HospitalInspections.org

Based on record review and interview the hospital failed ensure all contracted services were provided in a safe an effective manner as evidenced by: 1) inability to produce documented evidence contracted services were evaluated for performance before renewal of contracts in November 2011 and 2) failure to follow hospital policy and procedure for inclusion of contracted services into the quality assurance/performance improvement program. Findings:

1) inability to produce documented evidence contracted services were evaluated for performance before renewal of contracts in November 2011
In face to face interview on 03/15/12 at 1:00pm S1 Administrator indicated he was sure annual evaluations were performed on the contracted services; however he could not submit any documented evidence of the results of those evaluations.

Review of the Governing Body Meeting Minutes dated 011/09/11 revealed the continuation of the established services were approved.


2) failure to follow hospital policy and procedure for inclusion of contracted services into the quality assurance/performance improvement program
Review of the Performance Improvement Committee Meeting Minutes for October 2011, November 2011, December 2011 and January 2011 revealed no documented evidence contracted services for Radiology, Laboratory, Pharmacy, Respiratory and Plant Maintenance were included in the performance improvement program.

Review of the Performance Improvement Plan submitted by the hospital as the one currently in use revealed.... "C. Data are systematically collected regarding: 1. The dimensions of performance of patient-focused functions involving assessment, continuum of care, patient rights and responsibilities, and ethical practices and patient/family grievances. (This includes the quality and appropriateness of ancillary patient care services: i.e. dietary, laboratory, pharmacy, radiology, and rehabilitation services, as applicable to the organization)".

In a face to face interview on 03/15/12 at 1:00pm S9 Corporate Administrator indicated contracted services should have been included in the performance improvement program.

Based on record review and interview, the hospital, in its resolution of a grievance, failed to ensure the effective operation of the grievance process by failing to provide the patient and/or patient representative with a written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date of completion. Deficiencies were noted for 1 of 1 grievance (#5) reviewed out of a total sample of 20 patients. Findings:

Patient #5:
Review of the "Complaint & Grievance Log" revealed a grievance was reported by Patient #5's son regarding the care and services provided to Patient #5. Documentation revealed that on 11/21/11, Patient #5's son was angry and threatening to call the police because he thought his mother (Patient #5) was not being treated good and an employee had bruised her and other patients were taking her things including her shoes.

The Administrator (S1) was interviewed on 3/14/12 at 1:30 p.m. regarding the grievance filed on behalf of Patient #5. S1 indicated that a thorough investigation was conducted into the concerns voiced by Patient #5's son. S1 indicated the results of the investigation revealed no problems in relation to the care and services provided to Patient #5. S1 indicated the bruising that Patient #5's son was referring to was present at the time of her admission to the hospital and all of her things were accounted for including her shoes. S1 indicated that he spoke with Patient #5's son and felt the issue was resolved. When asked if a written notice was provided to Patient #5's son that included the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date of completion, S1 reported that a written notice was not provided.

The hospital's policy/procedure titled "Grievance Procedure" was reviewed. Page 5 of the policy/procedure indicates that a written notification of the findings of the investigation will be provided within 10 days of receipt of the written and/or verbal grievance. The policy/procedure indicates the written notification will include the actions taken to resolve the issue and the name of the person to contact if you are not satisfied with the resolution of the grievance.

20177

Based on record review and interview the hospital failed to follow their policy and procedure for initiating a Do Not Resuscitate Order as evidenced by failing to discuss the DNR request with the family, Power of Attorney and/or patient before writing the DNR order for 6 of 6 patients with DNR orders (#1, #11, #16, #17, #19, #20) out of a total of 20 sampled medical records. Findings:

Patient #1
Review of the medical record for Patient #1 revealed a 2 year old male admitted from a nursing home to the hospital on 12/21/11 under a Formal Voluntary Admit with the diagnosis of schizophrenia with increased aggression, frustration and agitation.

Review of the Physician's Orders dated 12/22/11 at 12 noon for Patient #1 revealed an order for DNR (Do Not Resuscitate).

Review of the form from the transferring nursing home titled "Therapeutic Life Support Form" dated 06/13/11 revealed a statement that Patient #1 had fully discussed terminal and/or acute care interventions with his physician and the decision had been made to use the following interventions listed below:
Cardiopulmonary Resuscitation (No)
Intravenous Fluids (Yes)
Intravenous Antibiotics (Yes)
Intravenous Pain Medications (Yes)
Feeding Tube (No)
Ventilator (Yes)
Oxygen (Yes)
Blood Transfusion (Yes)
The form was signed by a relative (not specified which one) and witnessed by a member of the nursing home staff.

Review of the Oceans Behavioral Advance Directive Acknowledgement dated 12/21/11 revealed an "X" was placed next to the statement indicating "I have executed an Advanced Directive". DNR was clearly printed next to the statement. Further review revealed the form was signed by the patient; however the signature was hard to read.

Further review of the medical record revealed no documented evidence end of life issues were discussed with the patient, family, or if a Power of Attorney existed who had the authority to make decisions.

Review of the nurses's notes dated/timed 01/01/12 at 05:10am revealed Patient #1 appeared to have no problems. At 05:20 the nurse was called to the room of Patient #1 by the MHT (Mental Health Technician) and he was found unresponsive and cyanotic. His airway was opened and oxygen given. Patient #1 was a DNR and was pronounced dead by the coroner at 7:25am.

Patient #11
Patient #11 was admitted to the hospital from a nursing home on 3/07/12. Review of the Multi-Disciplinary Note dated 03/07/12 revealed the patient is an 88 year old female admitted from a nursing home with her caretaker present for depressed mood, labile mood, combative with Activities of Daily Living, tried to hit staff, isolates to self, flat affect, sleep disturbances, and the patient stated to Nursing Home staff she wanted to kill herself with a gun. Her caretaker was named in the Multi-Disciplinary Note along with a statement that her nephew in New Mexico was notified of the situation.

Review of the copies of her Advance Directives from the Nursing Home revealed a DNR (Do Not Resuscitate) order dated 10/17/11 from S11MD and a Resident/Family Consent For Cardiopulmonary Resuscitation (CPR) form. The form was signed by Patient #11's caretaker and initialed by the caretaker indicating the patient did not want CPR performed on her if it became necessary. The statement initialed stated, " I understand that CPR constitutes an extraordinary measure and SHOULD NOT be done on this resident. However, I wish that essential life support interventions such as oxygen, nutrition, hydration, and certain medications for the relief of pain should be administered to maintain the resident's comfort. The form was dated 10/17/11 and signed by her caretaker.

Review of the Physician's Orders for the hospital revealed on 03/08/12 at 12 noon S8 MD wrote an order for DNR for Patient #11. Review of the Advance Directive Acknowledgment form from the hospital dated 3/07/12 revealed the patient had executed an Advance Directive and it was signed by her caretaker. Another form stated she had not executed a Mental Health Advanced Directive and this form was also signed by her caretaker.

An interview was conducted S2Director of Nurses on 3/12/12 at 3:15 p.m. She stated they typically contact the power of attorney for the DNR papers, but she spoke to the nephew in New Mexico and the patient didn't have a power of the attorney so the hospital went by the nursing home papers signed by the caretaker.

Patient #16
Review of the medical record for Patient #16 revealed a 74 year old male admitted on 02/28/12 from a nursing home under a Formal Voluntary Admission with the diagnoses of Alzheimer's dementia and depression and exhibiting outbursts, agitation and combative behavior.

Review of the Physician's Orders dated 03/01/12 at 1:30pm for Patient #16 revealed an order for DNR (Do Not Resuscitate).

Review of the "Living Will/Durable Power of Healthcare Attorney" form for Patient #16 revealed... "A competent adult should have the right to make a written advanced directive known as a Living Will/Durable Power of Attorney Healthcare, instructing his or her physician to withhold or withdraw life sustaining procedures in the event of a terminal condition". Further review revealed an "X" was made next to the statement indicating a living will/advanced directive was executed. The space provided for the exact name of the document was left blank. Another "X" was made next to the statement indicating a Do Not Resuscitate was executed. A blank next to the location of the document was left blank. A third "X" was placed next to the blank indicating a Healthcare Power of Attorney was executed in the form of a conservatorship, a copy of which was contained on the chart. The form was witnessed by two members of the nursing staff.

Review of the medical record revealed no documented evidence a physician had discussed end of life issues with the patient or the conservator or that Patient #16 had been assessed by his attending physician at being at the end of his life.

Patient #17
Medical record review revealed Patient #17 was an 83 year old who was admitted to the hospital from home on 2/24/12 with diagnoses that included Alzheimer's dementia and Major depressive disorder. Review of the medical record revealed Patient #17 had executed a "Declaration Directing Withholding or Withdrawal of Life Sustaining Medical Procedures" on 7/23/10. Review of the "Declaration Directing Withholding or Withdrawal of Life Sustaining Medical Procedures revealed the following instructions relating to Patient #17's wishes: "If at any time I should have an incurable injury, disease, or illness certified to be a terminal and irreversible condition by two physicians who have personally examined me, one of whom shall be my attending physician, and the physicians have determined that my death will occur whether or not life-sustaining procedures or used, and would serve only to prolong artificially the dying process, I direct that such procedures be withheld or withdrawn and that I be permitted to die naturally with only the administration of medication or the performance of any medical procedure deemed necessary to provide me with comfort care. It is my specific desire that use of artificial hydration and nutrition methods, including, but not limited to intravenous fluids, gastrostomy and nasogastric tubes, not be used to prolong my life". There was no documentation in the medical record to indicate that Patient #17 had executed a request to be made a DNR (Do Not Resuscitate) status. Review of the medical record revealed orders dated 2/27/12 and signed by the attending psychiatrist (S8) indicating that Patient #17 was a DNR. Review of the medical record revealed no documentation to indicate the rationale for placing Patient #17 on a DNR status and no documentation to indicate Patient #17 wished to be placed on a DNR status.

In an interview on 3/15/12 at 10:05 a.m., S8 (Psychiatrist) reviewed the medical record of Patient #17 and verified the order dated 2/27/12 placing Patient #17 on a DNR status. S8 indicated that she was under the impression that Patient #17 had an advanced directive and was a DNR status prior to his admission to Oceans Behavioral Hospital of Kentwood. S8 was unable to locate any documentation to confirm that Patient #17 had an advanced directive and was on a DNR status prior to his admission to the hospital. S8 indicated that staff members may have mistakenly taken the "Declaration Directing Withholding or Withdrawal of Life Sustaining Medical Procedures" as a DNR status. S8 then verified the "Declaration Directing Withholding or Withdrawal of Life Sustaining Medical Procedures" was not a DNR. S8 indicated that Patient #17 was placed on a full code status on 3/13/12 due to the misunderstanding.

Patient #19
Review of the medical record for Patient #19 revealed a 66 year old woman admitted from a nursing home per Formal Voluntary Admission to the hospital on 02/15/12 with the diagnoses of bipolar disorder and anxiety. Further review revealed S19 was having crying spells, insomnia, decreased appetite and increased agitation.

Review of the Physician's Orders dated 02/15/12 at 1300 (1:00pm) for Patient #19 revealed an order for DNR (Do Not Resuscitate).

Review of the medical record revealed Patient #19 had delegated a Power of Attorney for healthcare matters on 03/03/05.

Review of the medical record revealed an Advanced Directives Flashsheet contained the label for Ocean's Behavioral Hospital. Further review revealed Advanced Directives was checked off and an "X" placed in the blank next to the statement "I do not wish to have CPR (Cardiopulmonary Resuscitation"). It was signed by the legal representative; however there was no documented evidence of the date or time the legal representative signed the form.
Further review revealed.... "This is a work-sheet only. It is not a final Advanced Directives statement, nor is it to be considered a legal or binding document.

Further review of the entire medical record revealed no documented evidence the physician discussed advanced directives with the Power of Attorney (POA) or a legal document was obtained from the POA with the wishes of making Patient #16 a DNR.

Patient #20
Review of the medical record for Patient #20 revealed an 87 year old woman admitted to the hospital on 02/09/12 under a Formal Voluntary Admission with the diagnosis of Alzheimer's with behavioral disturbances.

Review of the Physician's Orders dated 02/09/12 at 2:25pm for Patient #20 revealed an order for DNR (Do Not Resuscitate).

Review of the medical record revealed Patient #20 had delegated a Power of Attorney for healthcare matters on 05/07/03.

Review of the medical record revealed an Advanced Directive indicating Patient #20 did not want to be resuscitated. The space provided for the "Directive" was left blank. The document and was signed by the POA (Power of Attorney) on 06/03/11. There was no documented evidence the physician had spoken with the POA concerning end of life issues.

Review of policy NSG-38 "Do Not Resuscitate" DNR Guidelines, last revised 06/11 and submitted as the one currently in use, revealed.... "Procedure: .... If a patient requests a DNR order, the patient's response is recorded on the Advanced Directive form. Notifies nursing staff if patient request DNR order. Physician: Discusses DNR request with patient and family, and consults with the patient's primary care physician if appropriate..".

In an interview on 3/15/12 at 10:05 a.m., S8 (Psychiatrist) reviewed the medical record of Patient #1. S8 indicated she wrote the DNR order for Patient #1 because he had a previous order from the nursing home. Further S8 indicated she trusts that the MD who wrote the previous order followed the law in obtaining the DNR. When reviewing the chart with the S8 she was not able to show documented evidence that the person who signed the "Therapeutic Life Support Form" dated 06/13/11 by the nursing home had the authority to sign the form nor that it had been authenticated by a physician. S8 confirmed she had not discussed not documented end of life issues with the patient, POA or family. S8 indicated that there appears to be confusion at the time of admit by the admitting staff as to the meaning of the various forms coming from the different facilities.






26351

Based on observation, record review, and interview the hospital failed to provide a safe setting for a patient as evidence by his call bell being disassembled for 1 out 16 call bells observed (Patient R1). Findings:

Review of the hospital's policy and procedure revealed in part, "It is the policy of the facility to provide call bells in rooms for patients. Purpose: To ensure a safe and therapeutic environment for all patients. To provide a mechanism for patients to alert staff of need of assistance...Nursing staff: Instructs patient to use call bell for assistance if weak, dizzy, lightheaded, or distressed."

An observation was made on the initial tour on 03/12/12 at 9:30 a.m. of the call bell in room "a" having the top of the silver bell off the base of the bell rendering the bell dysfunctional. S1Administrator verified the observation.

An interview was conducted with S6 Recreational Therapist on 03/15/12 at 9:15 a.m. S6 reported she conducted the hospital's environmental rounds Monday through Friday (when she worked). She went on to report on Friday the bell was just loose, not disassembled.

Patient R1 was the patient residing in room "a" with the broken call bell. Review of Patient R1's medical record revealed he was a 50 year old male admitted from a nursing home. He had a history of Schizoaffective disorder, bipolar, seizure disorder, and Diabetes Type II. Review of his Observation Check Sheet dated 03/14/12 revealed he was a high fall risk and on seizure precautions.

Based on record review and interview the hospital failed to implement a quality assessment/performance improvement program which measured, analyzed, and tracked quality indicators as evidence by: 1) failing to include the Intensive Out Patient Clinic in the performance improvement program and 2) failed to collect sufficient data in order to identify problems as evidenced by basing compliance on nursing assessments, treatment plans, psych evaluations, discharge planning, medication administration, and nutritional assessments on review of three charts. Findings:

Review of the Performance Improvement Meeting Minutes for 01/12/12 revealed no documented evidence the Intensive Out-Patient Clinic was included in the performance improvement activities. Further review revealed a total of three discharged charts were used to obtain the data for clinical services. No problems were identified with clinical services and no corrective action was necessary.

In a face to face interview on 03/15/12 at 11:00am S1 Administrator agreed that the performance improvement process should have identified the problems identified.

Based on record review an interview the hospital failed to develop quality indicators for contracted services of radiology, laboratory, respiratory and plant management concerning safety and quality of care provided by the hospital. Findings:

Review of the Performance Improvement Committee Meeting Minutes dated 09/11 through 01/12 revealed no documented evidence quality indicator data had been included for radiology, laboratory, respiratory and plant management.

In a face to face interview on 03/15/12 at 11:00am RN S2 Director of Nursing and the person responsible for coordinating the performance improvement program verified there were no indicators for contracted services.

Based on record review and interview the hospital failed to ensure participation of the contracted services for pharmacy, radiology, respiratory, laboratory and plant maintenance in the Quality Assurance/Performance Improvement program as evidenced by failure to develop indicators in order to evaluate and monitor the safety and quality of care provided. This resulted in the hospital's failure to: 1) ensure the pharmacist was performing monthly chart audits to determine an accurate medication error rate and identify other medication adminsitration problems; 2) ensure all expired medications were not avaliable for administration to patients; 3) ensure patients were receiving first dose medications after regular pharmacy hours; 4) ensure all x-rays were performed in a timely manner; and 5) ensure plant facilites were maintained . Findings:

Review of the meeting minutes of the Performance Improvement Committee for September 2011 theough January 2012 revealed no documented evidence performance improvement data was submitted by pharmacy, radiology, respiratory, laboratory or maintenance services.

1) ensure the pharmacist was performing monthly chart audits to determine an accurate medication error rate and identify other medication adminsitration problems
Review of the Consultant Pharmacist Contract dated 07/27/11 revealed ..... "2. c. The Consultant Pharmacist will review all patient charts each month and shall submit a written report to the Administrator and/or Director of Nursing....".

The hospital could not submit to the survey team any documented evidence chart audits were performed by the pharmacist or nursing.

Review of the Pharmacy monthly reports submitted by S2, Director of Nursing, revealed no documented evidence chart audits were performed by the pharmacist.


2) ensure all expired medications were not avaliable for administration to patients
Observation on 03/13/12 at 10:00am of the medication room located in the Nurse's Station of the hospital revealed a box with expired medications (from the Outpatient Clinic) stored on the top of the cabinet with medications.

In a face to face interview on 03/13/12 at 10:10am LPN S12 indicated the box of expired drugs were brought in from the Outpatient Clinic and had been there for quite a while. Further S12 indicated she thought the pharmacist would take care of removing the drugs, since the drugs were not the ones given by the staff at the hospital. S12 verified the medication cart was dirty and needed to be cleaned.

In a face to face interview on 03/14/12 at 8:20am Administrator S1 indicated the pharmacist comes once a month and picks up the medications in the box. Further S1 indicated the expired medications from the clinic should not have been brought to the hospital. S1 verified emergency drugs are nor kept on-site.


3) ensure patients were receiving first dose medications after regular pharmacy hours
Patient #2
Review of the clinical record face sheet revealed Patient #2 was admitted on 2/21/12 at 1800 (6:00 p.m.) with an admit diagnosis of Schizoaffective disorder, bipolar type. Her chief complaints were listed as being combative, having increased confusion, and paranoia.

Review of the admit Physician's Orders for Patient #2 dated 2/21/12 at 1800 (6:00pm) revealed an order for the asthma medication Symbicort 160/45 two puffs twice per day. No orders were written to hold the first dose of the medication.

Review of the Medication Administration Record (MAR) for Patient #2 dated 2/21/12 revealed no nurse's initials next to the 2100 (9:00 p.m.) dose of Symbicort. There were no indications on the MAR as to why the dose had not been given. After admit, the first dose charted as having been given was on 2/22/12 at 9:00 a.m.

Review of the Nurse's Notes for Patient #2 revealed no entry as to why the Symbicort had not been given on 2/21/12. No entry was recorded for the Physician having been notified of the missed dose.

In an interview on 3/14/12 at 10:30 a.m. Director of Nursing S2, indicated medications for Patient #2 should have been started on 2/21/12 after the Physician's Order was written. S2 indicated if a dose of a medication was not given, the nurse should have circled the missed dose, written an explanation as to why the dose was held, and notified the Physician the dose was given. After reviewing the clinical record for Patient #2, S2 verified the 2100 dose on 2/21/12 of Symbicort had not been charted as having been given or no documentation as to why the medication had not been given or the Physician notified. S2 indicated the medication was probably not in the stock medications, but the nurse should have obtained the medication. She also stated the nurse should have written an explanation of why the dose was not given.

In a face to face interview on 3/15/12 at 10:30 a.m., S8 Physician indicated she expected all of her patients to get their medications beginning the day they were ordered.


Patient #12
Review of the clinical record face sheet revealed Patient #12 was admitted from North Oaks Hospital in Hammond on 2/29/12 at 7:15 p.m. Her diagnosis was listed as Vascular Dementia with Behavioral Disturbances. Her chief complaints were mood swings, sleeping a lot, change in energy, hallucinations, and paranoia.

Review of the admit Physician's Orders for Patient #12 dated 2/29/12 at 1905 (7:05 p.m.) revealed an order for Ditropan (overactive bladder medication) 10 milligrams by mouth at bedtime. An order was also written for Zyprexa (Bipolar medication) 2.5 milligrams by mouth at bedtime. No orders were written to hold the first dose of either medication.

Review of the Medication Administration Record (MAR) for Patient #12 dated 2/29/12 revealed no nurse's initials next to the 2100 (9:00 p.m.) dose of Ditropan or Zyprexa, which indicated the medications had not been charted as having been given. The spaces for the nurse' s initials had not been circled to indicate the dose had been held and no note had been written as to why the doses had been held. Both medications were not initialed as having been given until 3/1/12 at 2100.

Review of the Nurse's Notes for Patient #12 revealed no entry stating why the 2100 doses on 2/29/12 of the Ditropan or Zyprexa had been held. No entry was found of the Physician being notified of the missed doses.

In an interview on 3/12/12 at 3:25 p.m. with Director of Nurses S2, she stated if a medication had not been given, the space where the nurse was supposed to have placed her initials on the MAR should have been circled as an indication of the missed dose. She also stated admit medications should have been started as soon as ordered. After reviewing the clinical record for Patient #12, she stated the 9:00 p.m. doses on 2/29/12 of Zyprexa and Ditropan were not charted as having been given. She could also not find any written notification of the Physician or rational of why the medications had not been given. She stated both medications should have been given by the nurse on 2/29/12. She also stated the Pharmacy was available twenty four hours per day.

In an interview with S8 Physician on 3/15/12 at 10:30 a.m., she stated the patients were expected to get their medications beginning the day they were ordered.

Patient #13:
Review of Patient #13's medical record revealed the patient was admitted to the hospital on 3/08/12 with diagnoses that included Schizophrenia, Anemia, Hypokalemia and Hypertension. Further review revealed orders dated 3/08/12 at 9:00 p.m. for 100mg of Seroquel to be administered at HS (hour of sleep which is scheduled to be administered at 9:00 p.m.), 4mg of Periactin to be administered twice daily (9:00 a.m. and 9:00 p.m.), and 0.2mg of Desmopressin to be administered at HS (hour of sleep which is scheduled to be administered at 9:00 p.m.). Documentation revealed the patient's arrival time to the unit was 8:30 p.m. on 3/08/12. Review of the medical record including the medication administration records revealed no documented evidence to indicated that Patient #13 received the HS medications (Seroquel, Periactin, Desmopressin) on 3/08/12 at 9:00 p.m.

In an interview on 3/12/12 at 1:20 p.m., S3 (Licensed Practical Nurse) reviewed the medical record of Patient #13 and verified the HS medications were not administered to Patient #13 on 3/08/12. S3 reported she was working as the medication nurse on the p.m. shift on 3/08/12. S3 reported she did not administer the medications to Patient #13 due to Patient #13 being sedated at the time. When asked if she obtained an order to hold the HS medications on 3/08/12, S3 indicated that she did not obtain an order to hold the HS medications. When asked if she informed the ordering practitioner of her decision to hold the HS medications on 3/08/12, S3 indicated that she did not inform the ordering practitioner of her decision to hold the HS medications on 3/08/12.


4) ensure all x-rays were performed in a timely manner
Review of the medical record for Patient #6 revealed a 82 year old female admitted to the hospital on 10/04/11 for major depressive disorder. Review of the Multi-Disciplinary Notes for dated 10/10/11 revealed Patient #6 was found on the floor by her bed and was assessed with a bruise (located not documented), but was noted to have no swelling, no limited range of motion and no complaint of pain. According to the notes the MD was notified and an x-ray was ordered. The next entry was dated 10/11/11 (no time documented) which revealed the contract radiology service reported to the nurse no fracture to the elbow was seen to the shoulder or elbow; however the x-ray was not well demonstrated and the radiology tech would return tomorrow to re-x-ray the site. On 10/12/11 at 4:00pm the contracted radiology company notified the facility they would not be able to return to the facility to perform the x-ray as scheduled. This was reported to the Director of Nursing. Further review revealed no documented evidence the x-ray was repeated on Patient #6.

In a face to face interview on 03/15/12 at 1:00pm S9 Corporate Administrator indicated the x-ray should have been repeated on the same day and that this was not acceptable for this contracted service.

5) ensure plant facilites were maintained
Observations made on 03/12/12 at 10:45am of the exterior smoking area revealed V-shaped splits in several of the boards of the wood fence surrounding in the exterior smoking area resulting in weak pieces of board which can be removed and which contain sharp areas. Nails were noted in multiple areas to be protruding from the wood resulting in sharp edges that could be a safety hazard for psychiatric patients. The length of nails used to secure the pickets were so long that they extended through the wood resulting in the point sticking out of the wood in areas that patients had access to.

In an interview at the time of this observation, S1 (Administrator) verified the presence of the weak broken boards and acknowledged they needed to be fixed and/or replaced and the nails were protruding from the wood and the sharp edges of the point could be a safety hazard for psychiatric patients. .

Based on record review and interview the hospital failed to follow their Quality Assurance/Performance Improvement (QA/PI) Plan as evidenced by failure to set priorities for performance improvement activities which focused on high-risk, high-volume or problem-prone areas. This resulted in the hospital failing to follow their policy and procedure for initiating a Do Not Resuscitate Order as evidenced by failing to discuss the DNR request with the family, Power of Attorney and/or patient before writing the DNR order for 6 of 6 patients with DNR orders (#1, #11, #16, #17, #19, #20) out of a total of 20 sampled medical records. Findings:

Review of the Performance Improvement Meeting Minutes for 09/11 through 01/12 revealed no documented evidence Advanced Directives and orders for Do Not Resuscitate were included in the hospital's performance improvement program.

Patient #1
Review of the medical record for Patient #1 revealed a 2 year old male admitted from a nursing home to the hospital on 12/21/11 under a Formal Voluntary Admit with the diagnosis of schizophrenia with increased aggression, frustration and agitation.

Review of the Physician's Orders dated 12/22/11 at 12 noon for Patient #1 revealed an order for DNR (Do Not Resuscitate).

Review of the form from the transferring nursing home titled "Therapeutic Life Support Form" dated 06/13/11 revealed a statement that Patient #1 had fully discussed terminal and/or acute care interventions with his physician and the decision had been made to use the following interventions listed below:
Cardiopulmonary Resuscitation (No)
Intravenous Fluids (Yes)
Intravenous Antibiotics (Yes)
Intravenous Pain Medications (Yes)
Feeding Tube (No)
Ventilator (Yes)
Oxygen (Yes)
Blood Transfusion (Yes)
The form was signed by a relative (not specified which one) and witnessed by a member of the nursing home staff.

Review of the Oceans Behavioral Advance Directive Acknowledgement dated 12/21/11 revealed an "X" was placed next to the statement indicating "I have executed an Advanced Directive". DNR was clearly printed next to the statement. Further review revealed the form was signed by the patient; however the signature was hard to read.

Further review of the medical record revealed no documented evidence end of life issues were discussed with the patient, family, or if a Power of Attorney existed who had the authority to make decisions.

Review of the nurses's notes dated/timed 01/01/12 at 05:10am revealed Patient #1 appeared to have no problems. At 05:20 the nurse was called to the room of Patient #1 by the MHT (Mental Health Technician) and he was found unresponsive and cyanotic. His airway was opened and oxygen given. Patient #1 was a DNR and was pronounced dead by the coroner at 7:25am.

Patient #11
Patient #11 was admitted to the hospital from a nursing home on 3/07/12. Review of the Multi-Disciplinary Note dated 03/07/12 revealed the patient is an 88 year old female admitted from a nursing home with her caretaker present for depressed mood, labile mood, combative with Activities of Daily Living, tried to hit staff, isolates to self, flat affect, sleep disturbances, and the patient stated to Nursing Home staff she wanted to kill herself with a gun. Her caretaker was named in the Multi-Disciplinary Note along with a statement that her nephew in New Mexico was notified of the situation.

Review of the copies of her Advance Directives from the Nursing Home revealed a DNR (Do Not Resuscitate) order dated 10/17/11 from S 11 MD and a Resident/Family Consent For Cardiopulmonary Resuscitation (CPR) form. The form was signed by Patient #11's caretaker and initialed by the caretaker indicating the patient did not want CPR performed on her if it became necessary. The statement initialed stated, " I understand that CPR constitutes an extraordinary measure and SHOULD NOT be done on this resident. However, I wish that essential life support interventions such as oxygen, nutrition, hydration, and certain medications for the relief of pain should be administered to maintain the resident's comfort. The form was dated 10/17/11 and signed by her caretaker.

Review of the Physician's Orders for the hospital revealed on 03/08/12 at 12 noon S8 MD wrote an order for DNR for Patient #11. Review of the Advance Directive Acknowledgment form from the hospital dated 3/07/12 revealed the patient had executed an Advance Directive and it was signed by her caretaker. Another form stated she had not executed a Mental Health Advanced Directive and this form was also signed by her caretaker.

An interview was conducted S2Director of Nurses on 3/12/12 at 3:15 p.m. She stated they typically contact the power of attorney for the DNR papers, but she spoke to the nephew in New Mexico and the patient didn't have a power of the attorney so the hospital went by the nursing home papers signed by the caretaker.

Patient #16
Review of the medical record for Patient #16 revealed a 74 year old male admitted on 02/28/12 from a nursing home under a Formal Voluntary Admission with the diagnoses of Alzheimer's dementia and depression and exhibiting outbursts, agitation and combative behavior.

Review of the Physician's Orders dated 03/01/12 at 1:30pm for Patient #16 revealed an order for DNR (Do Not Resuscitate).

Review of the "Living Will/Durable Power of Healthcare Attorney" form for Patient #16 revealed... "A competent adult should have the right to make a written advanced directive known as a Living Will/Durable Power of Attorney Healthcare, instructing his or her physician to withhold or withdraw life sustaining procedures in the event of a terminal condition". Further review revealed an "X" was made next to the statement indicating a living will/advanced directive was executed. The space provided for the exact name of the document was left blank. Another "X" was made next to the statement indicating a Do Not Resuscitate was executed. A blank next to the location of the document was left blank. A third "X" was placed next to the blank indicating a Healthcare Power of Attorney was executed in the form of a conservatorship, a copy of which was contained on the chart. The form was witnessed by two members of the nursing staff.

Review of the medical record revealed no documented evidence a physician had discussed end of life issues with the patient or the conservator or that Patient #16 had been assessed by his attending physician at being at the end of his life.

Patient #17
Medical record review revealed Patient #17 was an 83 year old who was admitted to the hospital from home on 2/24/12 with diagnoses that included Alzheimer's dementia and Major depressive disorder. Review of the medical record revealed Patient #17 had executed a "Declaration Directing Withholding or Withdrawal of Life Sustaining Medical Procedures" on 7/23/10. Review of the "Declaration Directing Withholding or Withdrawal of Life Sustaining Medical Procedures revealed the following instructions relating to Patient #17's wishes: "If at any time I should have an incurable injury, disease, or illness certified to be a terminal and irreversible condition by two physicians who have personally examined me, one of whom shall be my attending physician, and the physicians have determined that my death will occur whether or not life-sustaining procedures or used, and would serve only to prolong artificially the dying process, I direct that such procedures be withheld or withdrawn and that I be permitted to die naturally with only the administration of medication or the performance of any medical procedure deemed necessary to provide me with comfort care. It is my specific desire that use of artificial hydration and nutrition methods, including, but not limited to intravenous fluids, gastrostomy and nasogastric tubes, not be used to prolong my life". There was no documentation in the medical record to indicate that Patient #17 had executed a request to be made a DNR (Do Not Resuscitate) status. Review of the medical record revealed orders dated 2/27/12 and signed by the attending psychiatrist (S8) indicating that Patient #17 was a DNR. Review of the medical record revealed no documentation to indicate the rationale for placing Patient #17 on a DNR status and no documentation to indicate Patient #17 wished to be placed on a DNR status.

Patient #19
Review of the medical record for Patient #19 revealed a 66 year old woman admitted from a nursing home per Formal Voluntary Admission to the hospital on 02/15/12 with the diagnoses of bipolar disorder and anxiety. Further review revealed S19 was having crying spells, insomnia, decreased appetite and increased agitation.

Review of the Physician's Orders dated 02/15/12 at 1300 (1:00pm) for Patient #19 revealed an order for DNR (Do Not Resuscitate).

Review of the medical record revealed Patient #19 had delegated a Power of Attorney for healthcare matters on 03/03/05.

Review of the medical record revealed an Advanced Directives Flashsheet contained the label for Ocean's Behavioral Hospital. Further review revealed Advanced Directives was checked off and an "X" placed in the blank next to the statement "I do not wish to have CPR (Cardiopulmonary Resuscitation"). It was signed by the legal representative; however there was no documented evidence of the date or time the legal representative signed the form.
Further review revealed.... "This is a work-sheet only. It is not a final Advanced Directives statement, nor is it to be considered a legal or binding document.

Further review of the entire medical record revealed no documented evidence the physician discussed advanced directives with the Power of Attorney (POA) or a legal document was obtained from the POA with the wishes of making Patient #16 a DNR.

Patient #20
Review of the medical record for Patient #20 revealed an 87 year old woman admitted to the hospital on 02/09/12 under a Formal Voluntary Admission with the diagnosis of Alzheimer's with behavioral disturbances.

Review of the Physician's Orders dated 02/09/12 at 2:25pm for Patient #20 revealed an order for DNR (Do Not Resuscitate).

Review of the medical record revealed Patient #20 had delegated a Power of Attorney for healthcare matters on 05/07/03.

Review of the medical record revealed an Advanced Directive indicating Patient #20 did not want to be resuscitated. The space provided for the "Directive" was left blank. The document and was signed by the POA (Power of Attorney) on 06/03/11. There was no documented evidence the physician had spoken with the POA concerning end of life issues.

Review of policy NSG-38 "Do Not Resuscitate" DNR Guidelines, last revised 06/11 and submitted as the one currently in use, revealed.... "Procedure: .... If a patient requests a DNR order, the patient's response is recorded on the Advanced Directive form. Notifies nursing staff if patient request DNR order. Physician: Discusses DNR request with patient and family, and consults with the patient's primary care physician if appropriate..".

In a face to face interview on 03/15/12 at 11:00am S2 Director of Nursing indicated she was not aware of any problems with Advanced Directives and verified Advanced Directives were not being monitored at the present time.

Based on record review and interview the hospital failed to ensure 1) after life care was provided according to the policy and procedure of the hospital for 1 of 1 patients who died in the facility out of a total of 20 sampled patients;







1) after life care was provided according to the policy and procedure
Review of the medical record for Patient #1 revealed a 62 year old male admitted to the hospital under a Formal Voluntary Admission on 12/21/11 with increased agitation, frustration with simple tasks, refusing ADLs (Activities of Daily Living), aggression and paranoia. Past history included schizophrenia, hypertension, impaired renal function and hematuria.

Review of the Multi-Disciplinary Notes dated 01/01/12 revealed the nurse was called to Patient #1's room by the MHT (Mental Health Tech) because he was found to be unresponsive and cyanotic. Patient #1 had a Physician's Order not to resuscitate and at 0725 (7:25am) the coroner pronounced Patient #1 deceased. Further review of the medical record revealed no documented evidence after-life care had been provided for Patient #1.

Review of policy NSG-30 titled "Post Mortem Care/Death of a Patient/Discharge Death Summary" submitted as the one currently in use revealed... "Procedures: Nurse - Don gloves and appropriate protective equipment to protect staff from body fluids; Hold eyelids closed until they remain closed or place a 4 X 4 gauze on lids to fix eyelids in a natural closed position before the onset of rigor mortis; Remove extra equipment from the room; Wash secretions from the face and body; Replace the soiled linens with clean ones to improve appearance of body and decrease room odor; Remove soiled linens from room in biohazard bags; Position body supine with arms at side palms down; Place dentures in mouth, close mouth; Remain will be identified by name bracelet attached to right wrist...".

In a face to face interview on 03/15/12 at 1:30pm RN S2 Director of Nursing indicated the care provided after the patient has died should be documented in the chart by the nurse.

Based on record review and interview, the registered nurse failed to ensure medications were administered in accordance with the orders of the practitioner and failed to ensure the ordering practitioner was notified of the medication administration errors for 3 of 3 patients (#2, #12, #13) whose medical record were reviewed for medication administration out of a total sample of 20 patients. Findings:

Patient #2
Findings:
Review of the clinical record face sheet revealed Patient #2 was admitted on 2/21/12 at 1800 (6:00 p.m.) with an admit diagnosis of Schizoaffective disorder, bipolar type. Her chief complaints were listed as being combative, having increased confusion, and paranoia.

Review of the admit Physician's Orders for Patient #2 dated 2/21/12 at 1800 revealed medication orders which included an order for the asthma medication Symbicort 160/45 two puffs twice per day. No orders were written to hold the first dose of the medication.
Review of the Medication Administration Record (MAR) for Patient #2 dated 2/21/12 revealed no nurse's initials next to the 2100 (9:00 p.m.) dose of Symbicort. There were no indications on the MAR as to why the dose had not been given. After admit, the first dose charted as having been given was on 2/22/12 at 9:00 a.m.

Review of the Nurse's Notes for Patient #2 revealed no entry as to why the Symbicort had not been given on 2/21/12. No entry was recorded for the Physician having been notified of the missed dose.

In an interview on 3/14/12 at 10:30 a.m. with Director of Nursing S2, she stated medications for Patient #2 should have been started on 2/21/12 after the Physician's Order was written. She stated if a dose of a medication was not given, the nurse should have circled the missed dose and written an explanation as to why the dose was held. She stated the nurse should have also notified the Physician if a dose had not been given. After reviewing the clinical record for Patient #2, S2 stated the 2100 dose on 2/21/12 of Symbicort had not been charted as having been given. She also stated there was no documentation as to why the medication had not been given or documentation of where the Physician had been notified of the held dose. She said the medication was probably not in the stock medications, but the nurse should have obtained the medication. She also stated the nurse should have written an explanation of why the dose was not given.

In an interview with S8 Physician on 3/15/12 at 10:30 a.m., she stated the patients were expected to get their medications beginning the day they were ordered.

Patient #12
Findings:
Review of the clinical record face sheet revealed Patient #12 was admitted from North Oaks Hospital in Hammond on 2/29/12 at 7:15 p.m. Her diagnosis was listed as Vascular Dementia with Behavioral Disturbances. Her chief complaints were mood swings, sleeping a lot, change in energy, hallucinations, and paranoia.

Review of the admit Physician ' s Orders for Patient #12 dated 2/29/12 at 1905 (7:05 p.m.) revealed medication orders which included an order for Ditropan (overactive bladder medication) 10 milligrams by mouth at bedtime. An order was also written for Zyprexa (Bipolar medication) 2.5 milligrams by mouth at bedtime. No orders were written to hold the first dose of either medication.

Review of the Medication Administration Record (MAR) for Patient #12 dated 2/29/12 revealed no nurse's initials next to the 2100 (9:00 p.m.) dose of Ditropan or Zyprexa, which indicated the medications had not been charted as having been given. The spaces for the nurse' s initials had not been circled to indicate the dose had been held and no note had been written as to why the doses had been held. Both medications were not initialed as having been given until 3/1/12 at 2100.

Review of the Nurse's Notes for Patient #12 revealed no entry stating why the 2100 doses on 2/29/12 of the Ditropan or Zyprexa had been held. No entry was found of the Physician being notified of the missed doses.

In an interview on 3/12/12 at 3:25 p.m. with Director of Nurses S2, she stated if a medication had not been given, the space where the nurse was supposed to have placed her initials on the MAR should have been circled as an indication of the missed dose. She also stated admit medications should have been started as soon as ordered. After reviewing the clinical record for Patient #12, she stated the 9:00 p.m. doses on 2/29/12 of Zyprexa and Ditropan were not charted as having been given. She could also not find any written notification of the Physician or rational of why the medications had not been given. She stated both medications should have been given by the nurse on 2/29/12. She also stated the Pharmacy was available twenty four hours per day.

In an interview with S8 Physician on 3/15/12 at 10:30 a.m., she stated the patients were expected to get their medications beginning the day they were ordered.

Patient #13:
Review of Patient #13's medical record revealed the patient was admitted to the hospital on 3/08/12 with diagnoses that included Schizophrenia, Anemia, Hypokalemia and Hypertension. Further review revealed orders dated 3/08/12 at 9:00 p.m. for 100mg of Seroquel to be administered at HS (hour of sleep which is scheduled to be administered at 9:00 p.m.), 4mg of Periactin to be administered twice daily (9:00 a.m. and 9:00 p.m.), and 0.2mg of Desmopressin to be administered at HS (hour of sleep which is scheduled to be administered at 9:00 p.m.). Documentation revealed the patient's arrival time to the unit was 8:30 p.m. on 3/08/12. Review of the medical record including the medication administration records revealed no documented evidence to indicated that Patient #13 received the HS medications (Seroquel, Periactin, Desmopressin) on 3/08/12 at 9:00 p.m.

In an interview on 3/12/12 at 1:20 p.m., S3 (Licensed Practical Nurse) reviewed the medical record of Patient #13 and verified the HS medications were not administered to Patient #13 on 3/08/12. S3 reported she was working as the medication nurse on the p.m. shift on 3/08/12. S3 reported she did not administer the medications to Patient #13 due to Patient #13 being sedated at the time. When asked if she obtained an order to hold the HS medications on 3/08/12, S3 indicated that she did not obtain an order to hold the HS medications. When asked if she informed the ordering practitioner of her decision to hold the HS medications on 3/08/12, S3 indicated that she did not inform the ordering practitioner of her decision to hold the HS medications on 3/08/12.








30364

Based on observation and interview the hospital failed to ensure all medical records were protected from fire and water damage as evidenced by storing charts of recently discharged patients on an open, uncovered cart when the medical records department consisting of a single room with two sets of windows, was unattended and/or closed after scheduled working hours. Findings:

Observation on 03/13/12 at 9:10am of the medical records department was located in a trailer outside of the main hospital building and consisted of a single room with two sets of windows with no sprinkler system. Further observations revealed the medical records of eight recently discharged patients were stored on an open uncovered cart within the room.

In a face to face interview on 03/12/12 at 9:25am Medical Records Manager S7 verified there was no sprinkler system in the trailer and the charts were left uncovered at all times. Further S7 indicated three months of discharged patient medical records were kept on-site in covered, secured files; however she had not considered the files left open on the cart being at risk if the building caught fire of if leakage from water occurred.

Based on record review and interview the hospital failed to ensure all entries in the medical record contained the date/time the person responsible for providing the service as evidenced by 6 of 6 medicial records reviewed for discharge summaries (#1, #6, #8, #16, #19, #20) out of a total of 20 sampled medical records. Findings.

Review of the Discharge Summary for Patient #1, #6, #8, #16, #19, #20 written and signed by Nurse Practitioner S10 and co-signed by MD S8 revealed no evidence the date or time the documents were signed.

In a face to face interview on 03/15/12 at 9:30am MD S8 indicated the discharge summaries should be dated and timed when signed.

Based on record review and interview the hospital failed to ensure a discharge summary for a patient who died while hospitalized contained information on the events leading to his death, cause of death, or disposition of the body for 1 of 1 patients (#1) who died in-house out of a total of 20 sampled medical records. Findings:

Review of the Discharge Summary, dictated by Nurse Practitioner S10 and signed as the content being approved by MD S8 revealed ...... "Hospital Course of Treatment: ........Thorazine was continued as ordered, along with Cogentin. Depakote ER was started. Liver function test were monitored. Ambien was started to help with insomnia. He continue to have episodes of tearfulness and agitation. IM (Intramuscular) prn (as needed) meds were used as needed. Medication changes were made slowly while observing for side or adverse effects. Levaquin was prescribed for a UTI (Urinary Tract Infection). Geri chair was used for gait stability. Condition at the time of Discharge: On 01/01/12 the patient was pronounced deceased by the coroner". Further review revealed no documented evidence of the events that led to the death of the patient, cause of death, or the disposition of the patient.

In a face to face interview on 03/15/12 at 9:30am MD S8 the attending psychiatrist for Patient #1 indicated she did not know the cause of death because the family did not want an autopsy performed. Further S8 indicated she assumed the coroner, who pronounced the patient, completed the death certificate; but verified the medical record for Patient #1 contained no documented evidence of a death certificate. S8 indicated the Discharge Summary should have contained additional information as to what happened to Patient #1.

Based on record review and interview the hospital failed to ensure the pharmacist was responsible for the coordination and supervision of all hospital activities related to medication administration as evidenced by: 1) failing to ensure Pharmacy Services were available 24/7 as evidenced by the contract stating the normal working hours as 8:00am - 5:00pm and any medication ordered outside that time frame was considered an emergency delivery resulting in 3 newly admitted patients failing to receive their next scheduled dose of regularly scheduled medications out of of 20 sampled (#2, #12, #13); 2) failing to perform monthly chart audits resulting in unidentified medication variances for 3 of 30 sampled patients (#2, #12, #13); 3) failing to perform accurate medication area inspections as required by the contracted agreement with the hospital; 4) failing to participate in the Performance Improvement Program of the hospital. Findings:

1) failed to ensure Pharmacy Services were available 24/7 as evidenced by the contract stating the normal working hours as 8:00am - 5:00pm
Review of the Contract with Pharmacy "a" dated 04/28/11 revealed ..... "A call-out is any request by any of the Behavioral Hospitals for delivery or Pharmacy Servicing during any period outside of Pharmacy "a's" normal hours of operation (Monday through Friday, 8:00am to 5:00pm), including, but not limited to, the request by any of the Behavioral Hospitals for a delivery that is other than a scheduled delivery, the request by any of the Behavioral Hospitals for an emergency delivery and the request by any of the Behavioral hospitals for any delivery of emergency drug services, the timing of which precludes it from otherwise being incorporated into a scheduled delivery, Oceans Management, each of the Behavioral Hospitals and Pharmacy "a" mutually agree that the maximum number of call-outs for each of the Behavioral Hospitals is set for (4) and that there will be a $35.00 charge per call-out for each of the Behavioral Hospitals, which shall be accumulated on a monthly basis and included as a separate part of the billing for Pharmacy Servicing fees for that month".

Patient #2
Review of the clinical record face sheet revealed Patient #2 was admitted on 2/21/12 at 1800 (6:00 p.m.) with an admit diagnosis of Schizoaffective disorder, bipolar type. Her chief complaints were listed as being combative, having increased confusion, and paranoia.

Review of the admit Physician's Orders for Patient #2 dated 2/21/12 at 1800 (6:00pm) revealed an order for the asthma medication Symbicort 160/45 two puffs twice per day. No orders were written to hold the first dose of the medication.

Review of the Medication Administration Record (MAR) for Patient #2 dated 2/21/12 revealed no nurse's initials next to the 2100 (9:00 p.m.) dose of Symbicort. There were no indications on the MAR as to why the dose had not been given. After admit, the first dose charted as having been given was on 2/22/12 at 9:00 a.m.

Review of the Nurse's Notes for Patient #2 revealed no entry as to why the Symbicort had not been given on 2/21/12. No entry was recorded for the Physician having been notified of the missed dose.

In an interview on 3/14/12 at 10:30 a.m. Director of Nursing S2, indicated medications for Patient #2 should have been started on 2/21/12 after the Physician's Order was written. S2 indicated if a dose of a medication was not given, the nurse should have circled the missed dose, written an explanation as to why the dose was held, and notified the Physician the dose was given. After reviewing the clinical record for Patient #2, S2 verified the 2100 dose on 2/21/12 of Symbicort had not been charted as having been given or no documentation as to why the medication had not been given or the Physician notified. S2 indicated the medication was probably not in the stock medications, but the nurse should have obtained the medication. She also stated the nurse should have written an explanation of why the dose was not given.

In a face to face interview on 3/15/12 at 10:30 a.m., S8 Physician indicated she expected all of her patients to get their medications beginning the day they were ordered.


Patient #12
Review of the clinical record face sheet revealed Patient #12 was admitted from North Oaks Hospital in Hammond on 2/29/12 at 7:15 p.m. Her diagnosis was listed as Vascular Dementia with Behavioral Disturbances. Her chief complaints were mood swings, sleeping a lot, change in energy, hallucinations, and paranoia.

Review of the admit Physician's Orders for Patient #12 dated 2/29/12 at 1905 (7:05 p.m.) revealed an order for Ditropan (overactive bladder medication) 10 milligrams by mouth at bedtime. An order was also written for Zyprexa (Bipolar medication) 2.5 milligrams by mouth at bedtime. No orders were written to hold the first dose of either medication.

Review of the Medication Administration Record (MAR) for Patient #12 dated 2/29/12 revealed no nurse's initials next to the 2100 (9:00 p.m.) dose of Ditropan or Zyprexa, which indicated the medications had not been charted as having been given. The spaces for the nurse' s initials had not been circled to indicate the dose had been held and no note had been written as to why the doses had been held. Both medications were not initialed as having been given until 3/1/12 at 2100.

Review of the Nurse's Notes for Patient #12 revealed no entry stating why the 2100 doses on 2/29/12 of the Ditropan or Zyprexa had been held. No entry was found of the Physician being notified of the missed doses.

In an interview on 3/12/12 at 3:25 p.m. with Director of Nurses S2, she stated if a medication had not been given, the space where the nurse was supposed to have placed her initials on the MAR should have been circled as an indication of the missed dose. She also stated admit medications should have been started as soon as ordered. After reviewing the clinical record for Patient #12, she stated the 9:00 p.m. doses on 2/29/12 of Zyprexa and Ditropan were not charted as having been given. She could also not find any written notification of the Physician or rational of why the medications had not been given. She stated both medications should have been given by the nurse on 2/29/12. She also stated the Pharmacy was available twenty four hours per day.

In an interview with S8 Physician on 3/15/12 at 10:30 a.m., she stated the patients were expected to get their medications beginning the day they were ordered.

Patient #13:
Review of Patient #13's medical record revealed the patient was admitted to the hospital on 3/08/12 with diagnoses that included Schizophrenia, Anemia, Hypokalemia and Hypertension. Further review revealed orders dated 3/08/12 at 9:00 p.m. for 100mg of Seroquel to be administered at HS (hour of sleep which is scheduled to be administered at 9:00 p.m.), 4mg of Periactin to be administered twice daily (9:00 a.m. and 9:00 p.m.), and 0.2mg of Desmopressin to be administered at HS (hour of sleep which is scheduled to be administered at 9:00 p.m.). Documentation revealed the patient's arrival time to the unit was 8:30 p.m. on 3/08/12. Review of the medical record including the medication administration records revealed no documented evidence to indicated that Patient #13 received the HS medications (Seroquel, Periactin, Desmopressin) on 3/08/12 at 9:00 p.m.

In an interview on 3/12/12 at 1:20 p.m., S3 (Licensed Practical Nurse) reviewed the medical record of Patient #13 and verified the HS medications were not administered to Patient #13 on 3/08/12. S3 reported she was working as the medication nurse on the p.m. shift on 3/08/12. S3 reported she did not administer the medications to Patient #13 due to Patient #13 being sedated at the time. When asked if she obtained an order to hold the HS medications on 3/08/12, S3 indicated that she did not obtain an order to hold the HS medications. When asked if she informed the ordering practitioner of her decision to hold the HS medications on 3/08/12, S3 indicated that she did not inform the ordering practitioner of her decision to hold the HS medications on 3/08/12.


2) failing to perform monthly chart audits resulting in unidentified medication variances
See findings in #1.
Review of the Consultant Pharmacist Contract dated 07/27/11 revealed ..... "2. c. The Consultant Pharmacist will review all patient charts each month and shall submit a written report to the Administrator and/or Director of Nursing....".

The hospital could not submit to the survey team any documented evidence chart audits were performed by the pharmacist or nursing.

Review of the Pharmacy monthly reports submitted by S2, Director of Nursing, revealed no documented evidence chart audits were performed by the pharmacist.


3) failing to perform accurate medication area inspections as required by the contracted agreement with the hospital
Review of the Pharmacy monthly reports submitted by S2, Director of Nursing, revealed no documented evidence chart audits were performed by the pharmacist. Review of the monthly "Medication Area Inspection Record" dated 09/16/11, 10/16/11, 11/16/11, 12/22/11, 01/24/12 and 0202/12 revealed the results of all six months were the same, "no problems were identified in the cleanliness of the medication room, proper labeling of the drugs, temperature of the room and the refrigerator, drug storage and security, availability of emergency drugs, and storage of expired drugs.

Observation on 03/13/12 at 10:00am of the medication room located in the Nurse's Station of the hospital revealed the following: 1) a box with expired medications (from the Outpatient Clinic) stored on the top of the cabinet with medications; 2) medication cart used to keep medications pulled from the Pyxsis system for administration to patients with visible dirt buildup in the single drawers storing individual patient medications: 3) no evidence emergency medications were kept in the hospital.

In a face to face interview on 03/13/12 at 10:10am LPN S12 indicated the box of expired drugs were brought in from the Outpatient Clinic and had been there for quite a while. Further S12 indicated she thought the pharmacist would take care of removing the drugs, since the drugs were not the ones given by the staff at the hospital. S12 verified the medication cart was dirty and needed to be cleaned.

In a face to face interview on 03/14/12 at 8:20am Administrator S1 indicated the pharmacist comes once a month and picks up the medications in the box. Further S1 indicated the expired medications from the clinic should not have been brought to the hospital. S1 verified emergency drugs are nor kept on-site.


4) failing to participate in the Performance Improvement Program
Review of the Contract with Pharmacy "a" dated 04/28/11 and the Consultant Pharmacist Contract dated 07/27/11 revealed no documented evidence the contracts included information concerning responsibilities for performance improvement.

Review of the Performance Improvement Meeting Minutes for 09/11 through 02/12 revealed no documented evidence the pharmacist attended the meeting or submitted any documented information.

In a face to face interview on 03/15/11 at 10:00am RN S2 Director of Nursing and Performance Improvement Coordinator indicated the pharmacist does not participate in performance improvement.

Based on observation, record review and interview the hospital failed to ensure expired medication brought in from their outpatient clinic were not available for patient use as evidenced by placing the medications on the shelf above where the stock medications were kept in the hospital's medication room. Findings:

Observation on 03/13/12 at 10:00am of the medication room located in the Nurse's Station of the hospital revealed a large wood box to the right of the door with an opening and with a small lock on the door. Located on the top of the cabinet storing stock medications was a box with expired medications.

In a face to face interview on 03/13/12 at 10:10am LPN S12 indicated the box of expired drugs were brought in from the Outpatient Clinic and had been there for quite a while. Further S12 indicated she thought the pharmacist would take care of removing the drugs, since the drugs were not the ones given by the staff at the hospital.

In a face to face interview on 03/14/12 at 8:20am Administrator S1 indicated the pharmacist comes once a month and picks up the medications in the box. Further S1 indicated the expired medications from the clinic should not have been brought to the hospital.

Based on review of the Radiological Services Contract and interview, the hospital failed to provide documented evidence to indicate that Radiological Services were available on a 24 hour a day 7 day a week basis. This resulted in failure of a patient to receive a repeat x-ray on her shoulder/elbow, due to a film which was not well demonstrated, on the same day the need for the repeat x-ray was determined for 1 of 1 patients reviewed for performance of an in-house x-ray (#6) out of a total sample of 20 medical records. Findings:

The Radiological Services Contract was reviewed. There was no documentation in the contract to indicate that Radiological Services were available on a 24 hour a day 7 day a week basis.

In an interview on 3/14/12 at 10:05 a.m., S1 (Administrator) reviewed the Radiological Services Contract and verified the contract did not indicate that Radiological Services were available on a 24 hour a day 7 day a week basis. S1 reported Radiological Services are available on a 24 hour a day 7 day a week basis in the hospital even though the documentation was not included in the contractual agreement.

Review of the medical record for Patient #6 revealed a 82 year old female admitted to the hospital on 10/04/11 for major depressive disorder. Review of the Multi-Disciplinary Notes for dated 10/10/11 revealed Patient #6 was found on the floor by her bed and was assessed with a bruise (located not documented), but was noted to have no swelling, no limited range of motion and no complaint of pain. According to the notes the MD was notified and an x-ray was ordered. The next entry was dated 10/11/11 (no timed documented) which revealed the contract radiology service reported to the nurse no fracture to the elbow was seen to the shoulder or elbow; however the x-ray was not well demonstrated and the radiology tech would return tomorrow to re-x-ray the site. On 10/12/11 at 4:00pm the contracted radiology company notified the facility they would not be able to return to the facility to perform the x-ray as scheduled. This was reported to the Director of Nursing. Further review revealed no documented evidence the x-ray was repeated on Patient #6.

In a face to face interview on 03/15/12 at 1:00pm S9 Corporate Administrator indicated the x-ray should have been repeated on the same day and that this was not acceptable for this contracted service.






20177

Based on interview and record review, the hospital failed to ensure the person designated to function as the dietary manager was qualified by experience and/or training. Findings:

In an interview on 3/14/12 at 10:55 a.m., S2 (Director of Nursing) reported S4 is the hospital's Dietary Manager.

The personnel and training records for S4 were reviewed. This review revealed no evidence to indicate that S4 had any experience in dietary services and no evidence to indicate that S4 had received any training in dietary services.

S4 was interviewed on 3/14/12 at 2:30 p.m. S4 verified she was the hospital's dietary manager. When asked if she had any experience working in dietary services or if she had any training in dietary services, S4 reported she does not have any experience in dietary services and has not received any training in dietary services.

Based on observations and interview, the hospital failed to ensure all facilities and equipment were maintained in a manner to ensure an acceptable level of safety and quality as evidenced by 1) nails protruding from the wood in the exterior smoking area of the hospital resulting in sharp edges that could be a safety hazard for psychiatric patients; 2) V-shaped splits in several of the boards of the wood fence surrounding in the exterior smoking area resulting in weak pieces of board which can be removed and which contain sharp areas that could pose a safety hazard for psychiatric patients. Findings:

1. Nails
Observations were made in the area designated for smoking on 3/12/12 at 10:45 a.m. These observations revealed a wood fence around the perimeter of the smoking area. Nails were noted in multiple areas to be protruding from the wood resulting in sharp edges that could be a safety hazard for psychiatric patients. The length of nails used to secure the pickets were so long that they extended through the wood resulting in the point sticking out of the wood in areas that patients had access to.

In an interview at the time of this observation, S1 (Administrator) verified that the nails were protruding from the wood and the sharp edges of the point could be a safety hazard for psychiatric patients.


2. Wood
Observations made on 03/12/12 at 10:45am of the exterior smoking area revealed V-shaped splits in several of the boards of the wood fence surrounding in the exterior smoking area resulting in weak pieces of board which can be removed and which contain sharp areas.

In an interview at the time of this observation, S1 (Administrator) verified the presence of the weak broken boards and acknowledged they needed to be fixed and/or replaced.

Based on record review and interview the hospital failed to ensure the designated Infection Control Officer was qualified as evidenced by: 1) appointing an LPN (Licensed Practical Nurse) with no documented evidence of prior work experience in infection control; 2) failing to provide a job-specific orientation and assessment of competency prior to the performance of the duties of an Infection Control Officer; and 3) failing to provide additional training after the annual evaluation of the Infection Control Officer indicated she needed improvement in the performance of her infection control duties. Findings:


1) appointing an LPN (Licensed Practical Nurse) with no documented evidence of prior work experience in infection control
Review of the application for LPN S12 Infection Control Officer revealed she was hired by the hospital in 2009 as a weekend nurse and had no experience listed in infection control.

In a face to face interview on 03/14/12 at 2:15pm LPN S12 verified the only previous experience in infection control was in the performance of the duties of a staff nurse.


2) failing to provide a job-specific orientation and assessment of competency prior to the performance of the duties of an Infection Control Officer;

In a face to face interview on 03/14/12 at 2:15pm LPN S12 indicated the consultant nurse provided an inservice when she was hired and S12 continued the program that was already in place.


3) failing to provide additional training after the annual evaluation of the Infection Control Officer indicated she needed improvement in the performance of her infection control duties.
Review of the Job Description/Performance Review for the job title of Infection Control Officer for the time period of 10/01/10 through 10/01/11 revealed the scoring as follows: 2 as meeting the standards and 1 as needing improvement. Further review of the performance review revealed S12 was assessed as scoring a (1) and in need of improvement in.... "10. Performs employee health screening, record keeping and testing. 11. Performs infection control in-service training to all new employees and annually. 15. Maintains accurate and confidential records on employees. 18. Develops, plan and provides in-services for inter/intra-community staff on a minimum of a bi-annual schedule".

Further review of the personnel file of S12 revealed no documented evidence additional training was provided to assist S12 to improve her skills in the area needing improvement noted in her annual evaluation.

In a face to face interview on 03/14/12 at 2:00pm S9 Corporate Administrator indicated additional training should have been offered to the Infection Control Officer when her evaluation indicated improvements in performance were needed.

Based on observation, record review and interview the Infection Control Officer failed to include disinfection of equipment as part of the weekly infection control inspection resulting in a medication cart used for storing patient medications observed with drawers containing visible dirt, glucometer failing to be cleaning between use and nebulizer with visible dirt on the machine. Findings:

Review of the form used to perform weekly Infection Control Inspections revealed the following was being monitored: 1. Patients rooms are clean and free of clutter; 2. Patient's personal use supplies are properly labeled and stored; 3. Patient's bedpans, urinals, nuns caps, graduated cylinders are individually stored in paper bags at the patient's bedside; 4. Beds are cleaned weekly and at discharge; 5. Wheelchairs are cleaned weekly; 6. Washer and dryer are disinfected after each patient use; 7. Foley catheter bags are not touching the floor; 8. TB testing for a patient is done upon admit according to protocol; 9. Staff is educated on infection control policies and procedures; 10. Staff id monitored for illness and sent home when needed; 11. All admit urinalysis and lab complete with 48 hours; and 12. All follow-up urinalysis completed per orders. Further review revealed no documented evidence equipment for patient use (i.e. glucometers, nebulizers or medication carts were included in the inspections).

Observation on 03/13/12 at 10:00am of the medication room located in the Nurse's Station of the hospital revealed the following: the medication cart used to keep medications pulled from the Pyxsis system for administration to patients with visible dirt buildup in the single drawers storing individual patient medications and in the bottom drawer a nebulizer with sings of dirt on the outside of the machine.

Observation of the glucometer on 03/13/12 at 10:15am revealed it was being stored on top of the medication cart. Further review revealed visible smudges on the surface of the machine.

In a face to face interview on 03/13/12 at 10:10am LPN S12 indicated verified the medication cart was dirty and needed to be cleaned. Further S12 indicated the equipment was not part of the weekly infection control inspection. When asker how often the glucometer was cleaned, S12 responded weekly. S12 also indicated the glucometer was cleaned with alcohol.

Review of the manual for the Quintet Glucometer for professional and home use revealed... "Cleaning Meter: Clean the outside of the meter with a damp cloth and mild soap/detergent. Keep the teat strip port and Smart Code Key base from getting wet.

Review of the Capillary Blood Glucose Competency for Nurses revealed cleaning of the unit was in included in the inservice or competency assessment.

Based on review of the Respiratory Care Services Contract and interview, the hospital failed to provide documented evidence to indicate that Respiratory Care Services were available on a 24 hour a day 7 day a week basis. Findings:

The Respiratory Care Services Contract was reviewed. There was no documentation in the contract to indicate that Respiratory Care Services were available on a 24 hour a day 7 day a week basis.

In an interview on 3/14/12 at 10:05 a.m., S1 (Administrator) reviewed the Respiratory Care Services Contract and verified the contract did not indicate that Respiratory Care Services were available on a 24 hour a day 7 day a week basis. S1 reported Respiratory Care Services are available on a 24 hour a day 7 day a week basis in the hospital even though the documentation was not included in the contractual agreement.

Based on record review and interview the hospital failed to individualize a patient's comprehensive treatment plan after her daughter/power of attorney died while she was in the hospital obtaining psychiatric care for 1 out 20 sample patients (Patient # 3 ) Findings:

Review of Patient #3's medical record revealed she was a 71 year old female who lived with her daughter. She was admitted from another hospital on 02/01/12 because she was arguing with her family. She hit her daughter in the face. The patient had a history of anoxic brain damage, history of brain tumor, and two myocardial infarctions.

Review of the Physician's Order dated 2/06/12 at 12:45 p.m. revealed the following orders: Change from POA (power of attorney) to NCA(noncontested admission) (daughter passed away) NH (nursing home) work up. Arrange to attend daughter funeral services. The order was signed by S8MD.

Review of S8MD's Progress Notes dated 2/09/12 revealed in part , "Presentation: The patient is depressed and does not want to talk about her daughter's death. She brushes it away stating that, "I do not know what happened. She did not do the right thing." She is very quiet, withdrawn, no socialization noted. When I asked about whether she wants to go to her daughter's services she report, "She does not know." It appears like she is in shock at the same time does not want to talk about her daughter's death. Withdrawn,depressed, anxious, preoccupied about going home. She believes that she can live by herself and she has friends who can help her. She has crying episodes when she talks about her daughter..."

Review of the Multidisciplinary Integrated Treatment Plan revealed no revision to the treatment plan after the patient was notified of her daughter's death on 2/06/12.

An interview was conducted with S8MD on 03/15/12 at 9:30 a.m. She stated during the treatment plan meetings her and the staff will do the treatment plan. Sometimes she stated she would write orders for 1:1 grieving process for patients if they had encountered a loss. She went on to state as she review the patient's medical record that she didn't for Patient #3, but she said she did arrange for the patient to go to her daughter's funeral.

Based on record review and interview the hospital failed to revised a patient's treatment plan after her daughter/power of attorney died while in the hospital obtaining psychiatric care for 1 out 20 sample patients (Patient # 3) Findings:

Review of Patient #3's medical record revealed she was a 71 year old female who lived with her daughter. She was admitted from another hospital on 02/01/12 because she was arguing with her family. She hit her daughter in the face. The patient had a history of anoxic brain damage, history of brain tumor, and two myocardial infarctions.

Review of the Physician's Order dated 2/06/12 at 12:45 p.m. revealed the following orders: Change from POA (power of attorney) to NCA(noncontested admission) (daughter passed away) NH (nursing home) work up. Arrange to attend daughter funeral services. The order was signed by S8MD.

Review of S8MD's Progress Notes dated 2/09/12 revealed in part , "Presentation: The patient is depressed and does not want to talk about her daughter's death. She brushes it away stating that, "I do not know what happened. She did not do the right thing." She is very quiet, withdrawn, no socialization noted. When I asked about whether she wants to go to her daughter's services she report, "She does not know." It appears like she is in shock at the same time does not want to talk about her daughter's death. Withdrawn,depressed, anxious, preoccupied about going home. She believes that she can live by herself and she has friends who can help her. She has crying episodes when she talks about her daughter..."

Review of the Multidisciplinary Integrated Treatment Plan revealed no revision to the treatment plan after the patient was notified of her daughter's death on 2/06/12.

An interview was conducted with S8MD on 03/15/12 at 9:30 a.m. She stated during the treatment plan meetings her and the staff will do the treatment plan. Sometimes she stated she would write orders for 1:1 grieving process for patients if they had encountered a loss. She went on to state as she review the patient's medical record that she didn't for Patient #3, but she said she did arrange for the patient to go to her daughter's funeral.