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Based on record reviews and interviews, the hospital failed to follow its policy and procedure for resolving a patient's grievance. The hospital failed to investigate and report to DHH (Department of Health and Hospitals) a patient's allegation of neglect for 1 of 10 patients' records reviewed for abuse or neglect from a total of 10 sampled patients (#4). There was a potential for the 16 inpatients on the psychiatric unit to be victims of neglect with no investigation being conducted and the allegation reported to DHH by administration. Findings:

Review of the hospital policy titled "Grievance Process", revised 01/15/13 and presented by Vice-President (VP) of Organizational EffectivenessS3 as the current policy on the grievance process, revealed that a patient grievance was identified as a formal or informal written or verbal complaint made by a patient or a patient's representative that is not resolved promptly by staff present. Further review revealed that all grievances should be recorded on an "Event Report". Further review revealed the procedure for resolution of grievances included the following:
1) All grievances should be referred to the Grievance Committee via the Risk Management Office;
2) Upon receipt of a grievance, the Risk Management Office will facilitate an investigation by notifying the relevant director and his/her executive contact;
3) The relevant director is responsible for conducting a thorough investigation and taking corrective actions as appropriate;
4) The steps in the investigation, the results of the investigation, and the corrective actions taken should be submitted to the Grievance Committee; the investigation should be completed within 7 business days or less in most cases;
5) The Grievance Committee will send a letter to the patient or representative which should include 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;
6) All grievances should be logged and maintained in a database by the Risk Management Office.

Review of the hospital policy titled "Abuse and Neglect", revised 11/29/12 and presented by VP of Organizational EffectivenessS3 as the current policy on the grievance process, revealed that it was the policy of the hospital to investigate all allegations of patient abuse or neglect. Further review revealed neglect was defined as the failure, by a caretaker or other parties, to provide the proper or necessary support of medical, surgical or any other care necessary for the individual's well being. Review of the policy revealed all cases of suspected hospital staff neglect or abuse to patients would be reported and investigated. Further review revealed that all hospital self-report of allegations of abuse and/or neglect would be submitted to DHH Health Standards Section within 24 hours of the facility having knowledge of the allegations, and the respective Vice President or their delegate was responsible for initial notification.

In a face-to-face interview on 02/04/13 at 11:40 a.m., Vice-President (VP) of Organizational EffectivenessS3 indicated the hospital had not received a grievance for the psychiatric unit from 12/01/12 to the present time.

Review of Patient #4's medical record revealed that she was a 50 year old female admitted on 12/13/12 at 1:30 a.m. with the diagnoses of Suicidal Ideations, Depression, and Anxiety. Further review revealed she was PEC'd (physician emergency certificate) on 12/12/12 at 7:20 p.m. due to being suicidal and a danger to self. Further review revealed she was CEC'd (coroner's emergency certificate) on 12/14/12 at 2:10 p.m. due to being a danger to self and unwilling and unable to seek voluntary admission.

Review of Patient #4's intake assessment performed by RNS13 on 12/13/12 at 1:42 a.m. revealed Patient #4 was brought to into the ED, and Patient #4 stated that she suffered from panic attacks, anxiety, depression, fibromyalgia, and pseudoseizures. Further review revealed Patient #4 stated that she got angry and shot a gun at the dresser. Further review revealed Patient #4's past medical history included the diagnoses of Hypertension, Fibromyalgia, GERD (gastroesophageal reflux disease), Lupus, Multiple Sclerosis, and Pseudoseizures. Further review revealed Patient #4's allergies included Imuran and Sulfonamides.

Review of LPNS14's (licensed practical nurse) documentation on 12/14/12 at 6:21 p.m. revealed Patient #4 complained that she was upset about her health and the "lack of care that she has been receiving, she feels that no one is giving her informative information about her health". Review of LPNS14's documentation on 12/15/12 at 6:40 p.m. revealed Patient #4 complained of "poor treatment by last shift pt (patient) states that she was unable to walk due to side effects of the medication that she received last PM and that she received no assistance from Nursing staff".

In a face-to-face interview on 02/06/13 at 10:05 a.m., LPNS14 indicated Patient #4 told her during the morning medication pass about what had happened during the previous night shift. She further indicated Patient #4 was "still having problems on 12/15/12 about her treatment". LPNS14 indicated she reported Patient #4's complaints to the charge nurse RNS15 (registered nurse). LPNS14 indicated she was aware of the hospital policy related to patient grievances and knew that a patient had the right to file a complaint either verbally or in writing. She further indicated a complaint was "when you have a problem and a grievance is when a problem is unresolved". After LPNS14 gave the definition of a complaint and grievance, she was asked if the comments made to her by Patient #4 would be considered a complaint or a grievance. LPNS14 indicated it would be a complaint. When asked if Patient #4's complaints were resolved by her, LPNS14 indicated the complaint wasn't fully resolved and should have been handled as a grievance. LPNS14 indicated she did not document that she reported Patient #4's complaints to Charge RNS15.

In a face-to-face interview on 02/06/13 at 10:55 a.m., Contracted Clinical DirectorS4 of the psychiatric unit indicated he would have to look at the computer to review the grievance policy. He further indicated a patient had a right to file a grievance, he would investigate to see what the complaint was, and he would "take it up if the patient wanted to pursue it". Contracted Clinical DirectorS4 indicated he spoke with Patient #4 about her complaints, but she said that "she'd take care of it". He further indicated he asked her if she wanted to file a grievance, and if she wanted to take it further. He further indicated he had an obligation to report it as a grievance and confirmed that he did not do report it to the hospital's risk management department or DHH as an allegation of neglect.

In a face-to-face interview on 02/06/13 at 3:05 p.m., VP of NursingS2 indicated the employees contracted through Hospital A to provide services to the psychiatric unit were not trained, oriented, and evaluated for competency by hospital-employed nurses. He further indicated Patient #4's allegation of neglect had not been reported to DHH as required by the hospital's policy.

Based on record review and interviews, the hospital failed to ensure that a patient who reported a grievance was provided a written notice of the hospital's decision that contained 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. The hospital failed to identify a patient's complaint as a grievance, conduct an investigation, and provide a written response to the patient for 1 of 1 patient grievance reviewed (#4). There was a potential for the 16 inpatients on the psychiatric unit to file a complaint/grievance with no investigation being conducted and a written notice of the hospital's decision being sent to the patient by administration. Findings:

Review of the hospital policy titled "Grievance Process", revised 01/15/13 and presented by Vice-President (VP) of Organizational EffectivenessS3 as the current policy on the grievance process, revealed that a patient grievance was defined as a formal or informal written or verbal complaint made by a patient or a patient's representative that is not resolved promptly by staff present. Further review revealed that all grievances should be recorded on an "Event Report". Further review revealed the procedure for resolution of grievances included the following:
1) All grievances should be referred to the Grievance Committee via the Risk Management Office;
2) Upon receipt of a grievance, the Risk Management Office will facilitate an investigation by notifying the relevant director and his/her executive contact;
3) The relevant director is responsible for conducting a thorough investigation and taking corrective actions as appropriate;
4) The Grievance Committee will send a letter to the patient or representative which should include 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;
6) All grievances should be logged and maintained in a database by the Risk Management Office.

In a face-to-face interview on 02/04/13 at 11:40 a.m., Vice-President (VP) of Organizational EffectivenessS3 indicated the hospital had not received a grievance for the psychiatric unit from 12/01/12 to the present time.

Review of Patient #4's medical record revealed that she was a 50 year old female admitted on 12/13/12 at 1:30 a.m. with the diagnoses of Suicidal Ideations, Depression, and Anxiety. Further review revealed she was PEC'd (physician emergency certificate) on 12/12/12 at 7:20 p.m. due to being suicidal and a danger to self. Further review revealed she was CEC'd (coroner's emergency certificate) on 12/14/12 at 2:10 p.m. due to being a danger to self and unwilling and unable to seek voluntary admission.

Review of Patient #4's intake assessment performed by RNS13 on 12/13/12 at 1:42 a.m. revealed Patient #4 was brought to into the ED, and Patient #4 stated that she suffered from panic attacks, anxiety, depression, fibromyalgia, and pseudoseizures. Further review revealed Patient #4 stated that she got angry and shot a gun at the dresser. Further review revealed Patient #4's past medical history included the diagnoses of Hypertension, Fibromyalgia, GERD (gastroesophageal reflux disease), Lupus, Multiple Sclerosis, and Pseudoseizures. Further review revealed Patient #4's allergies included Imuran and Sulfonamides.

Review of LPNS14's (licensed practical nurse) documentation on 12/14/12 at 6:21 p.m. revealed Patient #4 complained that she was upset about her health and the "lack of care that she has been receiving, she feels that no one is giving her informative information about her health". Review of LPNS14's documentation on 12/15/12 at 6:40 p.m. revealed Patient #4 complained of "poor treatment by last shift pt (patient) states that she was unable to walk due to side effects of the medication that she received last PM and that she received no assistance from Nursing staff".

In a face-to-face interview on 02/06/13 at 10:05 a.m., LPNS14 indicated Patient #4 told her during the morning medication pass about what had happened during the previous night shift. She further indicated Patient #4 was "still having problems on 12/15/12 about her treatment". LPNS14 indicated she reported Patient #4's complaints to the charge nurse RNS15 (registered nurse). LPNS14 indicated she was aware of the hospital policy related to patient grievances and knew that a patient had the right to file a complaint either verbally or in writing. She further indicated a complaint was "when you have a problem and a grievance is when a problem is unresolved". After LPNS14 gave the definition of a complaint and grievance, she was asked if the comments made to her by Patient #4 would be considered a complaint or a grievance. LPNS14 indicated it would be a complaint. When asked if Patient #4's complaints were resolved by her, LPNS14 indicated the complaint wasn't fully resolved and should have been handled as a grievance. LPNS14 indicated she did not document that she reported Patient #4's complaints to Charge RNS15.

In a face-to-face interview on 02/06/13 at 10:55 a.m., Contracted Clinical DirectorS4 of the psychiatric unit indicated he would have to look at the computer to review the grievance policy. He further indicated a patient had a right to file a grievance, he would investigate to see what the complaint was, and he would "take it up if the patient wanted to pursue it". Contracted Clinical DirectorS4 indicated he spoke with Patient #4 about her complaints, but she said that "she'd take care of it". He further indicated he asked her if she wanted to file a grievance, and if she wanted to take it further. He further indicated he had an obligation to report it as a grievance and confirmed that he did not report it to the hospital's risk management department or DHH as an allegation of neglect.

In a face-to-face interview on 02/06/13 at 3:05 p.m., VP of NursingS2 indicated the employees contracted through Hospital A to provide services to the psychiatric unit were not trained, oriented, and evaluated for competency by hospital-employed nurses. He further indicated Patient #4's allegation of neglect had not been investigated as a grievance, and thus Patient #4 did not receive a letter that contained 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 as required by the hospital policy.

Based on observation of video surveillance tapes conducted via installed hospital security cameras, record reviews, and interviews, the hospital failed to ensure that each patient was free from all forms of neglect. The hospital failed to investigate a patient's allegation of neglect as required by hospital policy for 1 of 10 sampled patients' records reviewed for neglect from a total of 10 sampled patients (#4). There was a potential for the 16 inpatients on the psychiatric unit to be victims of neglect with no investigation being conducted by administration. Findings:

Review of the hospital policy titled "Abuse and Neglect", revised 11/29/12 and presented by VP of Organizational EffectivenessS3 as the current policy on the grievance process, revealed that it was the policy of the hospital to investigate all allegations of patient abuse or neglect. Further review revealed neglect was defined as the failure, by a caretaker or other parties, to provide the proper or necessary support of medical, surgical or any other care necessary for the individual's well being. Review of the policy revealed all cases of suspected hospital staff neglect or abuse to patients would be reported and investigated. Further review revealed that all hospital self-report of allegations of abuse and/or neglect would be submitted to DHH Health Standards Section within 24 hours of the facility having knowledge of the allegations, and the respective Vice President or their delegate was responsible for initial notification.

Review of Patient #4's medical record revealed that she was a 50 year old female admitted on 12/13/12 at 1:30 a.m. with the diagnoses of Suicidal Ideations, Depression, and Anxiety. Further review revealed she was PEC'd (physician emergency certificate) on 12/12/12 at 7:20 p.m. due to being suicidal and a danger to self. Further review revealed she was CEC'd (coroner's emergency certificate) on 12/14/12 at 2:10 p.m. due to being a danger to self and unwilling and unable to seek voluntary admission.

Review of Patient #4's intake assessment performed by RNS13 on 12/13/12 at 1:42 a.m. revealed Patient #4 was brought to the ED, and Patient #4 stated that she suffered from panic attacks, anxiety, depression, fibromyalgia, and pseudoseizures. Further review revealed Patient #4 stated that she got angry and shot a gun at the dresser. Further review revealed Patient #4's past medical history included the diagnoses of Hypertension, Fibromyalgia, GERD (gastroesophageal reflux disease), Lupus, Multiple Sclerosis, and Pseudoseizures. Further review revealed Patient #4's medication allergies included Imuran and Sulfonamides.

Review of LPNS14's (licensed practical nurse) documentation on 12/14/12 at 6:21 p.m. revealed Patient #4 complained that she was upset about her health and the "lack of care that she has been receiving, she feels that no one is giving her informative information about her health". Review of LPNS14's documentation on 12/15/12 at 6:40 p.m. revealed Patient #4 complained of "poor treatment by last shift pt (patient) states that she was unable to walk due to side effects of the medication that she received last PM and that she received no assistance from Nursing staff".

Observation of video surveillance tape conducted via installed hospital security cameras for 12/14/12 from 1:16 a.m. through 12/15/12 at 6:33 a.m., with Vice-President (V) of NursingS2, VP of Organizational EffectivenessS3, and Contracted Clinical DirectorS4 of the psychiatric unit present, revealed the following activity on 12/15/12:
3:00 a.m. - Patient #4 got out of bed, and RNS10 (registered nurse) and MHTS7 (mental health tech) assisted Patient #4 to the bathroom with RNS9 present in the room;
3:01 a.m. - Patient #4 drifted to the floor of the bathroom; staff left the room;
3:02 a.m. - Patient #4's feet moved and Patient #4 was no longer visible on the video screen (in the bathroom);
3:05 a.m. RNS10 came to the bathroom door, looked in, and left within 4 seconds;
3:10 a.m. - RNS10 and RNS9 entered Patient #4's room and went to the bathroom door;
3:11 a.m. - RNS9 closed the bathroom door and left the room with Patient #4 not visible on the video screen;
3:20 a.m. - bathroom door opened with Patient #4 standing in the doorway and then Patient #4 got on her knees;
3:20 a.m. - 41 seconds later - RNS10 entered Patient #4's room while Patient #4 started to crawl from the bathroom;
3:21 a.m. - RNS10 stood at the side of Patient #4 while she crawled to the bed; no observation of RNS10 moving into a position that looked like an attempt to assist Patient #4;
3:22 a.m. - RNS10 left the room with Patient #4 on the floor at the foot of the bed;
3:24 a.m. - Patient #4 got herself off the floor;
3:26 a.m. - Patient #4 got into bed;
No observation of staff entering room from 3:24 a.m. until 5:43 a.m. when RNS9 entered Patient #4's room;
3:33 a.m. - staff member checked from door of room;
3:57 a.m. - staff member checked from door of room (24 minutes from last observation);
4:16 a.m. - staff member checked from door of room (19 minutes since last observation);
5:02 a.m. - staff member checked from door of room (46 minutes since last observation);
5:25 a.m. - staff member checked from door of room (23 minutes since last observation);
5:38 a.m. - staff member checked from door of room.

Review of Patient #4's medical record revealed a note by RNS9 on 12/15/12 at 3:50 a.m. that Patient #4 complained of stomach cramps and was assisted to the bathroom (50 minutes after time observed on the video). Further review revealed no documented evidence of an assessment by an RN of Patient #4 when she drifted to the floor, remained in the bathroom for 20 minutes, and eventually crawled back to bed.

In a face-to-face interview on 02/06/13 at 8:00 a.m., MHTS7 indicated during rounds on 12/15/12 Patient #4 complained of leg pain and the need to go to the bathroom. He further indicated he called additional staff to the room, and he and RNS10 assisted Patient #4 to the bathroom. He further indicated when Patient #4 got to the bathroom door, she let her weight go and drifted to the floor. MHTS7 indicated Patient #4 said "leave me alone", so he asked RNS9 (female nurse) to come, since it was a female patient. MHTS7 indicated he remembered Patient #4 crawling and saying "leave me alone".

In a face-to-face interview on 02/06/13 at 8:45 a.m., RNS9 indicated a MHT, while making rounds, notified her that Patient #4 needed assistance to go to the bathroom since her legs were weak. She further indicated Patient #4 let herself drift to the floor, was agitated, and said "leave me alone". RNS9 indicated she stayed a few minutes with Patient #4 before leaving her in the bathroom. She further indicated when she went back to the bathroom, Patient #4 was on the toilet, so she (RNS9) placed toilet tissue within Patient #4's reach. She further indicated Patient #4 continued to say "leave me alone". RNS9 indicated Patient #4's roommate came to get the staff when Patient #4 was on her knees in the doorway of the bathroom. She further indicated the male staff wanted to assist Patient #4, but she kept saying "leave me alone". She further indicated she didn't remember anyone actually attempting to assist Patient #4.

In a face-to-face interview on 02/06/13 at 9:15 a.m., RNS10 indicated he watched Patient #4 from the video monitor at the desk. He further indicated when she came out the bathroom, she was standing and then got to her knees and started to crawl. RNS10 indicated he asked her is she needed help, and she said "don't need no damn help get out of here". He further indicated he didn't physically attempt to help her, because if a patient says "don't touch, I don't touch".

In a face-to-face interview on 02/06/13 at 10:05 a.m., LPNS14 indicated Patient #4 told her during the morning medication pass about what had happened during the previous night shift. She further indicated Patient #4 was "still having problems on 12/15/12 about her treatment". LPNS14 indicated she reported Patient #4's complaints to the charge nurse RNS15 (registered nurse). LPNS14 indicated she was aware of the hospital policy related to patient grievances and knew that a patient had the right to file a complaint either verbally or in writing. She further indicated a complaint was "when you have a problem and a grievance is when a problem is unresolved". After LPNS14 gave the definition of a complaint and grievance, she was asked if the comments made to her by Patient #4 would be considered a complaint or a grievance. LPNS14 indicated it would be a complaint. When asked if Patient #4's complaints were resolved by her, LPNS14 indicated the complaint wasn't fully resolved and should have been handled as a grievance. LPNS14 indicated she did not document that she reported Patient #4's complaints to Charge RNS15.

In a face-to-face interview on 02/06/13 at 10:55 a.m., Contracted Clinical DirectorS4 of the psychiatric unit indicated he would have to look at the computer to review the grievance policy. He further indicated a patient had a right to file a grievance, he would investigate to see what the complaint was, and he would "take it up if the patient wanted to pursue it". Contracted Clinical DirectorS4 indicated he spoke with Patient #4 about her complaints, but she said that "she'd take care of it". He further indicated he asked her if she wanted to file a grievance, and if she wanted to take it further. He further indicated he had an obligation to report it as a grievance and confirmed that he did not do report it to the hospital's risk management department or DHH as an allegation of neglect.

In a face-to-face interview on 02/06/13 at 3:05 p.m., VP of NursingS2 indicated the employees contracted through Hospital A to provide services to the psychiatric unit were not trained, oriented, and evaluated for competency by hospital-employed nurses. He further indicated Patient #4's allegation of neglect had not been reported to DHH as required by the hospital's policy.

Based on observations, record reviews, and interviews, the hospital failed to ensure that a registered nurse (RN) supervised and evaluated the nursing care for each patient as evidenced by:
1) The RN failed to assess a patient upon her return from the ED (emergency department) for treatment of palpitations and accelerated heart rate, obtain orders for monitoring, and perform continued assessment of the patient throughout the remainder of the shift for 1 of 1 patient's record reviewed who was sent for treatment to the ED from a sample of 10 patients (#4);
2) The RN failed to document an assessment of a patient who was observed by video surveillance tapes conducted via installed hospital security cameras to have drifted to the floor in the bathroom on 12/15/12 at 3:01 a.m. and failed to perform continued assessments following the incident for 1 of 1 patient who was observed to have an episode of weakness from a sample of 10 patients (#4);
3) The RN failed to perform an assessment of a patient with elevated blood pressures that were taken by the mental health tech (MHT) or the LPN (licensed practical nurse) for 2 of 2 patients reviewed with elevated blood pressure from a sample of 10 patients (#4, #10);
4) The RN failed to supervise the observation of patients by the MHT that resulted in patient observations not being conducted as ordered by the physician for 1 of 10 sampled patients (#4).
Failure of the RN to supervise and evaluate the care of each patient had the potential to affect the 16 inpatients on the psychiatric unit.
5) The RN failed to ensure the code cart was checked monthly and available for immediate use in the event of an emergency. The code cart, defibrillator, suction machine and supplies were observed to be covered with an accumulation of dust, and supply packages were torn and discolored by age. Batteries available for use in the laryngoscope had been expired since March 2011. Findings:
1) The RN failed to assess a patient upon her return from the ED for treatment of palpitations and accelerated heart rate, obtain orders for monitoring, and perform continued assessment of the patient throughout the remainder of the shift:
Review of the hospital policy titled "Assessment and Re-Assessment", revised 10/12/12 and submitted as the current policy by Accreditation ManagerS6, revealed that a re-assessment would be completed as necessary based on the patient's plan of care or based on changes in the patient's condition. Further review revealed the assessment may include an assessment of the basic neurological status and level of consciousness, the basic respiratory status, a re-assessment of problems or abnormalities previously identified, identification of complaints, identification of patient identified needs, and a detailed assessment of the abnormalities/problems and risks identified. Further review revealed that documentation of the patient's reassessment was to be entered in the electronic medical record (EMR).

Review of the hospital policy titled "Vital Signs", revised 07/26/12 and submitted as the current policy by Accreditation ManagerS6, revealed that an assessment of vital signs included the temperature, pulse rate, respiratory rate, blood pressure, oxygen saturation if pulse oximeter is in use, and pain rating scale. Further review revealed that vital signs were assessed on admit, as indicated by a change in the patient's condition, and before and after the administration of prn (as needed) medications that affect cardiovascular, respiratory, or temperature control functions.

Review of Patient #4's medical record revealed that she was a 50 year old female admitted on 12/13/12 at 1:30 a.m. with the diagnoses of Suicidal Ideation's, Depression, and Anxiety. Further review revealed she was PEC'd (physician emergency certificate) on 12/12/12 at 7:20 p.m. due to being suicidal and a danger to self. Further review revealed she was CEC'd (coroner's emergency certificate) on 12/14/12 at 2:10 p.m. due to being a danger to self and unwilling and unable to seek voluntary admission.

Review of Patient #4's intake assessment performed by RNS13 on 12/13/12 at 1:42 a.m. revealed Patient #4 was brought to into the ED, and Patient #4 stated that she suffered from panic attacks, anxiety, depression, fibromyalgia, and pseudoseizures. Further review revealed Patient #4 stated that she got angry and shot a gun at the dresser. Further review revealed Patient #4's past medical history included the diagnoses of Hypertension, Fibromyalgia, GERD (gastroesophageal reflux disease), Lupus, Multiple Sclerosis, and Pseudoseizures. Further review revealed Patient #4's medication allergies included Imuran and Sulfonamides.

Review of Patient #4's MAR (medication administration record) revealed she was administered the following medications at 8:33 p.m. by RNS13:
Clonazepam 1 mg (milligram) by mouth (used for seizures);
Diovan HCT (hydrochlorothiazide-valsartan) 160 mg-12.5 mg 1 tablet by mouth (used to treat hypertension);
Procardia 10 mg by mouth (used to treat hypertension);
Phenergan 25 mg by mouth (ordered as needed for nausea and vomiting);
Refused Lactulose 10 gm (grams) (laxative) and Seroquel 50 mg by mouth (antipsychotic used to treat bipolar depression and manic episodes).

Review of Patient #4's vital sign record revealed the following vital signs on 12/13/12:
9:00 p.m. - blood pressure 139/68; pulse 123;
9:32 p.m. - blood pressure 138/68; pulse 156;
9:37 p.m. - pulse 162; respirations 20;
9:45 p.m. - pulse 151; respirations 18;
9:52 p.m. - blood pressure 142/72; pulse 162; respirations 20.

Review of documentation by RNS12 on 12/14/12 at 3:41 a.m. revealed Patient #4 was given her p.m. medications at 8:33 p.m., complained of palpitations and rapid heartbeat, continued to complain of weakness, dizziness, and palpitations at 9:32 p.m., was placed in a wheelchair with continued monitoring of her heart rate and pulse oximetry, EMS (emergency medical service) was called and ED, house supervisor, and DON (director of nursing) notified, and Patient #4 was transported to ED.

Review of Patient #4's "Emergency Documentation" revealed she arrived in the ED on 12/13/12 at 10:11 p.m. and presented with a history of heart racing. Further review revealed Patient #4's ED stay included lab work, EKG (electrocardiogram), chest x-ray, 1000 ml (milliliter) 0.9% (per cent) Normal Saline intravenously bolus and Acetaminophen 650 mg by mouth. Further review revealed she was discharged to the psychiatric unit on 12/14/12 at 1:08 a.m. with an impression of "palpitations".

Review of Patient #4's medical record revealed a note by RNS13 on 12/14/12 at 3:43 a.m. that included "pt (patient) arrived back from ER (emergency room), vital signs stable, no distress noted, ongoing monitoring". Further review revealed a note by RNS12 on 12/14/12 at 3:44 a.m. that included "pt arrived back on unit via ems VSS (vital signs) stable no distress noted, ER report in chart will continue to monitor". Further review revealed a note by RNS13 on 12/14/12 at 3:44 a.m. that included "pt sleeping, no distress noted, ongoing, monitoring". Review of RNS13's note on 12/14/12 at 3:49 a.m. included "pt sleeping, ongoing monitoring".

Review of Patient #4's medical record revealed no documented evidence that PsychiatristS11 was notified of Patient #4 being sent to the ED. There was no documented evidence of orders from PsychiatristS11 for monitoring of Patient #4 upon her return from the ED. Further review revealed no documented evidence of an assessment of Patient #4 upon her return from the ED that included vital signs. Further review revealed no documented evidence that Patient #4's vital signs were assessed by the RN for the rest of the shift. Patient #4 left the ED on 12/14/12 at 1:08 a.m., and the first vital signs documented in the medical record from the psychiatric unit was at 6:12 a.m. on 12/14/12 (5 hours and 4 minutes after her return from treatment for palpitations and increased heart rate).

In a face-to-face interview on 02/06/13 at 9:45 a.m. RNS12 indicated that RNS13 was assigned the care of Patient #4 on 12/13/12. He further indicated he received a call from RNS13 reporting that Patient #4 had a rapid heartbeat. RNS12 indicated he went to monitor Patient #4 until EMS arrived to transport her to the ED. RNS12 could offer no explanation for not having documented Patient #4's vital signs upon her return from the ED.

In a face-to-face interview on 02/06/13 at 9:55 a.m., RNS13 indicated Patient #4 was very anxious when she came to take her medications and stated that she felt she was having a panic attack. RNS13 indicated Patient #4 took her medications and went to the dining area. She further indicated Patient #4 came back and complained of not feeling well. RNS13 indicated Patient #4 was "tachy" (meaning her heart rate was elevated). RNS13 indicated she called Charge RNS12 to report that she thought Patient #4 needed an ED evaluation. She further indicated Patient #4's heart rate had decreased before EMS arrived. RNS13 could offer no explanation for not having documented an assessment of Patient #4's vital signs upon her return from the ED and throughout the shift.

2) The RN failed to document an assessment of a patient who was observed by video surveillance tapes conducted via installed hospital security cameras to have drifted to the floor in the bathroom on 12/15/12 at 3:01 a.m. and failed to perform continued assessments following the incident:
Review of the hospital policy titled "Assessment and Re-Assessment", revised 10/12/12 and submitted as the current policy by Accreditation ManagerS6, revealed that a re-assessment would be completed as necessary based on the patient's plan of care or based on changes in the patient's condition. Further review revealed the assessment may include an assessment of the basic neurological status and level of consciousness, the basic respiratory status, a re-assessment of problems or abnormalities previously identified, identification of complaints, identification of patient identified needs, and a detailed assessment of the abnormalities/problems and risks identified. Further review revealed that documentation of the patient's reassessment was to be entered in the electronic medical record (EMR).

Review of the hospital policy titled "Vital Signs", revised 07/26/12 and submitted as the current policy by Accreditation ManagerS6, revealed that an assessment of vital signs included the temperature, pulse rate, respiratory rate, blood pressure, oxygen saturation if pulse oximeter is in use, and pain rating scale. Further review revealed that vital signs were assessed as indicated by a change in the patient's condition.

Review of Patient #4's medical record revealed that she was a 50 year old female admitted on 12/13/12 at 1:30 a.m. with the diagnoses of Suicidal Ideations, Depression, and Anxiety. Further review revealed she was PEC'd on 12/12/12 at 7:20 p.m. due to being suicidal and a danger to self. Further review revealed she was CEC'd on 12/14/12 at 2:10 p.m. due to being a danger to self and unwilling and unable to seek voluntary admission.

Review of Patient #4's intake assessment performed by RNS13 on 12/13/12 at 1:42 a.m. revealed Patient #4 was brought to into the ED, and Patient #4 stated that she suffered from panic attacks, anxiety, depression, fibromyalgia, and pseudoseizures. Further review revealed Patient #4 stated that she got angry and shot a gun at the dresser. Further review revealed Patient #4's past medical history included the diagnoses of Hypertension, Fibromyalgia, GERD (gastroesophageal reflux disease), Lupus, Multiple Sclerosis, and Pseudoseizures. Further review revealed Patient #4's medication allergies included Imuran and Sulfonamides.

Review of LPNS14's (licensed practical nurse) documentation on 12/14/12 at 6:21 p.m. revealed Patient #4 complained that she was upset about her health and the "lack of care that she has been receiving, she feels that no one is giving her informative information about her health". Review of LPNS14's documentation on 12/15/12 at 6:40 p.m. revealed Patient #4 complained of "poor treatment by last shift pt (patient) states that she was unable to walk due to side effects of the medication that she received last PM and that she received no assistance from Nursing staff".

Observation of video surveillance tape conducted via installed hospital security cameras for 12/14/12 from 1:16 a.m. through 12/15/12 at 6:33 a.m., with Vice-President (V) of NursingS2, VP of Organizational EffectivenessS3, and Contracted Clinical DirectorS4 of the psychiatric unit present, revealed the following activity on 12/15/12:
3:00 a.m. - Patient #4 got out of bed, and RNS10 (registered nurse) and MHTS7 (mental health tech) assisted Patient #4 to the bathroom with RNS9 present in the room;
3:01 a.m. - Patient #4 drifted to the floor of the bathroom; staff left the room;
3:02 a.m. - Patient #4's feet moved and Patient #4 was no longer visible on the video screen (in the bathroom);
3:05 a.m. RNS10 came to the bathroom door, looked in, and left within 4 seconds;
3:10 a.m. - RNS10 and RNS9 entered Patient #4's room and went to the bathroom door;
3:11 a.m. - RNS9 closed the bathroom door and left the room with Patient #4 not visible on the video screen;
3:20 a.m. - bathroom door opened with Patient #4 standing in the doorway and then Patient #4 got on her knees;
3:20 a.m. - 41 seconds later - RNS10 entered Patient #4's room while Patient #4 started to crawl from the bathroom;
3:21 a.m. - RNS10 stood at the side of Patient #4 while she crawled to the bed; no observation of RNS10 moving into a position that looked like an attempt to assist Patient #4;
3:22 a.m. - RNS10 left the room with Patient #4 on the floor at the foot of the bed;
3:24 a.m. - Patient #4 got herself off the floor;
3:26 a.m. - Patient #4 got into bed;
No observation of staff entering room from 3:24 a.m. until 5:43 a.m. when RNS9 entered Patient #4's room;
3:33 a.m. - staff member checked from door of room;
3:57 a.m. - staff member checked from door of room (24 minutes from last observation);
4:16 a.m. - staff member checked from door of room (19 minutes since last observation);
5:02 a.m. - staff member checked from door of room (46 minutes since last observation);
5:25 a.m. - staff member checked from door of room (23 minutes since last observation);
5:38 a.m. - staff member checked from door of room.

Review of Patient #4's medical record revealed a note by RNS9 on 12/15/12 at 3:50 a.m. that Patient #4 complained of stomach cramps and was assisted to the bathroom (50 minutes after time observed on the video). Further review revealed no documented evidence of an assessment by an RN of Patient #4 when she complained of weakness, drifted to the floor, remained in the bathroom for 20 minutes, and eventually crawled back to bed. There was no documented evidence of an assessment of Patient #4 other than a note related to her appearance and mood between 12/14/12 at 7:49 p.m. and 12/15/12 at 9:45 a.m.(assessment by LPNS14).

Review of Patient #4's entire medical record revealed no documented evidence of her vital signs being assessed between 12/14/12 at 7:47 p.m. and 12/15/12 at 6:32 a.m.

In a face-to-face interview on 02/06/13 at 8:00 a.m., MHTS7 indicated during rounds on 12/15/12 Patient #4 complained of leg pain and the need to go to the bathroom. He further indicated he called additional staff to the room, and he and RNS10 assisted Patient #4 to the bathroom. He further indicated when Patient #4 got to the bathroom door, she let her weight go and drifted to the floor. MHTS7 indicated Patient #4 said "leave me alone", so he asked RNS9 (female nurse) to come, since it was a female patient. MHTS7 indicated he remembered Patient #4 crawling and saying "leave me alone".

In a face-to-face interview on 02/06/13 at 8:45 a.m., RNS9 indicated Patient #4 was upset about her medications, because she wanted 25 mg Seroquel, and her physician had ordered Seroquel 50 mg. She further indicated she administered Seroquel 50 mg orally on the night of 12/14/12, and she didn't remember if Patient #4 voiced why she didn't want to take 50 mg. RNS9 indicated Patient #4 did not voice any complaints to her about receiving too much medication or being too sedated. RNS9 indicated a MHT, while making rounds, notified her that Patient #4 needed assistance to go to the bathroom since her legs were weak. She further indicated Patient #4 let herself drift to the floor, was agitated, and said "leave me alone". RNS9 indicated she stayed a few minutes with Patient #4 before leaving her in the bathroom. She further indicated when she went back to the bathroom, Patient #4 was on the toilet, so she (RNS9) placed toilet tissue within Patient #4's reach. She further indicated Patient #4 continued to say "leave me alone". RNS9 indicated Patient #4's roommate came to get the staff when Patient #4 was on her knees in the doorway of the bathroom. She further indicated the male staff wanted to assist Patient #4, but she kept saying "leave me alone". She further indicated she didn't remember anyone actually attempting to assist Patient #4. RNS9 could offer no explanation why Patient #4 was not assessed during the episode of her complaining of weakness and drifting to the floor when assisted to the bathroom.

In a face-to-face interview on 02/06/13 at 9:15 a.m., RNS10 indicated the MHT called him to Patient #4's room. He further indicated when he got there, Patient #4 told him "I told you Seroquel made my legs weak". He further indicated he told her to go to bed, and she said she needed to go to the bathroom. RNS10 indicated he assisted her to the bathroom, and she put her weight on him and then let herself drift to the floor. He further indicated Patient #4 refused help after drifting to the floor. RNS10 indicated he watched Patient #4 from the video monitor at the desk. He further indicated when she came out the bathroom, she was standing and then got to her knees and started to crawl. RNS10 indicated he asked her if she needed help, and she said "don't need no damn help get out of here". He further indicated he didn't physically attempt to help her, because if a patient says "don't touch, I don't touch". RNS10 indicated he was aware Patient #4 was accustomed to taking Seroquel 25 mg, and her physician had ordered Seroquel 50 mg. He further indicated he didn't remember if Patient #4 told him at the time that Seroquel made her legs weak. He further indicated he didn't see the need to report a question about the dose of Seroquel to the physician, because the ordered dose of 50 mg was a sub-therapeutic dose. RNS10 could offer no explanation why Patient #4 was not assessed during the episode of her complaining of weakness and drifting to the floor when assisted to the bathroom.

3) The RN failed to perform an assessment of a patient with elevated blood pressures that were taken by the MHT or the LPN:
Review of the hospital policy titled "Vital Signs", revised 07/26/12 and submitted as the current policy by Accreditation ManagerS6, revealed that an assessment of vital signs included the temperature, pulse rate, respiratory rate, blood pressure, oxygen saturation if pulse oximeter is in use, and pain rating scale. Further review revealed that ancillary staff was to notify the nurse for an acute change in heart rate, systolic blood pressure, diastolic blood pressure, or respiratory rate. Further review revealed that vital signs that differ from the patient's base line were to be reported to the patient's nurse immediately, and the nurse was to re-assess the blood pressure using a manual method. Further review revealed that vital signs were to be documented in the EMR. Review of the procedure revealed the normal adult blood pressure range was 90/60 to 140/90. Further review revealed the appropriate size cuff was to be used, and it should encircle 2/3 of the adult arm. Further review revealed nurse and physician notification was to be documented.

Patient #4
Review of Patient #4's medical record revealed that she was a 50 year old female admitted on 12/13/12 at 1:30 a.m. with the diagnoses of Suicidal Ideations, Depression, and Anxiety. Further review revealed she was PEC'd (physician emergency certificate) on 12/12/12 at 7:20 p.m. due to being suicidal and a danger to self. Further review revealed she was CEC'd (coroner's emergency certificate) on 12/14/12 at 2:10 p.m. due to being a danger to self and unwilling and unable to seek voluntary admission.

Review of Patient #4's "Vital Signs" revealed her blood pressure taken by MHTS16 on 12/14/12 at 6:12 a.m. was 157/76 (157 was documented as "H" meaning high on the vital sign result form). Further review revealed no documented evidence the elevated blood pressure was reported to the RN and that the RN assessed Patient #4's blood pressure by the manual method as required by hospital policy. Further review revealed Patient #4's blood pressure taken by LPNS14 on 12/14/12 at 9:50 a.m. was 170(H)/78. There was no documented evidence the elevated blood pressure was re-assessed by the RN by the manual method as required by hospital policy. Review of nurse's notes documented by RNS15 on 12/14/12 at 10:09 a.m. revealed he notified the physician of Patient #4's increasing blood pressure, and new orders were received. Review of the entire medical record revealed no documented evidence of a physician's order received by RNS15 related to monitoring Patient #4's blood pressure.

Review of Patient #4's "Vital Signs" revealed her blood pressure taken by LPNS14 on 12/19/12 at 10:00 a.m. was 164(H)/78. Further review revealed no documented evidence the elevated blood pressure was reported to the RN, and the blood pressure was re-assessed by manual method by the RN as required by hospital policy. Further review revealed her blood pressure taken by MHTS8 on 12/20/12 at 8:01 p.m. was 146(H)/66. Further review revealed no documented evidence the elevated blood pressure was reported to the RN, and the blood pressure was re-assessed by manual method by the RN as required by hospital policy.

In a face-to-face interview on 02/06/13 at 10:25 a.m., RNS15 indicated he reviewed patients' vital signs in the computer, and staff reported elevated blood pressures to him. He further indicated when an elevated blood pressure was reported to him, he directed the LPN to monitor the patient's blood pressure. RNS15 indicated he didn't always perform a physical assessment of the patient with an elevated blood pressure. When asked if the hospital had a policy that required an RN to assess a patient with a change in condition, RNS15 indicated he didn't know. He further indicated he was aware that the State Board of Registered Nursing required an RN to assess a patient with a change in condition. When asked why he didn't perform a physical assessment of patients with a change in condition, RNS15 indicated he "was utilizing my staff with their report".

In a face-to-face interview on 02/06/13 at 11:20 a.m., RNS15 indicated, after reviewing Patient #4's medical record, he did not perform an assessment of Patient #4 when she had episodes of elevated blood pressure.

Patient #10
Review of Patient #10's medical record revealed she was a 38 year old female admitted on 12/12/12 with diagnoses of Depressive Disorder, Generalized Anxiety Disorder, Panic Attack, Anemia, GERD (gastroesophageal reflux disease), Lupus, and Tietze's Syndrome.

Review of Patient #10's "Vital Signs" revealed the following blood pressure readings:
12/15/12 at 9:47 a.m. by LPNS14 - 158(H)/94(H);
12/15/12 at 1:07 p.m. by MHTS17 - 166(H)/92(H);
12/15/12 at 8:08 p.m. by MHTS8 - 161(H)/97(H);
12/15/12 at 8:09 p.m. by MHTS8 - 157(H)/101(H);
12/16/12 at 7:54 p.m. by MHTS8 - 163(H)/92(H);
12/17/12 at 6:18 a.m. by MHTS8 - 152(H)/97(H).
Review of the medical record revealed no documented evidence of an RN assessment of the elevated blood pressures obtained by the LPN and MHTs that included a manual blood pressure assessment as required by hospital policy.

In a face-to-face interview on 02/06/13 at 8:20 a.m., MHTS8 indicated when he took a patient's blood pressure that was high, he would report it to the nurse. He further indicated there was no way for him to document in the system that he reported it to the nurse. MHTS8 indicated he usually called the nurse to come if the blood pressure was really high, and he also showed the written blood pressures of the patients to the nurse. MHTS8 indicated the nurses did not give him instructions on parameters to use for reporting abnormal blood pressures. He further indicated some of the elevated blood pressures that he would report were 200/110, 190/108, and 180/100.

In a face-to-face interview on 02/06/13 at 10:05 a.m., LPNS14 indicated she reports elevated blood pressures of patients to the charge nurse verbally. She further indicated the elevated blood pressure was "flagged" in the computer as high, and the charge nurse was able to see the results in the computer. LPNS14 indicated she did not document her report of elevated blood pressures to the RN in the patient's medical record. LPNS14 indicated all abnormal blood pressures have to be reported to the RN whether taken by the LPN or the MHT. When asked about Patient #10's blood pressure being 158/94 on 12/15/12 at 9:47 a.m. and not being re-assessed by an RN for the remainder of the shift (blood pressure taken at 1:07 p.m. by MHTS17 was 166/92), LPNS14 offered no explanation.

4) The RN failed to supervise the observation of patients by the MHT that resulted in patient observations not being conducted as ordered by the physician:
Review of the hospital policy titled "Observation Status", revised 01/13/12 and presented by administration as the current policy for patient observations, revealed staff were assigned to monitor and maintain documentation on patients based on their observation status. Further review revealed staff were responsible for maintaining each patient's level of observation during their shift as per their assignment, and communication and coverage between staff members for breaks or off unit activities is essential. Review of the procedure revealed routine observation was defined as a staff member is assigned to observe specific patients every 15 minutes and record the observation on the "Unit Observation" form. Review of the section titled "Document" revealed observations of patients was to be made on the designated form. Review of the entire policy revealed no documented evidence of the specific staff member (RN/LPN/MHT) responsible for making every 15 minute observations, what specifically was to be documented on the form (location and activity), whether the RN was responsible to review and sign the form as required on the observation form, and whether the forms were to be included in the patient's medical record.

Review of the "BMC (Behavioral Medicine Center) Inpatient Unit Monitor" form revealed the following directions: verify each patient's name is correct to the room number, check identification bands and replace as needed, observe patients every 15 minutes, and include location and activity. Further review revealed there were numerous locations listed on the first and second floors with a letter to be entered for each site. Further review revealed there were numerous activities to be selected with a letter to be entered for each activity. The form included a list of room numbers with a space for the patient's name to be written next to it, 15 minute increments for documentation, a space for staff initials, a space for the MHT's name, and a space for the signature of the RN reviewing the observation form.

Review of the "BMC Inpatient Unit Monitor" forms for 12/12/12 at 11:00 p.m. through 12/16/12 at 7:00 a.m. revealed no documented evidence of the name of the MHT who made observations (only initials documented). Further review revealed no documented evidence an RN reviewed the observation forms as evidenced by no form having a signature of the RN in the space provided for the RN review.

Review of Patient #4's medical record revealed that she was a 50 year old female admitted on 12/13/12 at 1:30 a.m. with the diagnoses of Suicidal Ideations, Depression, and Anxiety. Further review revealed she was PEC'd on 12/12/12 at 7:20 p.m. due to being suicidal and a danger to self. Further review revealed she was CEC'd on 12/14/12 at 2:10 p.m. due to being a danger to self and unwilling and unable to seek voluntary admission.

Review of Patient #4's intake assessment performed by RNS13 on 12/13/12 at 1:42 a.m. revealed Patient #4 was brought to into the ED, and Patient #4 stated that she suffered from panic attacks, anxiety, depression, fibromyalgia, and pseudoseizures. Further review revealed Patient #4 stated that she got angry and shot a gun at the dresser. Further review revealed Patient #4's past medical history included the diagnoses of Hypertension, Fibromyalgia, GERD (gastroesophageal reflux disease), Lupus, Multiple Sclerosis, and Pseudoseizures. Further review revealed Patient #4's medication allergies included Imuran and Sulfonamides.

Review of Patient #4's medical record revealed she had physician orders upon admit for "routine observation".

Observation of video surveillance tape conducted via installed hospital security cameras for 12/14/12 from 1:16 a.m. through 12/15/12 at 6:33 a.m., with Vice-President (V) of NursingS2, VP of Organizational EffectivenessS3, and Contracted Clinical DirectorS4 of the psychiatric unit present, revealed the following activity on 12/15/12:
3:26 a.m. - Patient #4 got into bed;
No observation of staff entering room from 3:24 a.m. until 5:43 a.m. when RNS9 entered Patient #4's room;
3:33 a.m. - staff member checked from door of room;
3:57 a.m. - staff member checked from door of room (24 minutes from last observation);
4:16 a.m. - staff member checked from door of room (19 minutes since last observation);
5:02 a.m. - staff member checked from door of room (46 minutes since last observation);
5:25 a.m. - staff member checked from door of room (23 minutes since last observation);
5:38 a.m. - staff member checked from door of room.

In a face-to-face interview on 02/06/13 at 8:00 a.m., MHTS7 indicated on the night shift the MHTs do rounds every 15 minutes, but he "can't say we do it like clockwork". He further indicated if an observation wasn't made every 15 minutes, it was due to the MHT being delayed while providing to care or attention to a particular patient which could "throw the schedule off".

In a face-to-face interview on 02/06/13 at 8:20 a.m., MHTS8 indicated every 15 minute rounds may be "held up" if an admit comes in. He further indicated sometimes he made rounds via the video monitor in the nursing station while standing outside the nursing station. When informed that it was difficult to see a patient on the video screen while seated at the desk in the nursing station in front of the video monitor, MHTS8 indicated "I have done it".

In a face-to-face interview on 02/06/13 at 8:45 a.m., RNS9 indicated when she made patient rounds for every 15 minutes observations, she did not document on the observation form maintained by the MHT. She further indicated she did not review or sign the MHT's observation forms.

In a face-to-face interview on 02/06/13 at 10:55 a.m., Contract Clinical DirectorS4 indicated patients should be checked every 15 minutes through observation by video monitors or by direct visual observation. He further indicated the MHTs should be documenting the patient's location as well as the activity. Contract Clinical DirectorS4 indicated he was not aware the MHTs were not documenting the patient's activity on the observation form, and he did not review the observation forms on a regular basis. He further indicated the RN was supposed to review the observation form maintained by the MHT and sign the form as part of their review. After reviewing the MHT observation forms, Contract Clinical DirectorS4 confirmed none of the observation forms had been signed by an RN. Contract Clinical DirectorS4 indicated the observation forms did not become a part of the patient's record. He further indicated they were kept in a binder in the nurses' station for a few months and then discarded. He confirmed there was no documented evidence in the patient's medical record of every 15 minute observations as ordered by the physician.


30172

5) A review of the hospital policy entitled "Bin Inventory and Supply", revised o

Based on record reviews and interviews, the hospital failed to ensure the non-employee licensed nurses working on the psychiatric unit knew the hospital's policies and procedures in order to adhere to the hospital's policies and procedures. The nursing personnel working on the psychiatric unit of the hospital were contracted from Company A and received no hospital orientation that was provided to clinical staff employed by the hospital. The director of nurses failed to ensure the clinical activities of non-employee nursing personnel working the psychiatric unit were evaluated by an appropriately qualified hospital-employed RN (registered nurse) for 9 of 9 psychiatric nursing personnel files reviewed (S4, S7, S8, S9, S10, S12, S13, S14, S15). Findings:

Review of the hospital policy titled "Employee Orientation", revised 02/17/12 and presented as a current policy by Accreditation ManagerS6, revealed the policy applied to all West Jefferson Medical Center (WJMC) employees. Further review revealed new employees were required to attend general orientation prior to their first day of employment, and department specific orientation would begin immediately after general orientation and would be completed within 30 days of employment. General orientation included human resources policies and procedures, employee health and infection control, corporate compliance program, employee and fire safety, patient rights, sexual harassment, cultural diversity, performance improvement, and customer service. Department specific orientation included a review of the job description and job responsibilities, review of department policies and procedures, review of performance evaluation and expectations, and instructions on equipment used in the department. Review of the entire policy revealed no documented evidence regarding how contracted staff would be oriented.

Review of the hospital policy titled "Ongoing Competency Assessment:, revised 06/29/12 and presented as a current policy by Accreditation ManagerS6, revealed the employees' competency were assessed at hire, within 90 days of employment, and ongoing annually for employees who provide patient care, treatment, or services. Review of the entire policy revealed no documented evidence regarding how contracted staff's competency would be evaluated.

Review of the hospital policy titled "Performance Evaluations", revised )7/08/11 and presented by Accreditation ManagerS6, revealed all full-time and part-time WJMC employees would have introductory period evaluations conducted at the end of the 90 day introductory period and annual performance evaluations annually in October. Review of the entire policy revealed no documented evidence regarding how contracted staff's evaluations would be conducted.

Review of the contract entered into between the hospital and Company A (management of Hospital A) on 07/01/12 and effective until 06/30/13, presented by Vice-President of Organizational EffectivenessS3 as the current contract, revealed the following:
1) Company A was engaged in the business of furnishing psychiatric services, including clinical, clerical, administration, and management support services;
2) Company A would be the independent contractor of West Jefferson Medical Center, and it was agreed that Company A would act solely as an independent contractor in performing the services provided;
3) West Jefferson Medical Center was obligated to provide ready access to Company A the policies and procedures of the hospital that were applicable to the psychiatric unit and all books and records reasonably requested by Company A for the operation of the psychiatric unit;
4) Company A would recruit, hire, train, and maintain a staff of qualified, competent, and trustworthy Company A staff to perform the services and ensure the unit was properly staffed at all times;
5) Company A would have sole and exclusive responsibility for the annual performance evaluations of all Company A staff, subject to WJMC's input;
6) Company A's staff would be subject to the policies and procedures of WJMC to the extent that such policies and procedures do not conflict with the status of Company A as non-employees of WJMC and do not conflict with Company A's policies and procedures.

Review of the personnel files of Contract Clinical DirectorS4, Contract MHTS7 (mental health tech), Contract MHTS8, Contract RNS9, Contract RNS10, Contract RNS12, Contract RNS13, Contract LPNS14 (licensed practical nurse), and Contract RNS15 revealed no documented evidence that of the contracted clinical staff had received orientation, training, competency evaluations, and annual performance evaluations conducted by hospital-employed RN's. There was no documented evidence that any of the contracted clinical staff had received education on WJMC's policies and procedures.

In a face-to-face interview on 02/06/13 at 3:05 p.m., Vice-President of NursingS2 confirmed the contracted clinical staff of the psychiatric unit had not been trained, oriented, or evaluated for competency by a hospital-employed RN.

Based on interview and observation the facility failed to ensure that established policies and procedures were followed that addressed safe practices for the handling and storage of patient food items in patient refrigerator/freezers on patient units. The hospital had 8 pints of reduced fat milk with an expiration date of 01/27/13 on each carton that was available for use by the 16 inpatients.
Findings:
A tour was conducted of the psychiatric unit on 02/04/13 from 9:45 a.m. to 11:45 a.m. Vice-President of NursingS2, Vice-President of Organizational EffectivenessS3 and Contracted Clinical DirectorS4 were present during the entire tour.
An observation was made on 02/04/13 at 11:30 a.m. of the patient refrigerator/ freezer in Room "a". The observation revealed there were (8) pints of reduced fat milk all with expiration dates of 01/27/13.
An interview on 02/04/13 at 11:35 a.m. was conducted with Contracted Clinical DirectorS4. Contracted Clinical DirectorS4 indicated this refrigerator /freezer was for patient use only. Clinical Director S4 confirmed the cartons of milk were expired and indicated they should have been thrown away.

Based on interviews, observations, and record reviews, the hospital failed to ensure foods used for patient use were stored properly and in accordance with hospital policy as evidenced by: 1) staff food items being stored in 1 of 2 patient refrigerator/freezers, 2) staff failing to monitor the freezer temperatures in 2 of 2 patient refrigerator/freezers and 3) staff failing to take action when temperatures in 1 of 2 patient refrigerators were out of the acceptable temperature range for 2 of 3 days reviewed. This deficient practice had the potential to affect the 16 current inpatients.
Findings:
The facility's policy titled "Refrigerator/Freezer Temperature Log", revised on 01/30/13 and provided by administration as the current policy, revealed staff were to monitor and document the temperatures on patient refrigerators/freezers that store medications, food, reagents, and other items used in the care of the patient on the Refrigerator Temperature Log sheet. The policy further reads if the temperature is outside the acceptable range for the type of items being stored, it is to be recorded and immediately reported to the maintenance department as an equipment failure.
A tour was conducted of the psychiatric unit on 02/04/13 from 9:45 a.m. to 11:45 a.m. Vice-President of NursingS2, Vice-President of Organizational EffectivenessS3 and Contracted Clinical DirectorS4 were present during the entire tour.
An observation was made on 02/04/13 at 10:20 a.m. of the refrigerator /freezer in Room "b". The freezer had a container of a frozen green food , a piece of frozen meat partially wrapped in foil, (2) half liter frozen water bottles, (1) 8 ounce frozen water bottle, and (1) 20 ounce frozen PowerAde drink. A further observation of the patient refrigerator/freezer in Room "b" revealed no thermometer present in the freezer to monitor the temperature of the freezer.
An interview on 02/04/13 at 10:25 a.m. was conducted with Contracted Clinical DirectorS4. Contracted Clinical DirectorS4 indicated the refrigerator /freezer in Room "b" was for patient use only. Contracted Clinical DirectorS4 was asked if these above listed food items belonged to patients. Contracted Clinical DirectorS4 indicated these items belonged to staff, and they should not be in the patient's refrigerator/ freezer. Contracted Clinical DirectorS4 was asked if staff monitored the freezer temperatures in this freezer. Contracted Clinical DirectorS4 indicated the temperature of the freezer was not monitored.
An observation was made on 02/04/13 at 11:30 a.m. of the patient's refrigerator/ freezer in Room "a". The temperature log on the refrigerator revealed the temperature of the refrigerator on 02/01/13 was 35 degrees and on 02/03/13 was 34 degrees. The guidelines listed on the Refrigerator Temperature Log sheet taped to the refrigerator revealed guideline #3 "use action column to indicate corrective steps if temperature is not within specified range. Food 36 degrees-38 degrees F (Fahrenheit)". Under the Action column of the same Refrigerator Temperature Log sheet was a staff member's mark indicating no action was needed for the dates of 02/01/13 and 020/3/13. A further observation of the patient refrigerator/freezer revealed no thermometer present in the freezer to monitor the temperature of the freezer.
An interview on 02/04/13 at 11:40 a.m. was conducted with Contracted Clinical DirectorS4. Contracted Clinical DirectorS4 indicated the refrigerator /freezer in Room "a" was for patient use only. Contracted Clinical DirectorS4 indicated the Action column should have documented an action taken by staff to address the out of range temperature for both days. Contracted Clinical DirectorS4 was asked if staff monitored the freezer temperatures in this freezer. Contracted Clinical DirectorS4 indicated the temperature of the freezer was not monitored. .