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Based on observation, interview and record review, the Hospital failed to ensure bed siderails were only used when medically necessary and to eliminate an unnecessary ligature risk in the patients' environment, for 11 (Patient #31, 32, 33, 34, 35, 36, 37, 38, 39, 40 and 41) of 17 sampled psychiatric patients.

Findings include:

The Surveyor interviewed the Director of Rehabilitation Services on 6/12/18 at 1:40 P.M. The Director of Rehabilitation Services said that the Hospital had not conducted an adaptive equipment assessment to determine the medical necessity of siderails for its current patients.

The Surveyor interviewed the Director of Nursing (DON) on 6/11/18, at 11:05 A.M. and on 6/12/18 at 1:40 P.M. The DON said that all patients had been assessed for suicide risk and ligature risk prior to being placed in a bed with attached siderails. The DON said the Hospital was developing an expanded siderail assessment tool, assessing all patients for adaptive equipment need, and was removing siderails from beds when the assessment indicated it was medically unnecessary. The DON said there were approximately 28 beds which had siderails attached to them. The DON said it would take approximately 45 minutes to remove the siderails from a bed. The DON said the assessment and siderail removal process would begin during the follow-up survey visit.


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On 6/11/18 from 9:30 A.M. - 11:15 A.M., the Surveyor toured the Hospital's South Unit and North Unit and observed medical beds with attached siderails.

1. For Patient #31, the Hospital failed to evaluate the adaptive equipment need for the two bed siderails attached to the Patient's bed.

The Surveyor observed two 1/2 siderails attached to Patient #31's bed.

There was no evidence in Patient #31's chart that indicated an assessment to determine if the bed siderails were medically necessary.

2. For Patient #32, the Hospital failed to evaluate the adaptive equipment need for the two bed siderails attached to the Patient's bed.

The Surveyor observed two 1/2 siderails attached to Patient #32's bed.

There was no evidence in Patient #32's chart that indicated an assessment to determine if the bed siderails were medically necessary.

3. For Patient #33, the Hospital failed to evaluate the adaptive equipment need for the two bed siderails attached to the Patient's bed.

The Surveyor observed two 1/2 siderails attached to Patient #33's bed.

There was no evidence in Patient 33's chart that indicated an assessment to determine if the bed siderails were medically necessary.

4. For Patient #34, the Hospital failed to evaluate the adaptive equipment need for the two bed siderails attached to the Patient's bed.

The Surveyor observed two 1/2 siderails attached to Patient #34's bed.

There was no evidence in Patient #34's chart that indicated an assessment to determine if the bed siderails were medically necessary.

5. For Patient #35, the Hospital failed to evaluate the adaptive equipment need of the two bed siderails attached to the Patient's bed.

The Surveyor observed two 1/2 siderails attached to Patient #35's bed.

There was no evidence in Patient #35's chart that indicated an assessment to determine if the bed siderails were medically necessary.

6. For Patient #36, the Hospital failed to evaluate the adaptive equipment need of the two bed siderails attached to the Patient's bed.

The Surveyor observed two 1/2 siderails attached to Patient #36's bed.

There was no evidence in Patient #36's chart that indicated an assessment to determine if the bed siderails were medically necessary.

7. For Patient #37, the Hospital failed to evaluate the adaptive equipment need of the two bed siderails attached to the Patient's bed.

The Surveyor observed two 1/2 siderails attached to Patient #37's bed.

There was no evidence in Patient #37's chart that indicated an assessment to determine if the bed siderails were medically necessary.

On 6/12/18 from 9:00 A.M. - 11:00 A.M., The Surveyor toured the Hospital's South Unit and North Unit and observed medical beds with attached siderails.

8. For Patient #38, the Hospital failed to evaluate the adaptive equipment need of the two bed siderails attached to the Patient's bed.

The Surveyor observed two 1/2 siderails attached to Patient #38's bed.

There was no evidence in Patient #38's chart that indicated an assessment to determine if the bed siderails were medically necessary.

9. For Patient #39, the Hospital failed to evaluate the adaptive equipment need of the two bed siderails attached to the Patient's bed.

The Surveyor observed two 1/2 siderails attached to Patient #39's bed.

There was no evidence in Patient #39's chart that indicated an assessment to determine if the bed siderails were medically necessary.

10. For Patient #40, the Hospital failed to evaluate the adaptive equipment need of the two bed siderails attached to the Patient's bed.

The Surveyor observed two 1/2 siderails attached to Patient #40's bed.

There was no evidence in Patient #40's chart that indicated an assessment to determine if the bed siderails were medically necessary.

11. For Patient #41, the Hospital failed to evaluate the adaptive equipment need of the two bed siderails attached to the Patient's bed.

The Surveyor observed two 1/2 siderails attached to Patient #41's bed.

There was no evidence in Patient #41's chart that indicated an assessment to determine if the bed siderails were medically necessary.

Based on record review and interview, the Hospital failed to follow its policy for prescribers signing verbal (telephone) orders within 48 hours for 6 (Patient #31, 32, 38, 45, 46 and 47) of 17 patients.

Findings include:

The Hospital policy titled Nursing Medication Management, dated 5/24/18, indicated that telephone orders must be signed and dated by the prescriber, or covering prescriber, within 48 hours.

1. The Surveyor reviewed Patient #45's physician telephone order, dated 6/1/18, for Benadryl 50 milligrams (mg), by mouth, one time only. Review of the telephone order indicated that as of 6/11/18, there was no prescriber signature.

The Surveyor reviewed Patient #45's physician telephone order, dated 6/4/18, for Benadryl 50 mg, by mouth, nightly as needed, for insomnia. Review of the telephone order indicated that as of 6/11/18, there was no prescriber signature.

2. The Surveyor reviewed Patient #46's physician telephone order, dated 6/6/18, for Orajel to affected tooth, every 2 hours, as needed, for tooth pain. Review of the telephone order indicated that as of 6/12/18, there was no prescriber signature.

3. The Surveyor reviewed Patient #47's physician telephone order, dated 5/28/18, for Ativan 2 mg, by mouth, one time only. Review of the telephone order indicated that as of 6/12/18, there was no prescriber signature.

The Surveyor reviewed Patient #47's physician telephone order, dated 6/2/18, indicating, "May have A.M. meds now 6/2." Review of the telephone order indicated that as of 6/12/18, there was no prescriber signature.

The Surveyor interviewed Nurse #6 (unit charge nurse) on 6/12/18 at 1:05 P.M. Nurse #6 said that after accepting a telephone order from a prescriber it was the responsibility of the prescriber to sign the order in the patient's medical chart within 48 hours.


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4. The Surveyor reviewed Patient #31's medical record on 6/11/18. Patient #31's medical record indicated telephone orders were entered into the medical record on 6/1/18 and 6/2/18, and both telephone orders remained unsigned as of 6/11/18, longer than the required 48 hours.

5. The Surveyor reviewed Patient #32's medical record on 6/11/18. Patient #32's medical record indicated telephone orders were entered into the medical record on 6/4/18 and remained unsigned as of 6/11/18, longer than the required 48 hours.

6. The Surveyor reviewed Patient #38's medical record on 6/12/18. Patient #38's medical record indicated telephone orders were entered into the medical record on 5/30/18 and remained unsigned as of 6/12/18, longer than the required 48 hours.

In an interview with the Clinical Leader and RN #1 on the North unit on 6/12/18 at 12:45 P.M., they said that they believed the telephone orders should be signed by the physician within 24 hours of them being given.

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)

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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."