Three large fence posts had been placed in preparation for the 10 foot fence that was to be completed as an elopement deterrent. The 10 foot fence had not been completed at the time of the observation.

Review of Patient #F11's medical record revealed the patient was admitted to the locked psychiatric unit (Unit B) on 3/6/18 at 11:40 a.m. with admission diagnoses of major depressive disorder, and opioid (Heroin) abuse. Further review revealed the patient had been admitted for being a danger to self.

Review of an incident report for Patient #F11 dated 3/7/18 at 3:15 p.m. revealed the patient had been located outside of Unit B of the psychiatric hospital in the smoking section when he had eloped by jumping over a perimeter fence.

Review of Patient #F11's daily nursing notes, dated 3/7/18, revealed the following entry, in part: 3:15 p.m.: Code Purple- patient elopement. Patient jumped over chain link fence during 3:00 p.m. smoke break. Called 911; Code Purple paged throughout facility.

In an interview on 3/18/18 at 2:40 p.m. with SF21RN, he reported he was the charge nurse on Unit B. SF21RN indicated there had been one elopement since the last survey on 1/31/18. SF21RN indicated Patient #F11 had been admitted to the hospital for opiate detox and he had eloped from the unit. SF21RN reported Patient #F11 had been outside smoking with 2 staff members (SF7MHT and SF10MHT) and other patients when he had eloped. SF21RN indicated Patient #F11 had eloped at the exact same spot where the last patient had eloped on 1/24/18.

In an interview on 3/18/18 at 3:30 p.m. with SF4QA, she confirmed Patient #F11 had eloped from Unit B on 3/7/18 at 3:15 p.m. She reported the patient had not scored at high risk for elopement on the hospital's elopement risk screening tool. SF4QA also reported there were two staff members on the patio with the patients who were smoking when Patient #F11 eloped. SF4QA confirmed the 10 foot fence on Unit B had not been completed at the time of the elopement, so the identified elopement risk associated with exterior fences identified on the previous survey had not been mitigated. SF4QA also acknowledged the elopement risk assessments had been completed inaccurately at times and the purple gowns, indicating patients at risk for elopement, had also not been effective as part of the elopement corrective action plan. SF4QA reported the purple gowns were used for other patient purposes besides being used for patients at risk for elopement because purple was the only color they had.

2) Failing to ensure patients admitted for being a harm to themselves and/or others did not have access to contraband items in the inpatient care units.

Review of the hospital provided incident reports revealed the following incidents involving patients having contraband items:

Patient #FR15
Review of an incident report involving Patient #FR15 revealed that on 3/6/18 at 11:30 a.m. staff went in to check the gym (Unit B), smelled smoke, looked for evidence in the bathroom, and no evidence was found. Search was done and a pack of matches was found. Patient #FR15 admitted to smoking a cigarette in the bathroom.

Patient #FR14
Review of an incident report involving Patient #FR14 revealed that on 2/15/18 at 8:30 a.m. the patient brought to Unit A without being screened for weapons or contraband after the intake employee was verbally threatened by the patient. The patient had 2 knives in his belongings. Further review revealed the following documented statement made by the physician, SF18MD when she was informed of the incident: "It is unacceptable to allow unscreened patients to the unit, by then it is too late."

Patient #FR17
Review of an incident involving Patient #FR17 revealed that on 1/24/18 at 9:08 p.m. the patient walked up to the desk, on Unit A, with fireworks (contraband) in hand. Further review revealed the patient stated, "These were in the pants my Mom brought me today." Patient also stated that his brother had worn the pants last. Further review revealed staff was re-educated on searching belongings carefully.

Patient #FR12
Review of an incident report involving Patient #FR12 revealed that on 1/3/18 at 11:23 a.m. the patient came back into the hospital, after discharge, to get his shoelaces that he had forgotten under his mattress in inpatient Unit B. Further review of the incident report revealed the patient had not been searched and he had brought the shoelaces onto the unit (contraband).

In an interview on 3/21/18 at 3:00 p.m. with SF4QA, she reported the MHTs searched patient belongings on admission and any contraband items were taken at that time. She acknowledged inpatients on the care units did, at times, have contraband items such as the items (shoestrings, matches, and firecrackers) referenced above in their possession. She confirmed there were no contraband checks after patient visitation. SF4QA reported it was the hospital's plan to search patients and their belongings in intake and to store them outside of the inpatient unit in lockers, but they had not begun that process at the time of the survey. SF4QA reported there was a shortage of people in intake right now so they can't perform belonging searches, only searches of the patients. She said being short staffed is no excuse for not initiating the personal belonging searches in intake now because they may not be fully staffed for a while.

In an interview on 3/22/18 at 10:45 a.m. with SF29RN, she reported sometimes they find contraband items on patients on the unit. SF29RN also reported one of the patients had pulled out his own lighter when on a smoke break on the inpatient care unit. SF29RN reported there were no routine contraband checks performed on patients after being searched on admission and no contraband checks were performed after visitation.


3) Failing to maintain a safe environment for patients admitted for being at risk for harm to self and/or others by allowing psychiatric inpatients to use bathrooms that contained ligature risks without supervision.

An observation 3/19/18 at 9:00 a.m.,of the only two bathrooms in the gym, revealed following safety and ligature risks: In the Women's bathroom, stalls sourounding the toilets had a frame that included a separate bar above the wall, connected by a metal frame attached to the side walls, with greater than a foot between the top of the wall and the overhead bar. Further observation revealed individual ceiling tiles that were easily pushed up, and rested on a metal framework, an air vent to which a liguature could be attached, elongated levered handles for cold and hot water on the sink, grab/handicapped bars in the bathroom stalls with an open space between the bar and the wall that exceeded 1 and ½ inches. Water and drainage pipes below the open sink and behind the toilet were exposed without a cover. Observation of the men's room revealed the same design and ligature risks as the women's bathroom, with the addition of a urinals with exposed pipes above.


In an interview on 3/19/18 at 9:00 a.m. with SF9MHT, she said when patients went to the bathroom in the gym during visitation, the MHT would unlock the door and the patients were able to go into the bathrooms by themselves. SF9MHT said sometimes multiple people could go into the bathrooms but it depended on the patients.

In an interview on 3/19/18 at 9:02 a.m. with SF11MHT, she said the MHT's would stay outside of the bathroom door when patients went into the bathrooms during visitation.

In an interview on 3/19/18 at 9:00 a.m. with SF10MHT, she said when a patient went into the restroom during visitation, the staff stayed outside of the bathroom door and did not go into the bathroom with the patients.

In an interview on 3/19/18 at 9:30 a.m. with SF2DON, she said she would expect that a staff member go inside the door while a patient was in the restroom of the gym during visitation. She verified there were ligature risks in the bathrooms.


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Based on record reviews and interviews, the hospital failed to ensure adverse events were analyzed for cause and preventive actions were implemented and re-evaluated and clear expectations for patient safety were established. This deficient practice was evidenced by:
1) failure of the hospital to initiate preventive actions related to safety issues involving patient access to contraband items on the inpatient units for 4 (#FR12, #FR14, #FR15, #FR17) of 4 patient incident reports reviewed related to possession of contraband items; and

2) failure of the hospital to identify and mitigate safety risks (ligature risks) in the patient environment for patients admitted for being at risk for harm to self and/or others by allowing psychiatric inpatients to use bathrooms that contained ligature risks without supervision.


Findings:


1) Failure of the hospital to initiate preventive actions related to safety issues involving patient access to contraband items on the inpatient units.

Review of the hospital provided incident reports revealed the following incidents involving patients having contraband items:

Patient #FR15
Review of an incident report involving Patient #FR15 revealed that on 3/6/18 at 11:30 a.m. staff went in to check the gym (Unit B), smelled smoke, looked for evidence in the bathroom, and no evidence was found. Search was done and a pack of matches was found. Patient #FR15 admitted to smoking a cigarette in the bathroom.

Patient #FR14
Review of an incident report involving Patient #FR14 revealed that on 2/15/18 at 8:30 a.m. the patient brought to Unit A without being screened for weapons or contraband after the intake employee was verbally threatened by the patient. The patient had 2 knives in his belongings. Further review revealed the following documented statement made by the physician, SF18MD when she was informed of the incident: "It is unacceptable to allow unscreened patients to the unit, by then it is too late."

Patient #FR17
Review of an incident involving Patient #FR17 revealed that on 1/24/18 at 9:08 p.m. the patient walked up to the desk, on Unit A, with fireworks (contraband) in hand. Further review revealed the patient stated, "These were in the pants my Mom brought me today." Patient also stated that his brother had worn the pants last. Further review revealed staff was re-educated on searching belongings carefully.

Patient #FR12
Review of an incident report involving Patient #FR12 revealed that on 1/3/18 at 11:23 a.m. the patient came back into the hospital, after discharge, to get his shoelaces that he had forgotten under his mattress in inpatient Unit B. Further review of the incident report revealed the patient had not been searched and he had brought the shoelaces onto the unit (contraband).

In an interview on 3/21/18 at 3:00 p.m. with SF4QA, she reported the MHTs searched patient belongings on admission and any contraband items were taken at that time. She acknowledged inpatients on the care units did, at times, have contraband items such as the items referenced above, in their possession. She confirmed there were no contraband checks after patient visitation. SF4QA reported it was the hospital's plan to search patients and their belongings in intake and to store them outside of the inpatient unit in lockers, but they had not begun that process at the time of the survey. SF4QA reported there was a shortage of people in intake right now so they can't perform belonging searches, only searches of the patients. She said being short staffed is no excuse for not initiating the personal belonging searches in intake now because they may not be fully staffed for a while.

In an interview on 3/22/18 at 10:45 a.m. with SF29RN, she reported sometimes they find contraband items on patients on the unit. SF29RN also reported one of the patients had pulled out his own lighter when on a smoke break on the inpatient care unit. SF29RN reported there were no routine contraband checks performed on patients after being searched on admission and no contraband checks were performed after visitation.



2) Failure of the hospital to identify and mitigate safety risks (ligature risks) in the patient environment for patients admitted for being at risk for harm to self and/or others by allowing psychiatric inpatients to use bathrooms that contained ligature risks without supervision.

Review of the hospital's QA plan revealed no documented evidence that unsupervised patient use of the gym bathroom with ligature risks had been identified as a safety issue requiring mitigation thorugh corrective action.

An observation 3/19/18 at 9:00 a.m.,of the only two bathrooms in the gym, revealed following safety and ligature risks: In the Women's bathroom, stalls sourounding the toilets had a frame that included a separate bar above the wall, connected by a metal frame attached to the side walls, with greater than a foot between the top of the wall and the overhead bar. Further observation revealed individual ceiling tiles that were easily pushed up, and rested on a metal framework, an air vent to which a liguature could be attached, elongated levered handles for cold and hot water on the sink, grab/handicapped bars in the bathroom stalls with an open space between the bar and the wall that exceeded 1 and ½ inches. Water and drainage pipes below the open sink and behind the toilet were exposed without a cover. Observation of the men's room revealed the same design and ligature risks as the women's bathroom, with the addition of a urinals with exposed pipes above.


In an interview on 3/19/18 at 9:00 a.m. with SF9MHT, she said when patients went to the bathroom in the gym during visitation, the MHT would unlock the door and the patients were able to go into the bathrooms by themselves. SF9MHT said sometimes multiple people could go into the bathrooms but it depended on the patients.

In an interview on 3/19/18 at 9:02 a.m. with SF11MHT, she said the MHT's would stay outside of the bathroom door when patients went into the bathrooms during visitation.

In an interview on 3/19/18 at 9:00 a.m. with SF10MHT, she said when a patient went into the restroom during visitation, the staff stayed outside of the bathroom door and did not go into the bathroom with the patients.

In an interview on 3/19/18 at 9:30 a.m. with SF2DON, she said she would expect that a staff member go inside the door while a patient was in the restroom of the gym during visitation. She verified there were ligature risks in the bathrooms.

Based on record review, observation, and interview, the hospital failed to meet the requirements of the Condition of Participation for Nursing Services as evidenced by:
1) failure of the RN to ensure a patient admitted with thoughts of self-harm, who subsequently attempted suicide, had been observed at the ordered level of observation (Level II- Line of Sight) for 2 (#F12 and #F13) of 2 sampled patients reviewed for suicide attempts made in the hospital (See findings tag A-0395); and

2) failure of the RN to obtain patient admission orders from a licensed independent practitioner for 1 (#FR18) of 1 patient sampled for the admission process (see findings tag A-0395).

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Based on record reviews, observations, and interviews, the hospital failed to ensure the RN supervised and evaluated the nursing care of each patient. This deficient practice was evidenced by:
1) failure of the RN to ensure a patient admitted with thoughts of self-harm, who subsequently attempted suicide, had been observed at the ordered level of observation (Level II- Line of Sight) for 2 (#F12 and #F13) of 2 sampled patients reviewed for suicide attempts made in the hospital from a total patient sample of 13 (#F1-#F13); and

2) failure of the RN to obtain patient admission orders from a licensed independent practitioner for 1 (#FR18) of 1 patient sampled for the admission process; and

3) failure of the RN to ensure sliding scale insulin had been administered as ordered for 2(#FR4, #FR9) of 4 patients (#F5, #FR2, #FR4, #FR9) sampled with sliding scale insulin; and

4) failure to obtain a medical consult for a patient (#F2) with self-inflicted skin impairments/cuts to her hands for 1 of 1 patients reviewed for medical consults out of a total patient sample of 13 (#F1-#F13); and

5) failure to ensure elopement risk assessments and suicide risk assessments were accurately completed for 3 (#F5, #F7, #F11) of 13 (#F1-#F13) sampled patient records reviewed for elopement/suicide risk assessments; and

6) failure to ensure an effective system was in place to assure patient clothing items were not mistakenly given to other patients for 1 (#F2) of 1 patients reviewed for missing clothing out of a total patient sample of 13 (#F1-#F13).

Findings:

1) Failure of the RN to ensure patients admitted with thoughts of self-harm, who subsequently attempted suicide, had been observed at the ordered level of observation (Level II- Line of Sight).

Patient #F12
Review of Patient #F12's medical record revealed an admission date of 2/15/18 with an admission diagnosis of Acute Stress Disorder and Grief. The patient's legal status was PEC. Further review revealed the patient had arrived at an area emergency department with his 7 year old son who had been hit by a vehicle. The son died from cardiac arrest. Patient #F12 became acutely psychotic and began harming himself by banging his head against the wall. Patient #F12 indicated he wanted to die.

Review of Patient #F12's admission orders, dated 2/15/18, revealed the patient had orders for Level II observations (Line of Sight) and elopement/suicide precautions. Further review revealed the reason for hospitalization was documented as potential danger to self/others and legally mandated admission (PEC). Additional review of Patient#F12's physician's orders revealed an order dated 2/15/18 to place Patient #F12 on 1:1 observation for suicide attempt.

Review of Patient #F12's Suicide Risk Assessment, completed on admission on 2/15/18 revealed a score of 42- High Risk (a score of 42-58 is considered high risk).

Review of the hospital's self- reports to LDH-HSS for alleged abuse/neglect revealed Patient #F12 had attempted suicide, by strangulation, in the hospital on 2/15/18. Further review of the incident report revealed the following statement, in part, by SF25SW: SW witnessed SF24Activities and SF13ADON enter Patient #F12's room. SF24Activities soon screamed SW name due to emergent need. SW arrived to find Patient #F12 wrapped in sheet and blanket wrapped around his neck and body. He appeared to be losing consciousness. We urgently removed the blanket and sheet from his body. He would regain consciousness at this time after almost successfully committing suicide. Patient continued to be in shock, verbalizing thoughts of wanting to die. Additional review revealed the outcome section of the report indicated the allegation that the hospital was neglectful in the care of Patient #F12 was substantiated. SF26RN walked out of the patient's room to get paperwork and left the patient unattended. SF26RN was counseled verbally regarding ensuring patients are assessed and given a proper observation level assignment before they are allowed to go into their room unattended.

Review of an Interdisciplinary Note dated 2/15/18 at 4:00 p.m. revealed the following: SF24Activities, SF13ADON, and SF25SW found Patient #F12 trying to strangle himself. Patient #F12 came to the unit in shock, crying uncontrollably due to the death of his only child. Patient #F12 has been placed on a 1:1 for direct supervision as he is high risk. Incident report completed accordingly.

In an interview on 3/20/18 at 2:04 p.m. with SF13ADON, she reported Patient #F12 had been distraught when he came onto the unit. SF13ADON and SF24Activities had found the patient with the sheet around his neck. SF13ADON reported the patient had wrapped a sheet around his neck and was forcing his way up the cabinet, against the wall, tightening the sheet. SF13ADON confirmed Patient #F12 was on Level II, which was line of sight at that point. SF13ADON indicated this incident occurred right when the patient had arrived on the unit, approximately 15 minutes after arrival. SF13ADON said she was not sure why he was left alone in the room.

In an interview on 3/20/18 at 2:41 p.m. with SF26RN, she indicated she was told they were getting an admit and he was high profile. SF26RN indicated she had been told the patient's son had just been killed. SF26RN reported the patient arrived on unit with shoes having shoestrings in them. She said the patient had been hurried to the back by intake. SF26RN reported she had been told the patient was very upset and suicidal and had been banging his head on the wall at the hospital emergency department. SF26RN said the patient sat on the floor, sobbing inconsolably. SF26RN indicated she had brought him to the room behind the nurses' station for privacy and proximity to the nurses' station. SF26RN reported the patient was covered up with a sheet and she had gone in and out of the room, removing his shoestrings, and getting paperwork. SF26RN indicated SF13ADON and SF24Activities came to the unit to check on Patient #F12 and she told them to go to talk to the patient. She said when they entered the room they found the patient with a sheet wrapped around his neck. SF26RN reviewed the chart and verified the patient was on Level II (line of sight) observations. SF26RN indicated the LPN had written the admit orders.

In an interview on 3/21/18 at 10:51 a.m. with SF27LPN, she indicated she was working on the day of Patient #F12's admit and the day after. SF27LPN said she had signed off on his observations sheet. She said he was in the dayroom, then went into his room, then went into the quiet room when he first came in. She said SF26RN was in the room with him and he was sitting against the wall, hugging his knees and crying. SF27LPN reported SF26RN wasn't out of the room 5 minutes before she found him, but in that 5 minute period the patient was not within direct line of sight of any of the staff.

Patient #F13
Review of Review of Patient #F13's medical record revealed an admission date of 5/22/17 at 5:30 p.m. and a discharge date of 6/3/17 at 10:55 a.m. Further review revealed the patient had been admitted on a PEC for being a danger to self and unable to seek voluntary admission. Additional review revealed the patient's diagnoses were Depression with Suicidal Ideation, Anxiety, and Gender Dysmorphia.

Review of Patient #F13's initial inquiry information, completed by the hospital's intake department staff revealed in part: Presenting problem: Suicidal Ideation with plan to shoot himself in the head. Patient got to work and security found him in the parking lot with a gun to his head and called a Code Silver. Patient having marital problems and increased depression. Patient has had 2 prior suicide attempts and self-harming behavior (cutting as a teen).

Review of the hospital's self- reports to LDH-HSS for potential abuse/neglect revealed Patient #F13 had attempted suicide, by hanging, in the hospital on 5/24/18.

Review of Patient #F13's admit orders, dated 5/22/17 at 5:30 p.m., revealed the patient's admitting diagnosis was depression with suicide attempt, potential danger to self and others, legally mandated admission. Further review revealed the patient's immediate ordered goals were to stabilize the patient and prevent self-harm. Additional review revealed the patient's ordered observation level was Level II (at the time of the incident, the hospital's Level II observation was defined as the patient was to be kept within staff line of sight at all times). Patient #F13 was also on ordered suicide precautions.

Review of Patient #F13's admission Suicide Risk Assessment revealed a score of 46 which fell into the high risk range for suicide (High Risk Score: 42-58).

Review of Patient #F13's daily nursing notes revealed the following entry: 5/24/17 at 11:30 a.m. Patient attempted hanging. Patient placed 1:1- Level III. Physician informed, will continue to monitor.

In an interview on 3/21/18 at 10:23 a.m. with SF4QA, she confirmed Patient #F13 had attempted to commit suicide in his room, by hanging, with 2 gowns, tied together by the strings, that had been anchored under a cabinet with a crayon. SF4QA further reported the patent had then draped the anchored gowns over the bed, had sat on the floor, and had tied the gowns around his neck. SF4QA confirmed Patient #F13 had been on ordered Level II Observation which was line of sight at the time of the attempted hanging. SF4QA further confirmed Patient #F13 had not been observed line of sight, as ordered, by the assigned MHT at the time the patient attempted suicide. SF4QA reported the MHT had observed the patient on every 15 minute rounds and had checked on Patient #F13 last. SF4QA confirmed the MHT assigned to observe the patient had been counseled on her failure to observe the patient in her line of sight, as ordered. SF4QA stated it was the hospital's responsibility to ensure proper precautions were in place and observations were performed as ordered because the patients are there to be kept safe.

2) Failure of the RN to obtain patient admission orders from a licensed independent practitioner.

Review of Patient #FR18's PEC revealed it had been written on 3/20/18 at 4:42 p.m. and listed the patient as being a danger to himself and suicidal. He was admitted to the hospital on 3/21/18 at 5:15 a.m.

Review of Patient #FR18's Admit Orders revealed it was a pre-printed sheet with boxes next to various orders that could be "checked" to indicate it was ordered. Further review revealed he had orders selected for TSH, RPR, Free T4, Lipid Panel and Hemoglobin A1C. Level 1 observation level was selected as well as withdrawal precautions, suicide precautions, and a regular diet. Also daily group milieu therapies, Individual Therapy, Vital signs BID before medications and visiting privileges were selected. The order was written by SF34RN at 5:15 a.m. on 3/21/18 as a verbal/telephone order read back and verified from SF35MD.

In an interview on 3/21/18 at 9:46 a.m. with SF12LPN, she said the RN filled out the patient's admit orders and would assign an observation level, precautions, and labs. She said the RN's would call the doctor to continue medications, but not to get all of the admission orders. She said the intake staff member would call the doctor and ask if they would admit the patient, but did not get all admission orders from the doctor. She verified the admission orders did not have protocols for selection of orders.

In an interview on 3/21/18 at 10:00 a.m. with SF33NP, he said he was on call for psychiatry on the night of 3/20/18 and morning of 3/21/18. SF33NP said he had been called at 1:24 a.m. this morning and gave a verbal order to admit Patient #FR18 to Unit B. He said he was not called back at 5:15 a.m. for orders and SF35MD was not on call this morning and would not have been called for orders. He said he did not give a verbal order for observation levels, precautions, diet or consultations/assessments. He also said there were no standing orders or protocols for these particular orders. He said the RN would fill out these orders based on the discharge paperwork from the sending hospital or based on what they normally order. SF33NP agreed it was not within the scope of practice of a RN to write physician's admission orders.

In an interview on 3/21/18 at 11:00 a.m. with SF27LPN, she said when she was admitting patients she would select the observation levels, the labs, the precautions, diets, consultations, and assessments on the physician's order sheet. SF27LPN said none of the nursing staff calls the doctors for orders, they just actually signed a verbal order for whomever is on call for the unit. SF27LPN said the doctor would come in later in the morning or the next day and sign the verbal order but did not actually give all of the orders. SF27LPN said she had expressed concerns with SF2DON and SF1Adm about nurses writing orders, but nothing had changed.

In an interview on 3/21/18 at 11:45 a.m. with SF34RN, he said he worked the night of 3/20/18 and the morning of 3/21/18 at the hospital and had done the admission for Patient #FR18. He said the staff routinely completed the physician's order sheet by looking at the discharge paperwork of the transferring hospital and ordering other things they typically ordered on patients. SF34RN said he wrote the attending physician's name as who gave the order even if the practitioner gave the order. SF34RN verified he did not talk to SF33NP or SF35MD to obtain Patient #FR18's physician's admission orders but did write that it was a "Verbal/Telephone order read back and verified" by SF35MD. He said it was a "professional relaxation". SF34RN said the RN writing admission orders without speaking to the MD was the routine process everybody used to his knowledge. SF 34RN also verified it was not within his scope of practice to write physician's orders.

3) Failure of the RN to ensure sliding scale insulin had been administered as ordered.

Patient #FR4
Review of Patient #FR4's medical record revealed he had been admitted on 3/14/18 with diagnosis which included diabetes mellitus.

Review of Patient #FR4's medical record revealed an order dated 3/15/18 at 12:15 p.m. for blood glucoses twice a day with sliding scale insulin.

Review of Patient #FR4's Sliding Scale Insulin Medication Administration Record revealed a blood glucose recorded of 183 on 3/17/18 at 8:00 p.m. Review of the sliding scale insulin order revealed 2 units of regular insulin should have been administered but was not documented on the Medication Administration Record.

Patient #FR9
Review of Patient #FR9's medical record revealed she had been admitted on 3/15/18 with diagnosis which included diabetes mellitus.

Review of Patient #FR9's medical record revealed an order dated 3/15/18 at 10:45 a.m. for blood glucoses before meals and at bedtime with sliding scale insulin.

Review of Patient #FR9's Sliding Scale Insulin Medication Administration Record revealed a blood glucose recorded of 169 on 3/16/18 at 8:00 p.m. Review of the sliding scale insulin order revealed 2 units of regular insulin should have been given but was not documented on the Medication Administration Record.

In an interview on 3/19/18 at 3:19 p.m. with SF2DON, she verified the above mentioned insulins should have been administered as per sliding scale.

4) Failure to obtain a medical consult for a patient (#F2) with self-inflicted skin impairments/cuts to her hands.

Review of Patient #F2's medical record revealed an admission date of 2/13/18 and a discharge date of 2/18/18 with admission diagnoses of Major Depression and Anxiety.

Review of a grievance letter (dated 3/1/18) sent by Patient #F2, revealed a self-report that the patient had cuts on her hands from using nail clippers. Further review revealed the patient had been told by a nurse on the unit that she needed to be seen by a physician because she needed medical attention for her hands. Patient #F2 reported she had not been seen by a physician for her hands during her stay at the hospital (the patient was admitted on 2/13/18 and discharged on 2/19/18).

Review of Patient #F2's Admission Skin Assessment, dated 2/13/18 at 2:30 p.m., revealed in part: Redness and flaking skin on left hand where she picks at it with nail clippers.

Review of Patient #F2's entire medical record, including all physician orders, revealed no documented evidence that a medical consult had been ordered for evaluation and treatment of Patient #F2's hands.

In an interview on 3/21/18 at 2:00 p.m. with SF4QA, she confirmed there had been no medical consult obtained for evaluation and treatment of Patient #F2's hands after review of Patient #F2's entire medical record.


5) Failure to ensure elopement risk assessments and suicide risk assessment were accurately completed.

Patient #F5
Review of Patient #F5's Suicide Risk Assessment dated 3/17/18 at 4:00 a.m. revealed a score of 24 was written which qualified as a low risk (score 17-24). When the numbers were added by the surveyor, they actually totaled 25 which would have qualified as a medium risk (score 25-41). Further review revealed notifications should have been made to the practitioner or the nurse supervisor if a medium, high or severe risk.

In an interview on 3/19/18 at 2:30 p.m. with SF4QA, she verified the score was actually 25 instead of 24 on Patient #F5's Suicide Risk Assessment and the physician or nurse practitioner should have been notified.

Patient #F7
Review of Patient #F7's Suicide Risk Assessment revealed 2/20/18 at 12:22 a.m. revealed he had a score of 34 which assigned him as a medium risk. Further review revealed the section below the score titled Notifications/Actions if Medium, High or Severe risk was blank.

In an interview on 3/19/18 at 2:33 p.m. with SF4QA, said the RN should have notified SF2DON and should have notified the physician with a medium suicide risk assessment. SF4QA also said the notification should have been documented on the suicide risk assessment.

Patient #F11
Review of Patient #F11's medical record revealed the patient was admitted to the locked psychiatric unit (Unit B) on 3/6/18 at 11:40 a.m. with admission diagnoses of major depressive disorder, and opioid (Heroin) abuse. Further review revealed Patient #F11 had eloped from the hospital during a smoke break on 3/7/18 at 3:15 p.m.

Review of Patient #F11's Elopement Risk Assessment, dated 3/6/18 at 1:30 p.m., revealed the patient had been scored as low risk for elopement (score of 0-7). Further review revealed the patient had been assessed as a "No" which was a score of "0" on the section of the tool indicating whether the patient had a pertinent diagnosis (examples given: Dementia and Substance Abuse Disorder) that may increase their risk of elopement. Patient #F11 should have been scored as a Yes, which was a score of "3" because he was admitted for detox and had a substance abuse history. Additional review revealed a section asking if the patient had a history of elopement or escape and that section was assessed as a "No" which was a score of "0".

In an interview on 3/18/18 at 3:45 p.m. with SF4QA, she confirmed Patient #F11 had eloped from the hospital (from Unit B) on 3/7/18. SF4QA also confirmed Patient #F11's Elopement Risk Assessment had been scored wrong because they had not scored the patient as a "3" for a history of substance abuse/being admitted for detox. SF4QA reported Patient #F11 had also had a history of elopement in the past, but the patient had not informed them of that at the time the assessment had been performed. SF4QA indicated she had also identified issues with inaccurately scored Elopement Risk Assessments on other patients.

Review of Patient #F11's Suicide Risk Assessment, dated 3/6/18, revealed the patient had been scored as a "0" on the section of the suicide risk assessment tool that indicated whether or not a patient had an issue with substance abuse. The patient was also scored as a "0" for Depression/Agitation and a "0" for Hopelessness, despite having been assessed as having current depressive/affective symptoms as follows: Sad, depressed mood/Hopelessness; Low self-esteem/worthlessness; Fatigue, low energy; Excessive guilt/ feeling guilty for drug use; Loss of pleasure/ interest in activities; Depression/agitation affect; and Anxiety and restlessness. The patient had been scored as a "0" which fell into the very low risk category for suicide (score of 0-16).

In an interview on 3/19/18 at 10:30 a.m. with SF4QA, she confirmed SF11's Suicide Risk Assessment had been scored incorrectly.

6) Failure to ensure an effective system was in place to assure patient clothing items were not mistakenly given to other patients

Review of Patient #F2's medical record revealed an admission date of 2/13/18 and a discharge date of 2/18/18.

Review of a grievance letter (dated 3/1/18) sent by Patient #F2, revealed the patient reported she had brought a special shirt when she had been admitted that had been bought for her by her deceased mother on their last shopping trip. Patient #F2 further reported she had seen another patient wearing the shirt in the dining room. Patient #F2 indicated she knew it was her shirt because of the wear on the shirt. She said the patient asked her what her name was and reported she knew her name because that was the name on the bag she had been given to choose clothing from.

In an interview on 3/21/18 at 10:51 a.m. with SF27LPN, she indicated the patients are allowed 3 changes of clothing. SF27LPN said the process regarding patient clothing is never straight and more than once clothing went to the wrong person. SF27LPN reported someone even went home with another patient's clothing who had the same name as the discharged patient. She said Units A and C use the same laundry room and that contributes to the confusion regarding patient clothing.

In an interview on 3/21/18 at 3:00 p.m. with SF4QA, she reported she remembered there was an incident involving a patient's shirt being worn by another patient. She confirmed, at times, that patient clothing may get brought to the wrong patient.

In an interview on 3/22/18 at 10:45 a.m. with SF29RN, she reported sometimes there are issues with patient clothing getting mixed up. She said Units A and C shared the same washer and dryer and laundry area. She reported the process for washing the patient's clothing was to write their first name on the bag and at times their room number. She said when patients have the same first name on 2 units or even on the same unit it causes confusion and patient clothing may end up on the wrong unit and/or with the wrong patient on the same unit.

Based on observation and interview, the hospital failed to ensure paper medical records stored in the medical records department were protected against loss or destruction in the event the sprinkler system was activated.

Findings:

Observation of the medical records department on 3/20/18 at 12:40 p.m. revealed the room had a sprinkler system in the ceiling. Further observation revealed 5 cardboard boxes of paper medical records on top of metal cabinets. The room also contained 63 shelves that were three feet long containing paper medical records that were unprotected from water damage in the event the sprinkler system was activated.

In an interview on 3/20/18 at 12:50 p.m. with SF16HIM, he verified the paper medical records were not scanned into a computer and they were not protected from water damage if the sprinklers were activated. SF16HIM said they were looking into buying coverings for the shelving units.

Based on record review and interview, the hospital failed to ensure drugs and biologicals were controlled and distributed in accordance with applicable standards of practice, consistent with state law. This deficient practice was evidenced by failing to ensure all medication orders (except in emergency situations) were reviewed by a pharmacist before the first dose was dispensed for therapeutic appropriateness, duplication of a medication regimen, appropriateness of the drug and route, appropriateness of the dose and frequency, possible medication interactions, patient allergies and sensitivities, variations in criteria for use, and other contraindications for 1 (#FR11) of 1 patient reviewed for medications withdrawn from the automated dispensing machine before being reviewed by a pharmacist.

Findings:

Review of the Louisiana Administrative Code, Professional and Occupational Standards,
Title 46: LIII, Pharmacist, Chapter 15, Hospital Pharmacy, §1511. Revealed in part:
Prescription Drug Orders
A. The pharmacist shall review the practitioner's medical order prior to dispensing the initial
dose of medication, except in cases of emergency.

In an interview on 3/20/18 at 9:00 a.m. with SF30Pharmacy, he said the onsite pharmacy hours were from 7:30 a.m. until 3:00 p.m. Monday through Friday and 9:00 a.m. until 2:00 p.m. on Saturday and Sunday. He said if an order was written after hours and the medication was administered by the nurse, the medication was reviewed retrospectively the next morning by the pharmacist. SF30Pharmacy said if a physician wrote an order late at night, the nurse would review the order against the physician's order and give the medication without first having the pharmacist review for appropriateness.

Review of an Override Report dated 3/19/18 12:00 a.m. to 3/19/18 at 11:59 p.m. revealed SF31LPN had given Patient #FR11 Neurontin 100 mg cap at 8:00 p.m., Bentyl 10 mg cap at 9:33 p.m., Phenergan 25 mg tab at 9:33 p.m. and Motrin 800 mg tab at 9:33 p.m.

In an interview on 3/20/18 at 9:50 a.m. with SF26RN, she said SF31LPN had overridden the Med Dispense machine (automated medication dispensing machine) the night before and gave the medications to Patient #FR11. SF26RN said because the patient came in at the end of the day shift so the pharmacist did not review the medications. SF26RN said they do not wait for the pharmacist to review the medications before they are given to the patients.

In an interview on 3/21/18 at 10:00 a.m. with SF32LPN, she said the nursing staff did not have to wait for the pharmacist to review new medications before they gave the medications to the patients.

Based on policy review, medication variance review, and interview, the hospital failed to ensure drug administration errors were documented in the patient's medical records for 2 (#FR6, #FR7) of 2 patients reviewed for medication variances from a total patient sample of 13 (#F1-#F13) and 21 random sampled patients (#FR1- #FR21).

Findings:

Review of the hospital policy titled,"Medication Errors/Adverse Drug Events", policy number: PHR-127, revealed in part: 1.0 Statement of Purpose: Actual and/or Potential (near miss) adverse events and medication errors will be reported and reviewed by the organization in a timely manner to improve processes and patient outcomes. 2.0 Statement of Policy: 2.1 When an adverse event occurs, a specific procedure will be followed to ensure the safety of the patient and provide accurate documents of the occurrence. 4.0: Procedure: 4.1. When a medication error occurs, five things should occur in this order: ....4.1.2: Notify the physician immediately.....4.1.4: Record the medication error in the progress note and the medication administration record as given in the medical record.

Review of the hospital policy titled,"Medication Variances", policy number: NU 504, revealed in part: D. The licensed personnel who discovers the medication variance shall document the following statement in the patient's clinical record: "Patient was given [name of drug] instead of [name of drug, patient responded by [patient response], physician notified at [time].

Patient #FR6
Review of the hospital provided medication variance reports revealed a medication error involving Patient #FR6. Further review of the report revealed the following summary of events: While administering as needed medications to 2 patients the nurse inadvertently put the medicine cup containing Bentyl 20 milligrams on her left and was about to put a cup containing Tylenol on her right when she realized it was reversed. The patient took the Bentyl before she could verbally intervene. Medication variance type: Incorrect medication.

Review of Patient #FR6's medical record revealed no documented evidence of an account of the medication variance or notification of the physician.

In an interview on 3/21/18 at 3:00 p.m. with SF4QA, she confirmed, after she had reviewed the patient's entire medical record, that there was no documented evidence of an account of the medication variance or notification of the physician documented in Patient #FR6's medical record


Patient #FR7
Review of the hospital provided medication variance reports revealed a medication error involving Patient #FR7. Further review of the report revealed the following summary of events: Requested that a specific patient be brought to the medication room door for Carafate administration prior to breakfast. MHT brought this Patient #FR7 instead and Patient #FR7 responded that her name was the requested patient's name. The nurse administered requested patient's medication to this patient incorrectly and realized this when pulling remainder of the morning medications. Medications administered to Patient #FR7 in error: Multivitamins, Ferrous sulfate, Carafate, Vitamin B12, and Wellbutrin. Nurse reported she had not double checked the patient's identification by checking armband.

Review of Patient #FR7's medical record revealed no documented evidence of an account of the medication variance or notification of the physician.

In an interview on 3/21/18 at 3:00 p.m. with SF4QA, she confirmed, after she had reviewed the patient's entire medical record, that there was no documented evidence of an account of the medication variance or notification of the physician documented in Patient #FR7's medical record.

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

Findings:

Review of hospital policies and procedures, provided by SF4QA as current, revealed no policy and procedure for the provision of safety of staff, and patients during radiological services performed in the hospital.

In an interview 3/21/18 at 1:45 p.m., after review of the one radiology policy provided, SF4QA verified X-rays were taken in the hospital by an imaging contractor. SF4QA confirmed the policies and procedures did not address the safety of hospital staff, patients, or visitors.

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

1) Failure to have an employee appointed that served as director of food and dietetic services who was responsible for the daily managment of the dietary services, and was qualified by experience or training. (See Findings in A-0620)

2) Failure to have a qualified dietitian. (See Findings in A-0621),

3) Failure to ensure administrative and technical personnel were competent in their respective duties. (See Findings in A-0622),

4) Failure to ensure menus met the needs of patients. (See Findings in A-0629), and

5)Failure to ensure a current therapeutic diet manual, approved by the dietitian and medical staff was readily available to all medical, nursing, and food service personnel. (See Findings in A-0631).

Based on record review and interview, the hospital failed to ensure a full-time employee who was responsible for the daily management of the dietary services, and was qualified by experience or training, served as the director of the hospital's food and dietetic services. This deficient practice was evidenced by food and dietary services being overseen by SF14CFO who reported he had no prior experience or training in the direction of food and dietary services.

Findings:

Review of the hospital's organizational chart, presented as current by SF4QA, revealed the the block titled "Dietary" was documented as "open".

In an interview on 3/18/18 at 3:43 p.m. with SF1Adm, he confirmed SF17RD, the hospital's Dietician and Dietary Manager, had resigned, with no notice/warning, on 2/22/18. SF1Adm indicated Dietary Manager duties have been carried out by the kitchen staff in the absence of a Dietary Manager.

In an interview 3/20/18 at 9:45 a.m. SF14CFO reported he was responsible for overseeing the kitchen and dietary services. SF14CFO reported the hospital did not have any other supervisor of Dietary Services. He indicated he did not have any prior experience or education in Dietary and Food Services.

A request for any documentation of attempt(s) to fill a vacancy for a Dietician and/or Dietary Manager was made 3/20/18 at 9:45 a.m. No documentation related to an attempt to fill an opening was provided by the survey exit 2/22/18 at 7:30 p.m.



30984

Based on record review and interview, the hospital failed to ensure a qualified dietician was available to supervise the nutritional aspects of patient care. This deficient practice was evidenced by failure of the hospital to have a qualified dietitian.

Findings:

Review of the hospital's organizational chart, presented as current by SF4QA, revealed the the block titled "Dietary" was documented as "open".

Review of a resignation letter from SF17RD, the hospital's former dietician, revealed she had resigned as Dietary Manager/Registered Dietitian effective 2/21/18.

In an interview on 3/18/18 at 3:43 p.m. with SF1Adm, he confirmed SF17RD, the hospital's Dietician and Dietary Manager, had resigned, with no notice/warning, on 2/22/18.

In an interview 3/19/18 at 10:30 a.m. SF8Cook reported that the hospital did not have a dietician.

In an interview 3/20/18 at 9:45 a.m. SF14CFO reported that the hospital did not currently have a dietician.

A request for any documentation of attempt(s) to fill a vacancy for a Dietician and/or Dietary Manager was made 3/20/18 at 9:45 a.m. No documentation related to an attempt to fill an opening was provided by the survey exit 2/22/18 at 7:30 p.m.



30984

Based on record review and interview, the hospital failed to ensure administrative and technical personnel were competent in their duties . This was evidenced by no documentation of training or competencies for 3 of 3 (SF6Cook, SF8Cook, SF15Cook) kitchen staff, and 1 of 1 (SF14CFO) Dietary Administrator.

Findings:

Review of the personnel files for SF6Cook and SF15Cook revealed no documentation of training or compentencies related to their duties in the kitchen and dietary services.

No personnel file was provided for SF8Cook.

In an interview 3/22/18 at 4:45 p.m. SF4QA reported that SF8Cook was a contract employee and the hospital had no personnel file on him. SF4QA indicated the hospital had no documentation of information required in a personnel file related to training, experience, competencies, or Employee Health.

Review of the personnel file for SF14CFO revealed no training, experience, or documented competencies related to managment of the hospital's dietary services, a responsibility he confirmed he had assumed.

In an interview 3/20/18 at 9:45 a.m. SF14CFO confirmed he was responsible for the management of the hospital's Food and Dietary Services. SF14CFO reported he had no former experience or training in Food and Dietary Services .

Based on record review, observation and interview, the hospital failed to ensure individual patient nutritional needs were met in accordance with recognized dietary practices. This deficient practice was evidenced by patients not receiving ordered diabetic diets for 5 (#FR2, #F5, #FR4, #FR5, #FR3) of 5 patients with ordered special diets.

Findings:

Review of hospital policy # NU 416 titled "Diet Orders", (last revision date 5/21/17) provided by SF4QA as current, revealed it was the policy of Covington Behavioral Health that each patient would receive a diet as ordered by their physiican. It stated it was the dual responsibility of the nursing staff and the dietary staff to see that the patients receive their proper diets. The purpose of the policy was documented as, "To ensure that all patients receive their proper diet as ordered by their physician." The procedure steps were documented, in part, as ...2) each pateint coming into the hospital must have a written order for a diet by his/her physician. 3) If a patient is on a modified diet or in the case of a diet change, the nusing personnel receiving the physician's order will complete a Diet Order Requisition for a modified diet or diet change; the senior dietary person will complete a "special diet card' for this patient. This cared will then be placed in an index type file and kept on the cafeteria line during serving ttimes...

Observation on 3/18/18 beginning at 4:45 p.m. revealed all three units (A, B and C) came into the cafeteria for dinner. Further observation revealed all five patients with ADA diets were served the same meals as the other patients which was baked chicken, carrots, rice, a roll and a fruit cup with pineapple rings and a cherry.

Review of documents containing patient information from Units A, B and C revealed 4 patients were ordered to have an 1800 calorie ADA diets (Unit A- Patient #FR2, Unit B- Patient #F5 and Patient #FR4, Unit C - Patient #FR5 and 1 patient with a 2000 calorie ADA diet (Unit A- Patient #FR3).

In an interview on 3/18/18 at 4:50 p.m. with SF7MHT, she said she did not have any patients from unit B on a special diet (had Patient # #F5 and Patient #FR4 were both on an 1800 calorie ADA diet).

In an interview on 3/18/18 at 5:05 p.m. with SF12LPN, she said she did not have any patients from unit C on special diets (Patient #FR5 was on an1800 calorie ADA diet).

In an interview on 3/18/18 at 5:15 p.m. with SF5MHT, she said she did have 2 patients from unit A with ADA diets, Patient #FR3 on a 2000 calorie ADA diet and Patient #FR2 on an 1800 calorie ADA diet. When asked if they had gotten a different meal than any of the other patients, she replied, "No."

In an interview on 3/18/18 at 2:56 p.m. with SF6Cook, she said she made out the diets for the patients but she was not a dietician.

In an interview on 3/18/18 at 5:10 p.m. with SF6Cook, she said she had 5 patients' currently on diabetic diets and knew their names because they were written on a dry erase board in the kitchen. When asked, she could not point out the diabetic patients on special diets in the cafeteria because she did not know their names. SF6Cook said everybody today got the same meal. She said she just put the plates on top of the counter and the patients picked them up. When asked if it was a diabetic diet she said, "No."

In an interview 3/21/18 at 8:52 a.m. SF12LPN reported: "Special diets: tricky question: We don't have special diets, even though the patient's need them." We would send consults for Diabetic or Hypertensive patients, Pescatarian(vegetarian with fish ), vegetarian. The patient would get the consult, but I never saw any variance in the
food."


In an interview 3/20/18 at 3:15 p.m. SF19MHT reported MHTs take the written order of the patient's diet to the kitchen staff, nurses are supposed to fax it to kitchen.
If the kitchen doesn't know or remember to give the patient an ordered supplement, then we wouldn't know the patient didn't get it, we would have no way to know if they were supposed to get anything extra. We (the MHT's, who accompany the patients to the cafeteria) document the percentage of the meal eaten on the patient's observation sheets, but not anything about the type of diet. Patient get snacks at 9:30 a.m. and around 7:30 p.m. . Snacks do not get documented. We have snacks in the breakrooms, we put a variety of snacks, out for the patients. Patient's occasionally bring protein snacks from home, they are kept behind the nurses' station, and would be given by the nurses.

In an interview on 3/19/18 at 1:00 p.m. with SF4QA, she verified the hospital had no system in place to ensure patients on special diets received their meals.

In an interview on 3/21/18 with SF27LPN, she said diabetics did not get a diabetic diet in the cafeteria of the hospital. SF27LPN said she had three diabetic patients recently and they were complaining that their diets were not diabetic.


30364

Based on interviews the hospital failed to ensure a current therapeutic diet manual, approved by the dietitian and medical staff was readily available to all medical, nursing, and food service personnel. This deficient practice was evidenced by the failure to produce a therapeutic dietary manual and interviews confirming the hospital did not current have a dietary manual.

Findings:

In an interview 3/19/18 at 10:30 a.m. SF8Cook reported that the hospital did not have a dietary manual as far as he knew.

In an interview 3/20/18 at 9:45 a.m. SF14CFO indicated he was reponsible for the supervision of the kitchen and dietary services . He reported that the hospital did not have a therapeutic dietary manual.

Based on record review, observation and interview, the hospital failed to ensure the infection control officer developed and implemented a system for controlling infections and communicable diseases of patients and personnel. This deficient practice was evidenced by the following infection control breeches:
1) Failure to ensure food temperatures were measured (after preparation and prior to serving patients) and logged, failed to ensure refrigerator/freezer temperatures measured and logged, and failed to ensure chemicals used in the 3 compartment sink for sanitizing dishes were monitored and logged;
2) Failure to maintain a clean environment in the kitchen and dietary services;
3) Hand hygiene breeches and safe handling of laundry to prevent contamination;
4) Failure to maintain a clean and sanitary environment in patient care areas;
5) Failure to ensure staff not currently vaccinated against Influenza followed hospital policy by not correctly wearing a mask around patients.
Findings:

1) Failure to ensure food temperatures were measured (after preparation and prior to serving patients) and logged, failed to ensure refrigerator/freezer temperatures measured and logged, and failed to ensure chemicals used in the 3 compartment sink for sanitizing dishes were monitored and logged.

On 3/18/18 at 2:40 p.m. a review was conducted of the Refrigerator logs used for documenting temperatures for the walk-in freezer, walk-in cooler, cook's refrigerator, and cafeteria cooler. The only log produced for the surveyors by SF8Cook was for March 2018. Review of the log revealed entries had only been documented for the a.m. and p.m. shifts of March 13-March 17. SF8Cook reported there were no other logs available. He said the kitchen staff had no access to print new forms since the Dietician/Dietary Manager had resigned, so no logs had been documented.

On 3/18/18 at 2:41 p.m. a review was conducted of the 3 Compartment Sink Sanitation Record used for documenting the measure of the sanitizing chemical, in parts per million, per chemical strip, when dishes were washed. The only log produced for the surveyors by SF8Cook was for March 2018. Review of the log revealed entries had only been documented for the breakfast, lunch and dinner meal services for March 13-March 15. SF8Cook reported there were no other logs available. He said the kitchen staff had no access to print new forms since the Dietician/Dietary Manager had resigned, so no logs had been documented.

On 3/18/18 at 2:42 p.m. a request was made for the food temperature monitoring logs for review. SF8Cook could not produce any food temparture monitoring logs for surveyor review.


2) Failure to maintain a clean environment in the kitchen and dietary services.

An observation 3/20/18 from 10:30 a.m. to 11: 05 a.m.of the kitchen and dietary department revealed the following:
Dirty towels on condiment shelf with condiments, rolling carts reported to transport food items with dried light brown liquids on the bottom shelf soiled areas; the wheels and attachment mechanisms were noted to be encrusted with rust. Several walls were observed to have splatter and liquid run marks, oven racks with caked dark residue, a large shaker container of granulated seasoning with whitish residue on the sides of the container, open plastic tub like container on open shelf under 3 compartment sink with multiple soiled rags used stainless steel pads, long handles scrub brush reported by SF8Cook to be used to clean bottom racks. Large commercial mixer stand with spashes of yellow dried substance with the same substance on walls by the mixer stand. A storage drawer containing cooking utensils was observed to have an orange oily substance and fine debris in it. Dark grease-like build up was noted on stove, on, and around the control knobs. An observation of the walk in refrigerator revealed shredded lettuce dated 3/13/18, an apple core sitting by itself, a banana peel top, a package of slice turkey breast expired, with a yellow, thick, substance in a drip pattern on the outer package. A 1 gallon container of Sweet pickle relish, ½ full, with and date of 11/14/17 on it. On the outside of the walk-in refrigerator was observed to be blue tape covering an indented circle. SF8Cook indicated he didn't know why the tape was there or what it was covering up. SF3ICO agreed that the area with tape could not be cleaned and disinfected. An observation of the eye wash station revealed a greenish brown substance in the bowl, identified as mold by SF3ICO, also present for the kitchen observations. Observation of the serving area revealed a serving counter with built in steam trays with brownish- orange thick liquid in the water in the steam trays. The portion of the serving counter with a shelf and glass covering (not currently used for a salad bar) was noted to have rust spots on it. During this observation lunch was beginning to be served. SF8Cook was observed to put on disposable glove after performing hand hygiene, then pull up his pants and start serving without removing gloves, performing hand hygiene and donning fresh gloves. SF3ICO confirmed all observations noted and confirmed SF8Cook did not perform hand hygiene and change his gloves after touching his clothes and before beginning to serve food. SF3ICO also confirmed there was no sink or waterless hand sanitizer in the food serving area for which kitchen staff to perform hand hygiene while serving food, without returning to the kitchen area. She verified hand hygiene capabilities should be available to personnel working or serving in the serving area.


3) Hand hygiene breeches and safe handling of laundry to prevent contamination.

Review of hospital policy # IC-011 titled Handling of Wastes, Sharps and Linens, provided by SF3ICO as current revealed, in part sharps containers must be changed when 3/4 full, and never allowed to overfill. Further review revealed, under the heading of "Linen", that linen was to be placed in a BLUE biohazard linen bag, and were to be tied or secured before being placed ithe department-designated area. Standard Precautions were to be followed soiled or contaminated linen.

In an observation 3/22/18 at 10:55 a.m. revealed a group of dirty linens rolled up sitting on a ledge of the nurse's station on Unit B. When asked about the used-looking linens, SSF39RN picked them up with her bare hands and removed them from the area, stating, "They must be a patient's from their shower." SF3ICO, present for the observation verified the nurse should have performed hand hygiene and donned gloves before moving the gloves.

In an observation 3/20/18 at 11:05 a.m. SF8Cook was observed to put on disposable glove after performing hand hygiene, then pull up his pants and start serving meals to patients without removing gloves, performing hand hygiene and donning fresh gloves. SF3ICO confirmed SF8Cook did not perform hand hygiene and change his gloves after touching his clothes and before beginning to serve food.

4) Failure to maintain a clean and sanitary environment in patient care areas.

An observation 3/22/18 at 10:50 a.m., accompanied by SF3ICO , revealed the following: Patient exam room shared by Units B & C revealed a needle an examination table covered in a synthetic "leather-like" material with a tear towards the end of the table (where one would sit) approximately 5 1/2 inches long, and another tear just below that approximately 2 inches long, both with exposed foam padding. SF3ICO confirmed the observation and verified the tears with exposed foam presented an infection control risk and could not be properly disinfected. A portable Oxygen Concentrator was observed to have dop and run lines of a dried white substance and dust on it. SF3ICO verfied the observation and indicated there was no way to determine if and when the filter had last been cleaned. A biohazard sharps box filled with syringes, and gloves was noted to be filled above the "fill to" line. On Unit C, the soiled unility room had a large, open rolling bin approximately 1/3 to 1/2 full of soiled patient linens (bath linens, bed linens, patient gowns) open, unbagged. SF#ICO, present throughout the tour verified that the linens were not contained in a closed bag or container as they should be, and commented, "I don't know why they did that when there are linen bags right here" while pointing to a box of bags next to the large linen container. On Unit C, at the nursing desk was an inverted insulated plate cover which was 3/4 full of individual packets of sugar, coffee creamer, and pink packets of artificial sweetner. Further observation of the inverted lid revealed dried subtances of white, and dark orange in the cover and around the inner ridge of the cover. SF3ICO reported, "This shouldn't be here; I tell them almost everyday they can't keep food here, and they can't have personal food or drinks in here (patient care areas) almost everyday, and I come back and there's more." Observed on the nursing desk revealed a large disposable coffee cup with liquid in it, and a large metal drink holder, covered and with liquuid in it. SF3ICO disposed of the disposable cup of coffee in the trash, and verified with the charge nurse that the metal container of water was hers, then placed it in the staff break room. Further review of an open alcove with a portable blood pressure monitor revealed a bag in the cabinet with food and drink in it. When asked if patient food was kept in the area with a few supplies, SF3ICO reported it was a staff member's food, and she had instructed staff before not to keep their food in patient care areas.


5) Failure to ensure staff not currently vaccinated against Influenza followed hospital policy by not correctly wearing a mask around patients.

Review of hospital policy # IC0021 titled Influenza Vaccination (last revised 12/17), provided by SF3ICO as current, revealed , in part that to help protect staff, non-employees, patients, and families from acquiring seasonal infuenza, a requirement was that all healthcare personnel receive annual influenza vaccination. Further review revealed that upon verification of contridictions, all persons with approved contridictions to vaccination would be required to provide signed written documentation which states that he/she would wear a mask at all times during the scheduled shift.

In an observation 3/19/18 at 8:50 a.m of SF38MHT standing outside on the porch with patients. with a disposable mask over her mouth, but pulled down to just below her nose. SF4QA, present for the observation,verified that wasn't the correct way to wear the mask. She indicated SF38MHT was wearing the mask because she had not received a flu vaccine this season, and hospital policy required all staff having contact with patients and not receiving the flu vaccine to wear a mask while around patients. When SF39MHT returned inside the unit with the patients she was supervising, SF4QA signaled to her to pull her mask up, which she did.

An observation 3/19/18 at 9:05 a.m. revealed SF38MHT interacting with patients, wearing a disposable face mask over her mouth, but below her nose. The SF38MHT pulled her mask up to cover her nose when she saw surveyors. In an interview at that time, SF38MHT confirmed she had not been wearing her mask as she should have. She confirmed she had to wear a mask while around patients because she did not take the flu vaccine. She further confirmed that she had covered her nose when seen earlier by the surveyor because SF4QA had motioned her to pull it up. She confirmed she had again been wearing the mask incorrectly until she noticed the surveyor. SF38MHT acknowledged that wearing a mask over your mouth, but not your nose did not protect the patients from being exposed to the flu, if she had it.

An observation 3/19/18 at 9:10 a.m. in the kitchen revealed SF8Cook wearing a disposable mask around his neck. When asked about why he was wearing a mask around his neck, he reported he had to wear a mask when he was around patients because he hadn't had a flu vaccine this year. He removed his mask. SF4QA, present for the interview confirmed the observation.

An observation 3/22/18 at 10:33 a.m. of staff and patients on Unit B, SF23MHT was not wearing a mask. When asked if she had received a Flu Vaccine, she answered that she had not. She confirmed she was supposed to be wearing a mask. SF3ICO, present during the observation explained that the hospital process for identification of those staff members that had received the Flu Vaccine was to have a small circular sticker with her initials on the staff's identification badge that they are required to wear. She verified that SF34MHT did not have a sticker, and should have worn a mask when around patients. Further review of staff on the units revealed another MHT without a sticker or mask, but she reported the sticker signifying she had received the flu shot had come off. Another LPN had no sticker on her badge, but reported she had received the flu shot, and wasn't aware one was needed. SF3ICO, present during the observations and interviews agreed that the system did not seem to be fully implemented and did not work to ensure employees not receiving the vaccination were accurately identified, and therefore the enforcement of the hospital policy was not working.



30984

Based on record review and interview, the hospital failed to ensure Respiratory Care Services were under the direction of a Doctor of Medicine or Osteopathy on a full time or part time basis as evidenced by failure of the Governing Body to appoint a physician as Director of Respiratory Services.
Findings:

Review of a hospital organizational chart revealed no Respiratory Services listed.

Review of the hospital's provided contract(s) binder revealed no contract for Respiratory Services or a Respiratory Director.

Review of the Governing Body meeting minutes for 2017 and 2018 revealed no discussion or appointment of a Director of Respiratory Services.

In an interview 3/21/18 at 1:45 p.m. SF4QA confirmed the hospital's Governing Board had not appointed a physician as Director of Respiratory Services. She indicated the hospital did not have a doctor appointed to supervise and administer the hospital's respiratory services.

In an interview 3/22/18 at 4:35 p.m. SF2DON verified the hospital did not have a physician appointed as medical director of Respiratory Services.

Based on record review and interview the hospital failed to ensure personnel were qualified to perform specific respiratory care procedures. This deficient practice was evidenced by:
1) failure to provide policies and procedures that included the qualifications, including job title, education, training and experience of personnnel authorized to perform each type of respiratory care service and whether they may perform it without supervision; and

2) failure to provide documentation of current skills/competency evaluations on staff responsible for provision of respiratory care services for 4 of 4 (SF2DON, SF12LPN, SF26RN, SF37RN) nursing personnel records reviewed for current respiratory skills/competency evaluations.

Findings:


1) failure to provide policies and procedures that included the qualifications, including job title, education, training and experience of personnnel authorized to perform each ype of respiratory care service and whether they may perform it without supervision.

Review of hospital policies for Respiratory Services, provided by SF4QA as current, revealed they did not include the qualifications, education, trainng, and experience required of personnel authorized to perform each type of respiratory care service. Review of a policy title Intermittent Aerosol Therapy did not include the above listed required items, or the job ttile of personnel authorized to deliver the therapy.


2) failure to provide documentation of current skills/competency evaluations on staff responsible for provision of respiratory care services for 4 of 4 (SF2DON, SF12LPN, SF26RN, SF37RN) nursing personnel records reviewed for current respiratory skills/competency evaluations.

Review of the personnel records for SF2DON, SF12LPN, SF26RN, and SF37RN revealed no documented competencies in their personnel files. Further review revealed no documentation of any training or education related to respiratory services provided in the hospital.

In an interview on 3/22/18 at 4:35 p.m. SF2DON verified the hospital Respiratory Services policies did not specify which personnel was qualified to provide each respiratory service, including education, training, and whether they could perform it without supervision. SF2DON confirmed the hospital's RNs and LPNs provided respiratory services. She indicated the services provided were reviewed with the Nursing staff on hire, and during orientation, by a nursing supervisior. She verfied that the staff providing Respiratory Services were not trained by someone deemed competent to instruct staff in respiratory services, and the staff did not have documented annual competencies.

Based on policy review, record review and interview, the hospital failed to ensure each patient had a comprehensive treatment plan. This deficient practice is evidenced by failing to include a problem with interventions for patients with diabetes being treated with sliding scale insulin for 2 (#F5, #FR9) of 4 (#F5, #FR2, #FR4, #FR9) patients sampled with diabetes and 1 of 1 (#F3) sampled for Bariatric Dietary needs, out of a total patient sample of 13 (#F1-#F13) and a random patient sample of 21 patients (#FR1- #FR21).

Findings:

Patient #F5
Review of Patient #F5's medical record revealed she had been admitted on 3/17/18 with diagnosis which included diabetes mellitus.

Review of Patient #F5's medical record revealed an order dated 3/17/18 at 2:00 p.m. for blood glucose monitoring before meals and at bedtime with sliding scale insulin and a 2000 calorie ADA (American Diabetes Association) diet.

Review of the treatment plan for Patient #F5 revealed no treatment plan for a special diet or blood glucose monitoring.


Patient #FR9
Review of Patient #FR9's medical record revealed she had been admitted on 3/15/18 with diagnosis which included diabetes mellitus.

Review of Patient #FR9's medical record revealed an order dated 3/15/18 at 10:45 a.m. blood glucose monitoring before meals and at bedtime with sliding scale insulin.

Review of Patient #FR9's Treatment Plan revealed no problem had been identified for diabetes or sliding scale insulin.

In an interview on 3/19/18 at 2:30 p.m. with SF4QA, she verified Patient #F5 and Patient #FR9 did not have diabetes on their treatment plans but should have.

Patient #F3
Review of Patient #F3's medical record revealed she was admitted 11/10/17 with diagnoses that included Hypertension and a history of Bariatric Surgery in 2016. Further review revealed an admission order, signed by SF36Psychiatrist with a Bariatric Diet ordered. Review of the Medication Reconciliation forms, signed by a nurse and Medical Nurse Practitioner, revealed Medical Medications included Medical grade protein -1 scoop q a.m., and Bariatric vitamins 3 tabs q (every) a.m. Review of Patient #F3's Treatment plan revealed blank spaces in the Active Medical Problem List. Further review of the patient's treatment plan revealed no mention of hypertension or her specialized and ordered diet and nutritional needs.

In an interview 3/19/18 at 2:30 p.m. SF4QA verfied Patient #F3's treatment (care) plan did not address her dietary needs and Bariatric diet, but should have.