HospitalInspections.org

Based on observations made during a medication pass, the Hospital failed to ensure that the Patient received intramuscular injections in an environment that provided for the Patient's privacy for one patient (Patient A) out of a total sample of 30 patients and one non-sampled patient. Findings include:

On 4/10/18 at 8:45 A.M., the Surveyor observed Patient A standing at the door where the West Unit Nurse was in the process of administering medications to Patient A. The Nurse was in the process of drawing up insulin injections and telling Patient A what the medication was and the purpose, while another nurse inside the room was translating the information to Patient A in their native language. Patient A pulled down her shirt sleeve and the Nurse gave the injection. In total, the Nurse gave three injections, including an insulin injection. At one point, the Nurse asked Patient A if she/he wanted an injection in his/her abdomen, then looked up and noted the Surveyor standing there and said why don't we just use your arms.

While the injections were being administrated, there was another patient waiting for her/his medications in the hallway, several feet away from Patient A who was receiving the injections, and observing Patient A receiving the injections and able to overhear the conversations. Also observed were several patients and staff who were walking down the hallway at various times during which the injections were administered. At one point, a staff member directed a patient who was waiting to receive medications to move further away to offer Patient A privacy, but the patient moved about 4 feet back and was noted to continue to observe Patient A receiving the injections.

Based on observation, interview and record review, the Hospital failed to ensure that the environment of care for the secured psychiatric unit was reasonably safe. Examples included pillow covers, ceiling tiles and bed rails that presented a safety (ligature) risk for one sampled Patient (#21) in a total sample of 41 patients.

Findings include:

1.) For Patient #21, the Hospital failed to evaluate the ligature risk of the two bed rails attached to the Patient's bed.

The Surveyor observed two 1/2 side rails attached to Patient #21's bed on 4/10/18 at 4:00 P.M. and 4/11/18 at 10:30 A.M. At these times, one of the two bed rails was in a raised position.

There was no evidence in Patient #21's chart of an assessment to determine if the two 1/2 bed side rails posed a ligature risk to the Patient.

Staff evaluated Patient #21 on admission (4/2/18), and determined he/she was a low level for suicide risk.



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2.) The Surveyor toured the North Unit at 8:30 A.M. on 4/9/218 and interviewed the Director of Therapeutics. The doors on both the sensory room and the alternate television room had the conventional hinges on both entrance doors.

The Director of Therapeutics said the Hospital had identified this risk and was in the process of replacing all of the conventional hinges with an upgraded piano style that reduced the ligature risk of hinges. The Director of Therapeutics said the other secured units had been completed but this unit was still in the replacement process.

The Director of Therapeutics said the corridors were under observation by the staff performing checks as well as by camera's located in the public areas of the Unit.

The Surveyor later learned that the camera's were not under constant observation by the Hospital staff.

3.) The Surveyor toured Room 202 at 4:00 P.M. on 4/9/18. In the attached bathroom the ceiling tile was broken and could be easily pushed up to reveal what was above the dropped ceiling.

The Surveyor interviewed the Facilities Director at 9:20 A.M. on 4/11/18. The Facilities Director said that these tiles were designed to be sealed and screwed in place to prevent access to above the dropped ceiling and that this was a condition the the Maintenance and Nursing Departments would check when they made their rounds.

4.) The Surveyor toured Room 202 at 4:00 P.M. on 4/9/18. The Surveyor inspected the plastic pillow covers that are designed to be cleaned between each patient. The covers on the pillows were made of a plastic material that was heavier than a trash bag but more pliable than a plastic table cloth. The pillow covers could easily be separated from the pillow and might pose a suffocation risk if the patient placed the case over thier heads.

5.) During tour of the North unit on 04/11/18, the Surveyors observed pillows in patient areas with two types of coverings. The Director of Environmental Services said that if Hospital staff observed defects in the pillows, the pillows were discarded and new ones were ordered. At 9:40 A.M., the Director of Environmental Services provided the Surveyors with samples of pillows with the two different types of coverings. The Director of Environmental Services said one pillow cover was a thick vinyl-type material, which was incorporated as part of the pillow itself. The Director of Environmental Services said the other pillow cover was a thinner plastic-type material, which was more of a pillowcase as it was not incorporated with the structure of the pillow itself. The Director of Environmental Services said the Hospital was phasing out the pillows with the plastic-type material covering as they were less durable. The Director of Environmental Services said patients were able to more easily rip the plastic-type material and so there was a concern not only with the damage to the pillows themselves, but the potential risk to the patients.

Based on observations and staff interview, the Hospital failed to ensure that it secured the records of its discharged outpatient records in a similar secured manner as its inpatient discharged records, and exposed patients to breaches in confidentiality.

Findings include:

1. The Hospital lacked sufficient safeguards to ensure that access to all information regarding patients in the outpatient was limited to those individuals designated by law, regulation, and policy or duly authorized as having a need to know. The patient records were not kept secure.

2. Observations in the basement of the Hospital at approximately 10:50 A.M. on 4/10/18, indicated that approximately 8 boxes of patients' records were stored on open shelves or on the floor in a large room used for storage by the maintenance, dietary and housekeeping departments. The Surveyor observed that the patient records included names, dates of birth, social security numbers, insurance plan numbers, and other confidential information. Although the storage room was locked, staff from the above departments had access to the room, including unsupervised access to the confidential information contained in the records.

The Administrator said that the out patient records stored in the basement area did not contain clinical information and they were awaiting disposal.

Based on review of medical records and interviews, the Hospital failed to ensure that the Registered Nurse (RN) conducted initial nursing assessments and/or developed the initial plan of care for newly admitted patients from the hospital emergency room for 7 patients (Patient #2, #4, #6, #11, #15, #27, #30), out of a total sample of 41 patients.

Findings include:

Review of the Hospital policy titled, "Assessment/Reassessment and Documentation of Nursing Care" reviewed 1/17/17, section on policy, point 2 indicated, "the registered nurse must co-sign the nursing admission assessment form when completed by a licensed practical nurse. However, review of the policy titled "Licensed Practical Nurse Scope of Practice" indicated that the licensed practical nurse is responsible and accountable for the nursing tasks that are within the defined scope of practice of the Massachusetts Board of Nursing and to ensure compliance with all Joint Commission regulations, revised 11/1/16. Section B indicated, "it will be the policy that licensed practical nurse's scope of practice WILL NOT include: point 8 'Initial admitting assessments and care plans."

The Director of Nursing (DON) was interviewed on 4/11/18 at 9:20 A.M. The Surveyor asked the DON about the two policies and pointed out that the two policy statements were in conflict with each other - that the Licensed Practical Nurse (LPN) scope of practice indicated the LPN could not conduct the initial nursing assessment or develop the care plan, but the nursing assessment policy indicated the LPN could perform the assessment when a RN cosigned the assessment. The DON said that the two policies conflicted each other. The DON said that the Hospital had a position for an admission RN who was assigned to conduct all initial nursing assessments, but they no longer had this position.

1) Review of Patient #30's medical record indicated that he/she was admitted to the Hospital on 3/29/18 at 12:40 P.M. Review of the Patient Safety Assessment tool indicated the LPN conducted the assessment on 3/29/18 at 2:00 P.M. and it was cosigned by the RN on 3/30/18 at 2:50 A.M. The initial care plan, dated 3/29/18, indicated it was developed by the LPN.



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2) Review of Patient #27's medical record indicated that he/she was admitted to the Hospital on 4/06/18. Review of the Patient Safety Assessment tool indicated LPN #3 conducted the assessment on 04/06/18 at 9:00 P.M., and it was cosigned by RN #4 on 4/07/18 at 12:30 A.M.



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3) The Surveyor reviewed Patient #11's Admission Nursing Assessment dated 4/3/18, and it indicated that LPN #3 had completed the assessment and the RN signed the Assessment on 4/4/18.


4) The Surveyor reviewed Patient #15's Admission Nursing Assessment dated 4/7/18 and it indicated that LPN #4 had completed the assessment and the RN signed the Assessment on 4/8/18.




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5) Review of Patient #2's Admission Nursing Assessment, dated 4/3/18, indicated it was completed by LPN #5. Patient #2's Admission Nursing Assessment was cosigned by an RN on 4/3/18.

6) Review of Patient #4's Admission Nursing Assessment, dated 4/7/18, indicated it was completed by LPN #6. Patient #4's Admission Nursing Assessment was cosigned by an RN on 4/8/18.

7) Review of Patient #6's Admission Nursing Assessment, dated 2/20/18, indicated it was completed by LPN #5. Patient #6's Admission Nursing Assessment was cosigned by an RN on 2/20/18.

8.) The Surveyor interviewed RN #3 at 10:30 A.M. on 4/10/18. RN #3 said that when she reviews and signs the Admission Nursing Assessment form she is checking to be certain that the form has been completed and the different areas have been filled out. RN #3 said she is not present for the patient interview but reviews the form prior to her signing it.

Based on record review and staff interviews, the Hospital failed to develop, review, revise and/or implement the care plans for 3 sampled patients (#14, #18, and #21) in a total sample of 41 patients.

Findings include:

1) For Patient #14, the Hospital failed to develop a care plan for the Patient's active medical problem hypertension.

Patient #14 was admitted to the Hospital on 4/2/18, with the following diagnoses: paranoid schizophrenia, post traumatic stress disorder and hypertension.

Review of the physician's admission orders dated 4/2/18, indicated Metoprolol (used to treat high blood pressure) 50 mg. every day. Hold if the systolic blood pressure was less than 90 and the heart rate was less than 60 beats per minute.

Review of the nursing care plans indicated there was no nursing care plan to address the Patient's diagnosis of hypertension or symptoms of high blood pressure.

2) For Patient #18, the Hospital failed to develop a care plan for the Patient's active medical problem of sleep apnea.

Patient #18 was admitted to the Hospital on 4/4/18, with the following diagnoses: paranoia, bipolar disorder, psychosis, polysubstance abuse, auditory hallucinations and sleep apnea.

Review of the physician's admission orders dated 4/4/18, indicated 2 liters of oxygen via nasal cannula while asleep.

Review of the nursing care plans indicated there was no nursing care plan to address the Patient's diagnosis of sleep apnea or provisions to ensure the machine and tubing were planned for cleanliness and that tubing was changed on a regular basis.



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3) For Patient #21, the Hospital failed to develop a care plan for his/her active medical problem of diabetes insipidus.

Patient #21 was admitted to the Hospital on 4/2/18, with the following diagnoses: major depressive disorder, status post dehydration, status post hypernatremia, hypothyroidism, diabetes insipidus, overactive bladder and chronic kidney disease possibly related to long term Lithium use.

Review of the physician's orders dated 4/3/18, indicated that Patient #21 was placed on intake and output monitoring to assess for adequate fluid intake because he/she had an elevated sodium level. The nutrition assessment dated 4/4/18, indicated that Patient #21, "does not want to drink; afraid of incontinence."

Review of the nursing care plans indicated there was no nursing care plan to address Patient #21's diagnosis of diabetes insipidus or its symptoms, or the monitoring of the Patient's fluid intake and output, and sodium levels.

Based on medical record reviews and interview, the Hospital failed to use verbal orders infrequently throughout the patient care units for 6 records reviewed ( #7, #10, #18, #20, #21 and #25) in a total sample of 41. Findings include:

Review of the Hospital policy titled Medication Administration, last revised on 5/11/16, section III, point 1 Orders section c. indicated that, "Verbal orders are not permitted except in emergency situations. Once the emergency has been resolved, the MD will write the orders."

Review of point 1 Orders section b. Telephone Orders indicated that, "Routine telephone orders must be cosigned and dated by the physician within 48 hours or by a covering physician who is responsible for ordering, providing or evaluating the service furnished."


1) Review of Patient 18's medical record indicated that a telephone order was entered on 4/4/18 at 5:35 P.M., but remained unsigned by the physician as of 4/9/18 at 3:31 P.M. An additional order was entered on 4/4/18 at 8:20 P.M., but remained unsigned by the physician as of 4/9/18 at 3:31 P.M.

2) The Surveyor reviewed Patient #25's medical record on 4/10/18. Patient #25's medical record indicated telephone orders were entered into the medical record on 4/3/18 but remained unsigned as of 4/10/18, longer than the required 48 hours.

3) The Surveyor reviewed Patient #21's medical record on 4/11/18. Patient #21's medical record indicated a telephone order was entered into the medical record on 4/6/18 but remained unsigned as of 4/11/18, longer than the required 48 hours.

4) Surveyor reviewed Patient #7's medical record on 4/9/18. Patient #7's medical record indicated telephone orders were entered into the medical record on 4/6/18 but remained unsigned as of 4/9/18, longer than the required 48 hours.



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5) Patient #10 was admitted to the Hospital in March 2018 with diagnoses which included diabetes.

A Telephone Order, dated 03/26/18 at 3:45 P.M. for sliding scale Humalog (insulin dosed based on the person's blood sugar), was documented and it was not signed by the Physician until 04/03/18, 8 days after the order was received.

The Surveyor interviewed Nurse #1 at 10:08 A.M. on 04/10/18. Nurse #1 said the expectation was that physicians signed their telephone orders within 24 hours.

6) Patient #20 was admitted to the Hospital in March 2018.

A Telephone Order, was documented on 3/25/18 at 3:00 P.M. for as needed acetaminophen (a pain relieving and fever reducing medication), and it was not signed by the Physician until 11:00 A.M. on 04/05/18, 11 days after the order was received.

7) The Director of Nursing (DON) was interviewed on 4/10/18 at 4:15 P.M. The DON said that they do not consider telephone orders as verbal orders and that is why the Surveyors were observing a large amount of telephone orders in the medical records of patients on all three patient care units. The DON said that a verbal order is when a physician is right there and asks the nurse to write the order for him/her. The Surveyor provided documentation in the Federal Regulations, Medical Records Condition which define a verbal order that is transmitted as oral, spoken communications between senders and receivers, delivered either face-to-face or via telephone. Following this discussion, the DON said she understood it clearly now.

Based on records reviewed and interview, the Hospital failed to consistently provide entries into the medical record that were legible for 7 of 41 medical records reviewed (#3, #5, #6, #8, #15, #18 and #22). Findings include:

1) The Surveyor reviewed the medical record of Patient #8 on 4/9/18. The Surveyor was unable to decipher either the Psychiatry Admission Note, the Physician Problem List or the Provider's signature on the notes dated 3/30/18.

The Provider was later identified by the Director of Nursing as Physician #1

2) The Surveyor reviewed the medical record of Patient #15 on 4/9/18. The Surveyor was unable to decipher the Psychiatry Admission Note dated 4/7/18.

The Provider was later identified by the Director of Nursing as Physician #1.


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3) The Surveyor reviewed the medical record of Patient #22 on 4/11/18. The Surveyor was unable to decipher the Physician Progress Notes, dated 4/4/18 and 4/9/18.

The Provider was later identified by the Director of Nursing as Physician #3.




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4) Patient #18's medical record was reviewed on 4/11/18. The Surveyor was unable to decipher the Physician's order, dated 4/9/18 at 11 A.M. There was a telephone order of clarification soon after the order by the nurse at 2:00 P.M. Physician's orders dated 4/5/18 and 4/6/18 were also illegible. The Surveyor asked a nurse at the nursing station to identify the Physician who wrote the orders.

The Provider was identified as Physician #3.


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5) The Surveyor reviewed the medical record of Patient #3 on 4/10/18. The Surveyor was unable to decipher the hand writing on the Physician Progress Note, dated 4/1/18, and specifically the reasons for hospitalization.

6) The Surveyor reviewed the medical record of Patient #5 on 4/10/18. The Surveyor was unable to decipher the hand writing on the Psychiatry Admission Note, dated 3/21/18, and specifically the mental status examination, primary diagnosis and initial treatment plan.

7) The Surveyor reviewed the medical record of Patient #6 on 4/11/18. The Surveyor was unable to decipher the hand writing on the Psychiatry Admission Note, dated 2/20/18, and specifically the history of present illness, chief complaint, formulation, diagnosis and initial treatment plan.

The Provider was later identified by the Director of Nursing as Physician #3.

Based on records reviewed and interview the Hospital failed to consistently follow its policy for signing verbal (telephone) orders within 48 hours for 4 patients (Patient #7, #18, #21, #25) of 30 patient records reviewed.

The Hospital Policy titled Medication Administration, dated 5/11/16, indicated that telephone orders must be cosigned by the physician within 48 hours.

1) The Surveyor reviewed Patient #7's medical record on 4/9/18. Patient #7's medical record indicated telephone orders were entered into the medical record on 4/6/18 but remained unsigned as of 4/9/18, longer than the required 48 hours.

2) The Surveyor reviewed Patient #25's medical record on 4/10/18. Patient #25's medical record indicated telephone orders were entered into the medical record on 4/3/18 but remained unsigned as of 4/10/18, longer than the required 48 hours.



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3) The Surveyor reviewed Patient #21's medical record on 4/11/18. Patient #21's medical record indicated a telephone order was entered into the medical record on 4/6/18 but remained unsigned as of 4/11/18, longer than the required 48 hours.



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4) Review of Patient 18's medical record indicated that a telephone order was entered on 4/4/18 at 5:35 P.M., but remained unsigned by the physician as of 4/9/18 at 3:31 P.M. An additional order was entered on 4/4/18 at 8:20 P.M., but remained unsigned by the physician as of 4/9/18 at 3:31 P.M.

Based on records reviewed and interviews, the Condition of Utilization Review (UR) was not met because the Hospital failed to implement its UR Plan, which included: (a) forming or assigning a UR Committee; (b) reviewing Medicare and Medicaid patients for admission, duration of stay, or professional services for outlier cases, conducted by a UR Committee; (c) making determinations of medical necessity for admissions and continued stays by a UR Committee; (d) periodic review of outlier extended stays by a UR Committee; (e) and review of professional services by a UR Committee.

Findings include:

Review of the Hospital's UR Plan, dated 11/2017, indicated at least two or more members of the UR Committee are required to be physicians and that these physicians will carry out the functions of the UR Committee. The UR Plan indicated, "A systematic review of open charts will occur and feedback will be brought into treatment team by the UR Coordinator." The UR Plan indicated that UR Coordinators may refer certain cases to the UR Committee for physician review. The UR Plan indicated that the UR Committee will identify problems and trends in the utilization of resources and review the medical necessity of professional services. The UR Plan indicated the UR Committee will review the medical necessity of admissions and extended stays, and a physician member of the UR Committee will consult on cases submitted for review by UR Coordinators. The UR Plan indicates only one physician member of the UR Committee is required to review and make a final decision on a case (regardless of whether the attending physician in question agrees or disagrees with the finding). The UR Plan does not specifically indicate that the UR Committee will provide written notification to the Hospital, the attending physician, or to the patient that the admission or continued stay was medically unnecessary. The Hospital's UR Plan did not reference threshold criteria for diagnoses to define extended stay, or to define an outlier case. The UR Plan did not reference when a periodic peer review was required or scheduled to occur. The UR Plan indicated the UR Committee will review the medical necessity and appropriateness of professional services provided to patients.

a. The Surveyor interviewed the Director of UR on 4/10/18 at 9:05 A.M. The Director of UR said that the Hospital did not have a UR Committee with physician membership. The Director of UR said that physicians often attend UR meetings, but that they did not actively carry out the UR function. The Director of UR said that the department's nurses and social worker (Coordinators) conducted documented audits for extended stay, admission and active treatment criteria.

The Director of UR provided documentation of seven UR meetings held between 1/6/16 and 3/30/17. The agendas for these meetings indicated that topics ranged from medicare audits, communications with insurance companies, comprehensiveness of physician notes, managed care inpatient criteria, department staffing changes, insurance reimbursement for certain diagnoses and barriers to discharge. No more than one physician signed for attendance at these meetings. The agendas and minutes did not reference medical necessity of admission, duration of stays, professional services, including drugs or biologicals, peer review, or patient review.

The Surveyor interviewed the Administrator on 4/10/18 at 10:00 A.M. The Administrator said that the Hospital has been without a UR Committee for approximately 18 months due to changes in the medical leadership at the Hospital.

b. The Director of UR said she was unaware of a formal or ongoing physician peer review process for patient clinical care.

The Administrator said that for approximately the past 18 months the Hospital's physicians had not been conducting UR of their peers' charts to determine medical necessity or of the Hospital's professional services provided to outlier cases.

c. The Director of UR said she there was no formal or ongoing physician peer review process for determination of medical necessity.

The Administrator said that for approximately the past 18 months the Hospital's physicians had not been conducting UR of their peers charts or had a formal review process to determine medical necessity for admissions or continued stays.

d. The Director of UR said the Hospital did not have a formal or ongoing physician peer review process for extended stays and outlier cases.

The Administrator said that for approximately 18 months the Hospital's physicians had not been conducting a review of medical necessity of extended stay cases.

e. The Director of UR said there was no formal or ongoing physician review of professional services for outlier cases.

The Administrator that for approximately 18 months the Hospital's physicians had not been conducting a review of professional services for outlier cases.

Based on record review and interview, the Hospital failed to have a Utilization Review (UR) Committee since approximately late in 2016. Findings include:

Review of the Hospital's UR Plan, dated 11/2017, indicated at least two or more members of the UR Committee are required to be physicians and that these physicians will carry out the functions of the committee.

The Surveyor interviewed the Director of UR on 4/10/18 at 9:05 A.M. The Director of UR said there were four Coordinators of the UR department, which consisted of licensed nurses and a social worker. The Director of UR said that the Hospital did not have a UR Committee with physician membership. The Director of UR said that physicians often attend UR meetings, but that they did not actively carry out the UR function. The Director of UR said that the department's nurses and social worker conducted documented audits for extended stay, admission and active treatment criteria.

The Director of UR provided documentation of seven UR meetings held between 1/6/16 and 3/30/17. No more than one physician signed for attendance at these meetings. The agendas and minutes did not reference medical necessity of admission, duration of stays, professional services, including drugs or biologicals, peer review, or patient review.

The Surveyor interviewed the Administrator on 4/10/18 at 10:00 A.M. The Administrator said that the Hospital has been without a UR Committee for approximately 18 months due to changes in the medical leadership at the Hospital.

Based on records reviewed and interviews, the Hospital failed to have a UR Committee review Medicare and Medicaid patients for admission, duration of stay, and for professional services involving outlier cases. Findings include:

Review of the Hospital's UR Plan, dated 11/2017, indicated, "A systematic review of open charts will occur and feedback will be brought into treatment team by the UR Coordinator." The UR Plan indicated that Coordinators may refer certain cases to the UR Committee for physician review. The UR Plan indicated that the Committee will identify problems and trends in the utilization of resources and review the medical necessity of professional services.

The Surveyor interviewed the Director of UR on 4/10/18 at 9:05 A.M. The Director of UR said there were four Coordinators of the UR department, which consisted of licensed nurses and a social worker. The Director of UR said that the Hospital did not have a UR Committee with physician membership. The Director of UR said that physicians often attended UR meetings, but that they did not actively carry out the UR function. The Director of UR said she was unaware of a formal or ongoing physician peer review process for patient clinical care.

The Director of UR provided documentation of seven UR meetings held between 1/6/16 and 3/30/17. The agendas for these meetings indicated that topics included medicare audits, communications with insurance companies, comprehensiveness of physician notes, managed care inpatient criteria, department staffing changes, insurance reimbursement for certain diagnoses and barriers to discharge. The agendas and minutes did not reference medical necessity of admissions, duration of stays, or professional services of outlier cases, or problems and trends in the utilization of resources.

The Surveyor interviewed the Administrator on 4/10/18 at 10:00 A.M. The Administrator said that the Hospital has been without a UR Committee for approximately 18 months due to changes in the medical leadership at the Hospital. The Administrator said that, during this time period, the Hospital's physicians had not been conducting UR of their peers charts, medical necessity, or of the Hospital's professional services for outlier cases.

Based on records reviewed and interviews, the Hospital failed to have a UR Committee make determinations for the medical necessity of patient admissions and continued stays; failed to organize a peer review system to critique potentially medically unnecessary care; and failed to include in its UR Plan, or implement, an appropriate system of physician consultation or written notifications for when medically unnecessary care was determined. Findings include:

Review of the Hospital's UR Plan, dated 11/2017, indicated, the UR Committee will review the medical necessity of admissions and extended stays, and a physician member of the UR will consult on cases submitted for review by UR Coordinators. The UR Plan indicated only one physician member of the UR Committee was required to review and make a final decision on a case, regardless of whether the attending physician in question agreed or disagreed with the finding. The UR Plan does not specifically indicate that the UR Committee will provide written notification to the Hospital, the attending physician, or to the patient that the admission or continued stay was medically unnecessary.

The Surveyor interviewed the Director of UR on 4/10/18 at 9:05 A.M. The Director of UR said that Hospital physicians often attended UR meetings, but that they did not actively carry out the UR function. The Director of UR said she was unaware of a formal or ongoing physician peer review process for determination of medical necessity.

The Director of UR provided documentation of seven UR meetings held between 1/6/16 and 3/30/17. The agendas for these meetings indicated that topics ranged from medicare audits, communications with insurance companies, comprehensiveness of physician notes, managed care inpatient criteria, department staffing changes, insurance reimbursement for certain diagnoses and barriers to discharge. The agendas and minutes did not reference determinations of medical necessity for admissions and continued stays; did not reference a peer review system or physician consultation, or any written notifications for when medically unnecessary care was determined.

The Surveyor interviewed the Administrator on 4/10/18 at 10:00 A.M. The Administrator said that the Hospital has been without a UR Committee for approximately 18 months due to changes in the medical leadership at the Hospital. The Administrator said that the Hospital's physicians had not been conducting UR of their peers charts or had a formal review process by physicians of the medical necessity for admissions and continued stays during this time period.

Based on records reviewed and interviews, the Hospital failed to conduct periodic reviews of extended stays by a Utilization Review (UR) Committee. Findings include:

Review of the Hospital's UR Plan, dated 11/2017, indicated the UR Committee will review the medical necessity of extended stays. The Hospital's UR Plan did not reference threshold criteria for diagnoses to define extended stay, or to define an outlier case. The UR Plan did not reference when a periodic review was required or scheduled to occur.

The Surveyor interviewed the Director of UR on 4/10/18 at 9:05 A.M. The Director of UR said that the Hospital did not have a UR Committee with physician membership. The Director of UR said that the Coordinators use diagnoses as threshold indicators for case reviews, but that exceeding these thresholds did not trigger a physician peer review process.

The Surveyor interviewed the Administrator on 4/10/18 at 10:00 A.M. The Administrator said that the Hospital was paid under the acute Inpatient Prospective Payer System (IPPS).

The Administrator said the Hospital has been without a UR Committee for approximately 18 months due to changes in the medical leadership at the Hospital. The Administrator said that the Hospital's physicians had not been conducting a review of medical necessity of extended stay cases during this time period.

Based on records reviewed and interviews, the Hospital failed to have a review of professional services by a Utilization Review (UR) Committee. Findings include:

Review of the Hospital's UR Plan, dated 11/2017, indicated, the UR Committee will review the medical necessity and appropriateness of professional services provided to patients.

The Surveyor interviewed the Director of UR on 4/10/18 at 9:05 A.M. The Director of UR said that the Hospital did not have a UR Committee with physician membership. The Director of UR said that physicians often attended UR meetings, but that they did not actively carry out the UR function. The Director of UR said the Hospital did not have a formal or ongoing physician review of professional services.

The Director of UR provided documentation of seven UR meetings held between 1/6/16 and 3/30/17. The agendas for these meetings indicated there was no reference to a review of professional services as it pertains to medical necessity, or the efficacy of available health facilities and services.

The Surveyor interviewed the Administrator on 4/10/18 at 10:00 A.M. The Administrator said the Hospital has been without a UR Committee for approximately 18 months due to changes in the medical leadership at the Hospital. The Administrator said that the Hospital's physicians had not been conducting a review of professional services during this time period.

Based on observation and interviews, the Hospital failed to consistently provide a sanitary environment of care, clean and disinfect an ornamental water feature and demonstrate the proper use of biohazard bags according to accepted infection control standards. Findings include:

1) The Surveyor observed an ornamental fountain/waterfall in the lobby/waiting room at 8:00 A.M. on 4/9/18.

The Surveyor interviewed the Administrator of the Hospital at 1:00 P.M. on 4/11/18. The Administrator said the staff from the Outpatient Services added additional water to the fountain/waterfall in the lobby however there was no cleaning and disinfection program to maintain the water feature. The Administrator said the fountain/waterfall in the lobby had subsequently been removed from service.

The water feature could be a potential source of legionella and should have been identified in the water management program for routine disinfection.

2) The Surveyor toured the North Unit accompanied by the Director of Therapeutics at 9:15 A.M. on 4/9/18. The Emergency Cart, located in the clean utility room, was visibly soiled with tape residue, and dust and debris on the top of the cart.

The Surveyor and the Director of Therapeutics entered the Patient's Belonging Storage Room and observed a visibly soiled floor, miscellaneous debris on the floor and the ventilation grill was covered with dark dust and debris.

Poor routine cleaning of these areas leading to build up of dust and debris promote growth of bacteria, molds and other infectious organisms that staff can carry on their hands to patients.

3) The Surveyor returned to the North Unit at 8:30 A.M. on 4/10/18. The Surveyor interviewed RN #3 about a bio-hazard bag (medical waste bags that are specially made to contain medical or bio-hazard waste and are clearly labeled with the universal bio-hazard sign) on the counter of the Nurses station with a Patient label affixed to the outside of the bag. RN #3 said they used these bags to designate contraband that a patient may not have access to items such as cigarettes, matches or a lighter.

In appropriate use of biohazard bags can make staff not pay attention to the contents of the bag when actual biohazard waste is in the bag.

Based on record review and interview it was determined that for seven (7) of eight (8) patients (Patients 1, 2, 3, 4, 6, 7 and 8) the Psychiatric Evaluations failed to contain a description of patient assets in descriptive, not interpretive fashion. This failure to describe achievements, interests, or other personal attributes results in other members of the multidisciplinary team not knowing what patient attributes might be utilized in the selection of treatment modalities.

Findings include:

A Record Review:

1. Patient 1: The Psychiatric Evaluation, dated 3/21/18, for this 38-year old with the diagnosis "Mood disorder unspecified" stated as the patient assets: "[S/he] is seemingly capable to care for [him/herself]. [S/he] has a good sense of humor."

2. Patient 2: The Psychiatric Evaluation, dated 2/13/218, for this 53-year old with the diagnosis "Mood disorder, not otherwise specified" had no assets described.

3. Patient 3: The Psychiatric Evaluation, dated 4/03/18, for this 39- year old with the diagnosis "Major depressive disorder, recurrent, moderate without psychotic features" had as the sole asset determined "Motivated to get better."

4. Patient 4: The Psychiatric Evaluation, dated 4/03/18, for this 23-year old with the diagnosis "Mood disorder, not otherwise specified" stated as the sole asset "[S/he] states [S/he] is safe to [ him/herself] in the hospital."

5. Patient 6: The Psychiatric Evaluation, dated 4/03/18, for this 65-year old with the diagnosis Schizophrenia, undifferentiated" had no description of assets.

6. Patient 7: The Psychiatric Evaluation dated, 3/17/18, had no diagnosis present for this 60-year old patient. Under patient assets was: "[S/he] is cooperative at this time. There are no behavioral problems at this time."

7. Patient 8: In the Psychiatric Evaluation, dated 4/03/18, for this 52-year old with the diagnosis "Major depression, severe without psychosis," the asset statement was: "Some history of response to treatment, supportive family."


B Interview:

On 4/10 /18 at 2:00 p.m., the Clinical Director was interviewed. A partial focus in the interview was the lack of an assessment of patient assets within the Psychiatric Evaluations as described in Section A above. The clinical director did not dispute the findings.

Based on record review and interview it was determined that for six (6) of eight (8) active sample patients (1,2,3,4,5, and 7) the Master Treatment Plans failed to describe individualized interventions for the patients that were more than a statement of generic discipline functions. This failure results in neither the patient nor staff knowing the frequency of contacts, what the focus of encounters would be, or what information, such as anticipated types of medications, might occur.

Findings include:

A. Record Review:

1. Patient 1: The Master Treatment Plan, dated 3/21/18, stated for the psychiatrist interventions: "Assess for symptoms of mental illness. Assess for safety and encourage sobriety." The nursing interventions were: "Engage patient in reality-based conversations and activities q (each) shift. Reality orient pt (patient) as needed. Encourage day structure and group."

2. Patient 2: The Master Treatment Plan, dated 2/14/18, had the psychiatrist (MD only identifier) as sharing responsibility for 4 different interventions pertinent to the disciplines of nursing, social work staff and licensed mental health counselor. No specific interventions for the discipline of psychiatry were described. The nursing intervention was: "staff will assess pt with identifying coping skills, will also enc (encourage) pt to attend group."

3. Patient 3: The Master Treatment Plan, dated 4/5/18, had for the psychiatrist's intervention "Med. (medicine) adjustment to address symptoms of depression."

4. Patient 4: The Master Treatment Plan, dated 4/11/18, contained the psychiatrist intervention: "Med adjustment to address symptoms of psychosis." For nursing it stated: "Staff will encourage pt to attend coping skills to manage C/AH (Command Auditory Hallucinations)."

5. Patient 5. The Master Treatment Plan, dated 3/9/18, described the psychiatrist intervention as "Daily visit, psychopharmacology." For nursing the intervention was: "Engage pt in reality-based conversation and activities q shift. Reality orient as needed. Encourage day structure and group attendance."

6. Patient 7: The Master Treatment Plan, dated 3/19/18, described the psychiatric intervention as: "NP (Nurse Practioner) will assess daily & target sx (symptom) psych pharmacologically c (with) goal of returning to community in improved & stable condition."


B Interviews

1. On 4/10/18 at 2:15 p.m. the Clinical Director was interviewed. A partial focus of the interview was the generic interventions listed on the Master Treatment Plan as described in Section A above. He agreed that these findings were correct and agreed that interventions needed to be more patient specific.

2. On 4/09/18 at 11:45 a.m. the Therapeutic Program Director was shown the interventions listed on Patient 4's Master Treatment Plan. She replied "I would agree. They should be more detailed."

Based on record review and interview, the facility failed to ensure that the full name of the person responsible for seeing that an intervention on the Master Treatment Plans (MTPs) was present next to the assigned intervention for eight (8) of eight (8) active sample patients (1, 2, 3, 4, 5, 6, 7 and 8). This practice could result in the facility's difficulty in monitoring accountability of staff with same first initial and last name.

Findings include:

A. Record Review:

The following MTPs (dates of plans in parenthesis) had first initial and last name next to person assigned to seeing that the intervention was carried out: 1 (3/21/18), 2 (2/14/18), 3 (4/15/18), 4 (4/4/18), 5 (3/9/18), 6 (3/19/18), 7 (3/19/19, and 8 (4/4/18).

B. Interviews

1. In an interview on 4/10/18 at 8:25 a.m., the lack of full names of staff assigned to carrying out each intervention on the MTPs was discussed with the Director of Nursing. She did not dispute the findings.

2. In an interview on 4/10/18 at 2:20 p.m., the lack of full names of staff assigned to carry out each intervention on the MTPs was discussed with the Medical Director. He agreed with the findings.

Based on record review and staff interview, the Medical Director failed to monitor that:

1. The Psychiatric Evaluations contained a description of patient assets in descriptive not interpretive terms. (Refer to B117)

2. The Master Treatment Plans described individualized interventions for the patients that were more than a statement of generic discipline functions. (Refer to B122)

3. For the Master Treatment Plans of seven (7) of eight (8) active sample patients (1,2,3,4,5,6 and 7) the full name of the person responsible for an intervention on the plan was present next to the assigned intervention. (Refer to B123)

07814

Based on record review and interview, the Nursing Director failed to ensure that the Master Treatment Plans (MTPS) for four (4) of seven (7) active sample patients (1, 2, 4 and 5) described individualized nursing interventions for the patients that were more than a statement of generic discipline functions.

1. Patient 1: The nursing intervention was: "Engage patient in reality-based conversations and activities q (each) shift. Reality orient pt (patient) as needed. Encourage day structure and group."

2. Patient 2: The nursing intervention was: "Staff will assess pt with identifying coping skills, will also enc (encourage) pt to attend group."

3. Patient 4: The nursing intervention was: "Staff will encourage pt to attend coping skills to manage C/AH (Command Auditory Hallucinations)."

4. Patient 5: The nursing intervention was: "Engage pt. in reality-based conversation and activities q shift. Reality orient as needed. Encourage day structure and group attendance."