HospitalInspections.org

Based on review of Medical Staff Bylaws, hospital policies/procedures, hospital document, medical records and interviews, it was determined that the hospital failed to require that physicians provide orders with clear parameters for administration of medication to treat alcohol withdrawal for 3 of 3 patients admitted with alcohol dependence (Pts # 1, 8 and 9).

Findings include:

Review of the hospital's Medical Staff Bylaws dated April 2011 revealed: "...Basic Responsibilities of Medical Staff Members...Abide by the Medical Staff Bylaws and other lawful standards, policies and Rules & Regulations of the Medical Staff...Medical Staff Functions...The functions of the Medical Staff are to:...Conduct or coordinate quality, appropriateness and improvement activities, including procedures, use of medications, medical record...Develop and maintain surveillance over use of medications policies and practices...Coordinate the care provided by members of the Medical Staff with the care provided by the nursing service...."

Review of hospital policy/procedure titled Physician's Orders: (Receiving, Transcription and Verification) revealed: "...Orders written by the physician/practitioner will include:...Drug dosage (strength and concentration)...Quantity and duration...Indication for use on first time of order...."

Review of hospital policy/procedure titled Pharmacy Department-Medication Management Compliance Manual...Medication Ordering and Transcribing revealed: "...Preprinted Medical Orders...In the event an order set or protocol is ordered, it is the prescriber's responsibility to ensure these designated order sets and/or protocols are accurate and complete and meet the patient's needs...."

Review of the hospital form titled Inpatient Admission Orders page 2 revealed a list of medications with columns titled "Yes" and "No." The physician places a check mark in the "Yes" or "No" column to indicate whether the patient is to receive the medication listed. The form also contained a section titled "Dose" which contained dosage instructions for each medication. Review of the dosage instructions for the medication Valium (Diazepam) revealed: "...5 mg (milligrams) po (by mouth) every 2 hours prn (as needed), mild withdrawal symptoms x 5 days (for 5 days) and then discontinue...10 mg po every 2 hours prn, mild to moderate withdrawal symptoms x 5 days and then discontinue...15 mg po every 2 hours prn, moderate to severe withdrawal symptoms x 5 days and then discontinue...20 mg po every 2 hours prn, severe withdrawal symptoms x 5 days and then discontinue...."

Review of medical records:

Pt #1 was admitted on 1/25/12 with alcohol and opiate withdrawal syndrome. On 1/25/12 at 2210, an RN recorded a physician's telephone order for Pt #1, marking the "Yes" spaces by Valium, for each of the dosages listed above. Nursing documented at 0035 on 1/26/12: "...Presented (with) moderate hand tremors, skin dry. BP 136/97 Pulse 80. At 0006, Valium 15 mg, Bentyl 20 mg, TTS 1 patch (Clonidine), & scheduled methadone 10 mg given, Pt to bed-reassessment pending...0105...Pt reassessed-pt observed resting (with) eyes closed respirations even/unlabored with no s/s (signs/symptoms) of distress noted...0200...Pt in bed...(with) eyes closed...0210...Pt observed on floor, eyes rolled back in head...laceration on back of heald (sic)...."

Pt #8 was admitted on 3/27/12 with alcohol dependence. On 3/27/12 at 1630, an RN recorded a physician's telephone order for Pt #8, marking the "Yes" spaces by Valium, for each of the dosages listed above. At 1728, the RN documented: "...Pt continues to be cooperative and tremulous. He denies nausea, vomiting, diarrhea, constipation, hot sweats or cold flashes. His skin is moist and flushed...He has a dry, infrequent cough...he denies anxiety, depression, SI (Suicidal Ideation), HI (Homicidal Ideation) or psychosis & he contracts for safety. 'I'm just tired' he says. His mood is neutral and his affect is blunted. Pt medicated (with) Valium at 1759. Upon reassessment, Pt lying in bed snoring...." The RN recorded administration of 20 mg Valium at 1759 on the Medication Administration Record (MAR).

On 3/27/12, at 2016, the RN documented: "...Pt has warm + dry skin. No flushing. He has mild tremors. He denies nausea, vomiting or diarrhea. Pt is A+O x 4 (Alert and Oriented to person, place, situation and date). Medicated (with) Valium 15 mg and doxepin for insomnia...." The RN recorded administration of 15 mg of Valium at 2016 on the MAR.

On 3/27/12, at 2252, the RN documented: "...pt back at nsg station c/o (complaining of) minor tremors and insomnia. Pt is A+O x 4. He appears sleepy. His skin is warm + dry. He denies n + v (nausea and vomiting) or other w/d (withdrawal) symptoms except tremors. Pt medicated (with) Valium 10 mg and Vistaril...." The RN recorded administration of 10 mg Valium at 2252 on the MAR.

On 3/28/12, at 0600, the RN documented: "...up @ 0223...c/o restlessness; had mod tremor, face flushed, skin moist-BP 131/65 P 110- given Valium 20 mg po...." The RN recorded administration of 20 mg Valium at 0223 on the MAR.

On 3/28/12, at 0651, the RN documented: "...c/o w/d s/s-mod. tremors...face is flushed. Skin moist, P...116-BP 138/58-given Valium 20 mg po-to be assessed by morning RN...." The RN recorded administration of 20 mg Valium at 0651 on the MAR.

On 3/28/12, at 1835, an RN documented: "...Pt had decreased tremor at 751. Pt denied any GI (Gastrointestinal) distress. Skin warm & dry. He had elevated pulse 126 & fine tongue tremor & hand tremor. Pt was medicated (with) Valium 5 mg po at 1028...Pt denied withdrawal pain...pt had (increased) pulse 128-given at 1254 Valium 5 mg po. Had diarrhea...had (decreased symptoms at 1354...." The RN recorded administration of 5 mg Valium at 1028 and 1254 on the MAR.

On 3/28/12, at 1945, an RN documented: "...Valium 5 mg po admin @ 1845 for mild ETOH (alcohol) w/d sx (symptoms) of facial flushing, fine hand, facial & tongue tremors. V/S (vital signs) @ 1735: 99.9-117-18 126/62...denies n/v, dyspepsia, anorexia or diarrhea. Skin warm, dry. By 1945, V/S 98.9-110-18 128/69. No (change) noted in tremors as previously described...reporting chief c/o is that of...leg weakness...." The RN recorded administration of 5 mg Valium at 1845 on the MAR.

On 3/28/12, at 2330, an RN documented: "...cont'd to deny c/o pain @ time of doxepin 50 mg po admin prn insomnia. By 2330...on (right) side (with) eyes closed. Respirations slow, regular, deep...."

On 3/29/12, at 0630 an RN documented: "...pt in room in bed appeared asleep...."

On 3/29/12, at 1100 an RN documented: "...+ tongue tremor (with) very fine hand tremor. Continues to feel weak but says this is better. Poor sleep last noc. Eating & drinking fluids well...." The RN did not administer any Valium.

On 3/29/12, at 1330, an RN documented: "...Valium 5 mg given at 1210 (with) (decreased) tremor by 1310...." The RN recorded administration of 5 mg Valium at 1211 on the MAR.

Pt #9 was admitted on 3/26/12, with alcohol and benzodiazepine dependence. He was at risk for self harm as well. On 3/26/12, at 1345, an RN recorded a physician's telephone order for Pt #9, marking the "Yes" spaces by Valium, for each of the dosages listed above. The patient was also receiving Klonopin on a routine basis with gradually decreasing doses. At 1515, the RN documented: "...Feels under the influence of his benzos-lethargic...."

On 3/26/12, at 1630, an RN documented: "...describing his mood today as 'A little freaked out' 'Anxious'...rating anxiety level @ 8/10, Depression @ 7/10..." (on scale of 0-10 with 0 low).

On 3/26/12, at 1820, an RN documented: "...Valium 15 mg admin @ 1722 for ETOH withdrawal symptoms of fine hand & tongue tremors, diaphoresis & anxiety level rated @ 8. By 1820...states symptoms (without) (change). Describes his shallow breathing & anxiety as most troublesome...."

On 3/26/12, at 2000, an RN documented: "...Vistaril 50 mg po, Zofran 4 mg po admin @ 1907 for c/o anxiety rated @ 8-9/10, nausea (without) vomiting. By 2000, reports anxiety (decreased) 7/10, 'nausea's gone'...."

On 3/26/12, at 2215, an RN documented: "...Valium 20 mg po admin @ 2122 for mod hand & tongue tremors, diaphoresis. By 2215, tremors (decreased) by 50%...2330 Doxepin 50 mg po prn insomnia admin @ 2232...."

On 3/27/12, at 0625, an RN documented: "...Pt rested in bed (with) eyes closed. At 0300, BP 84/60 Pulse 88. Fine hand tremors, but BP (decreased). At 0523, BP 106/93 Pulse 92. Presented (with) mild hand/tongue tremors. Skin warm & dry. c/o jaw pain 6/10. Valium 15 mg, Ibuprofen 600 mg & Baclofen 10 mg given at 0523. By 0623, resting in bed (with) eyes closed. Respirations even & unlabored...."

On 3/27/12, at 1530, an RN documented: "...Given Valium 10 mg @ 1432 for facial flushing mild tremor- (decrease) in symptoms by 1532...."

On 3/27/12, at 1647, an RN documented: "...Pt socializing (with) peers in the dayroom. he rates anxiety '7/10' and depression '8/10'...'I was in my room all day sweating and thinking.' pt reporting visual hallucinations 'It's hard to describe'...Pt c/o mild nausea, sweats, anxiety...fine tremors...skin is warm & dry. pt medicated (with) Valium 10 mg...Upon reassessment...his tremors are no longer felt...anxiety ...'7/10'...appears totally relaxed & calm...."

On 3/27/12, at 2103, an RN documented: "...pt c/o abd. cramps and cold sweats. He has fine tremors. His skin is warm & dry. Pt medicated (with) Valium 20 mg...."

On 3/28/12, at 0656, an RN documented: "...Eyes closed, reg. resp. up @ 0556-mild-mod tremors-BP 111/73 P 90-Valium 10 mg po given fu (follow/up) c/o w/d s/s. On reassess @ 0656, pt expressed improvement of symptoms...." The RN recorded administration of 10 mg Valium at 0556 on the MAR.

On 3/28/12, at 1000, an RN documented: "...'So much anxiety'...#9...tense affect & restless...Rcvd his Klonopin & Valium re: withdrawal...fine tremor, sweats anxiety & visual disturbances...Given Valium 10 mg (with) (decrease) tremor...."

On 3/28/12, at 1530, an RN documented: "...Valium 10 mg for + tremor...."

On 3/28/12, at 1620, an RN documented: "...Pt is A+O x 4. His skin is flushed, warm + dry. he continues to report visual hallucinations at the same intensity as yesterday...Pt rates his anxiety '8/10' down from 9. He also is reporting transient irritability. He has no n + v. No tremors. He is asking for more Valium (denied)...."

On 3/28/12, at 2036, an RN documented: "...Pt has mild tremors. he is rating anxiety '7/10'...pt is A + O x 4. His skin is warm + dry. Pt medicated (with) Valium 10 mg...when reassessed at 2130, pts tremors are gone...."

On 3/29/12, at 0600, an RN documented: "...Pt in room in bed appeared asleep...."

On 3/29/12, at 0649, an RN documented: "...pt c/o hand tremors mild (with) face flushing & leg cramps given Valium 10 mg po...."

On 3/29/12, at 0900, an RN documented: "...Still asking for Valium 'to calm him'...c/o leg spasms, sweats last noc. No hand tremor-Very fine tongue tremor. Given his scheduled Klonopin...."

On 3/29/12, at 1730, an RN documented: "...VS 96.2-116-18 109/53 Fine hand tremors. Skin warm & dry. Facial Flushing noted. Very fine tongue tremors noted. Valium 5 mg given @ 1707. by 1800, (decreased) Facial Flushing, (decreased hand tremor noted...."

RN #30 confirmed during interview conducted on 3/30/12 at 1430, that the nurses do not have a definition of withdrawal symptoms to use to determine whether a patient's withdrawal symptoms are mild, mild to moderate, moderate to severe, or severe in order to determine the dose of Valium to administer in accordance with the order set. She stated that she has her own materials that she uses to assess patients' withdrawal symptoms and other nurses have their own reference materials. She confirmed that these materials have not been reviewed and accepted by the medical staff and that the hospital has not provided any objective means to determine severity of withdrawal symptoms and dosage of Valium to administer.

MD #1, the Medical Director, confirmed during an interview conducted on 4/3/12, that the facility does not have a protocol for alcohol detoxification. The physicians use the order set with the dosages of Valium and some physicians have their own protocols. He confirmed that there is not an objective definition of mild, mild to moderate, moderate to severe, or severe withdrawal symptoms to accompany the orders. He stated that in the past, the hospital had a scale which was used to provide an objective scoring tool to determine dosage of Valium based on symptoms of alcohol withdrawal, but this scale has not been used for several years. He did not believe that the medical staff made a decision to discontinue its use and he didn't know if the medical staff had originally adopted the scale. He stated that some of the nurses do well at assessing patients and determining dosage of Valium and some of the nurses are variable in their ability to determine dosage. In addition, he confirmed that the orders do not specify a maximum amount of Valium to administer in a 24 hour period without notifying the physician.

RN #7, confirmed during interview conducted on 4/4/12 at 1030, that the order set for administration of Valium for withdrawal symptoms does not include the frequency that nurses are to assess the patients for withdrawal symptoms. She stated that the Medical Staff has not developed definitions of symptoms for administration of Valium and has not given direction for required frequency of assessments of symptoms.

Based on review of hospital policies/procedures, hospital documents, medical records, direct observation and interviews, it was determined the hospital failed to protect and promote each patient's rights as evidenced by:

(A 143) failing to protect the patient's right to privacy; and

(A 144) failing to protect the patient's right to receive care in a safe setting.

The cumulative effect of these systemic problems resulted in the hospital's failure to protect and promote each patient's rights.

Based on review of hospital policies/procedures, interviews and review of hospital documents, it was determined that the hospital failed to protect the privacy of patients admitted to the Observation Services for Child and Adolescent (OSCA) Children & Adolescent Programs.

Findings Include:

Review of hospital policy/procedure titled Patient's Rights and Responsibilities revealed: "...Patient's rights are as follows:...To be treated with dignity, respect, and consideration...To privacy in treatment...."

Review of hospital policy/procedure titled Observation Services for Child & Adolescent-(OSCA) Children & Adolescent Programs revealed: "...(OSCA) program located on the CAS (Child and Adolescent Services) unit within St. Luke's Behavioral Health Center...Patients in the OSCA program will have an anticipated length of stay no longer than 23 hours...The RN or designee will ensure the patient's safety, privacy...."

Nurse Practitioner (NP) #8, the "OSCA" Coordinator, stated during interview conducted 4/3/12, that "OSCA" patients remain in the inpatient milieu (day room) throughout their stay in the program. They are integrated into the Inpatient Program on the Child and Adolescent Units. Patients 3 yrs old through 12 yrs old stay in the day room on the Child Unit and patients 13 yrs old through 17 yrs old stay in the day room on the Adolescent Unit. "OSCA" patients do not have assigned rooms. If they are present during the night, they sleep in the day room in a temporary bed. If the inpatient unit has a vacant bed, the "OSCA" patient may sleep in that bed, however, if an inpatient is admitted during the night and is in need of that bed, the "OSCA" patient will be moved to the day room. There is no maximum capacity to the OSCA program.

RN #50 stated during interview conducted on 4/5/12, that "OSCA" patients utilize a bathroom in a corridor adjoining the nurses' station. This bathroom is located between the Child Unit and the Adolescent Unit. (The nurses' station separates the two units.) She stated that "OSCA" patients also use inpatients' bathrooms, providing that the "OSCA" patient is the same gender as the inpatient assigned to the room with the bathroom.

Review of medical record:

Pt #38 was brought to the hospital and the OSCA program on 4/2/12, at 1745. His medical record contained documentation that he was assigned to "...295-D rollaway bed...." He was discharged at 1215 on 4/3/12.

Review of Child and Adolescent Unit Daily Patient Assignment Sheets and Station Census Sheets revealed the following "OSCA" patients:

2 adolescents on 7-3 shift 1/24/12;
2 adolescents on 11-7 shift 1/24/12;
2 adolescents on 7-3 shift 1/25/12;
2 adolescents on 11-7 shift 1/25/12;
1 adolescent on 7-3 shift 1/26/12;
2 adolescents on 3-11 shift 1/26/12;
1 adolescent on 11-7 shift 1/26/12;
1 child and 2 adolescents on 7-3 shift 1/27/12;
2 adolescents on 3-11 shift on 1/27/12;
2 adolescents on 11-7 shift on 1/27/12;
4 adolescents on 7-3 shift on 1/28/12;
1 child and 1 adolescent on 3-11 shift on 1/29/12;
1 child and 1 adolescent on 11-7 shift on 1/29/12;
1 child and 1 adolescent on 7-3 shift on 1/30/12;
1 adolescent on 7-3 shift on 1/31/12;
2 adolescents on 3-11 shift on 1/31/12;
1 adolescent on 11-7 shift on 1/31/12;
1 adolescent on 7-3 shift on 2/1/12;
2 adolescents on 3-11 shift on 2/1/12;
1 child and 2 adolescents on 11-7 shift on 2/1/12;
1 child and 2 adolescents on 7-3 shift on 2/2/12; and
2 children on 11-7 shift on 2/3/12.

One "OSCA" adolescent patient was present
during survey on the 7-3 shift 4/5/12.

Privacy was not provided for "OSCA" patients.

Based on review of hospital documents, medical records, direct observation and interview, it was determined that the hospital failed to protect the patients' right to receive care in a safe setting as evidenced by:

1. failing to prevent the elopement of 1 of 1 adolescent patient who required inpatient hospitalization and demonstrated aggressive and impulsive behaviors (Pt #29);

2. failing to provide an environment that is free of fixtures, surfaces, and/or equipment conducive to self-injury or suicide for children and/or adolescents in the "OSCA" program; and

3. failing to provide necessary supervision of Pt #2 to prevent unsafe behavior and failing to provide for safety of 1 of 1 adolescent patient (Pt #3) who was touched inappropriately by her roommate (Pt #4).

Findings include:

Review of the hospital document titled St. Lukes Behavioral Health Center Program Description revealed: "...Child/Adolescent Services/Urgent Care...The Child and Adolescent Inpatient Program...provides a 24-bed secure, inpatient program...provides a safe and therapeutic environment...."

Review of medical record:

Pt #29, a minor patient, was admitted on 1/9/12. His medical record contained documentation that the patient required 1:1 supervision from the date of his admission through 4/4/12 due to aggressive and impulsive behaviors. It also contained a physician's order written 2/6/12 at 1640: "...May go outside (with) 2 staff...." This order had not been changed as of 4/4/12.

On 4/3/12, at 1330, an RN documented: "...Pt engaged in threatening bx (behavior) towards staff per throwing feces at staff. Pt unable to contract for safety towards self or others...Pt became upset tearing posters in room & threatening staff. Pt escorted out of room by staff, & placed in S & R (Seclusion & Restraint) due to aggressive bxs (behaviors)...."

On 4/3/12, at 1615, an RN documented: "...At change of shift pt became agitated. Broke staff clipboard & began screaming...."

On 4/4/12, at 1130, an RN documented: "...Pt was on child side patio (with) psych tech. Pt asked PT (Psych Tech) to make a phone call. PT opened door to go back onto unit & pt pushed through the door & ran downstairs to courtyard. Pt went to (left) side of courtyard & climbed the fence. PT was able to stop pt. Security was called & pt was brought back to unit @ 0755...Pt noted to have multiple abrasions...."

On 4/5/12, direct observation of the hallway outside of the Child and Adolescent Units, the Child Side Patio, and the outside courtyard revealed:

The Child Side Patio is at the end of the hallway outside of the Children's Unit. RN #50 explained during interview conducted on 4/5/12, that Pt #29 was escorted by the PT from the Adolescent Unit to the Child Side Patio. The patio is locked. When the patient pushed the patio door open, he was able to access the unlocked door from the hallway to the outside courtyard. RN #50 confirmed that the door leading from the hallway to the courtyard is never locked. The Patient Safety Officer confirmed, on 4/6/12, that the door leading from the hallway to the courtyard is a "fire door" and not permitted to be locked.

Observation of the fence in the courtyard revealed that an individual can climb over one portion of the fence and leave the hospital grounds. RN #50 confirmed that Pt #29 succeeded in leaving the hospital grounds via that portion of the fence.

Pt #29 had been escorted by one PT down the hallway between the Adolescent Unit and the Children's Unit to the Child Side Patio. Once the patient was in the hallway, he had access to the outside via the unlocked door. The patient was only to be outside with 2 staff. Escorting the patient down the hallway by one PT created an unsafe condition and the courtyard itself was not fenced adequately to prevent his elopement.

2. On 4/6/12, direct observation of the bathroom utilized by patients in the "OSCA" program revealed the following safety hazards:

The bathroom has a full sized bathtub which presents a hazard itself. The bathtub spout is a horizontal surface of several inches. Guard rails surround the tub and a vertical rail is located on the wall above the tub. The toilet has exposed plumbing fixtures and guard rails surround the toilet.

Employee #13, the Patient Safety Officer, confirmed the safety hazards during tour of the bathroom conducted on 4/6/12. She stated that patients are allowed to use the bathroom with the door closed and staff standing outside the door.

3. Cross reference Tag A 0395 for information regarding Pts # 2, 3 and 4 and the policy/procedure titled Special Observation Precautions.

On 3/29/12, at 1600, the Lead Nurse Manager confirmed that Pt #2 was able to consume toilet water, enter another patient's room and pull a light fixture off the wall while on "Close Watch." She also confirmed that the patient's treatment plan did not address the patient's requirement for supervision, or any consideration to provide for closer supervision.

On 4/3/12, at 1200, MD #1 confirmed that he admitted Pt #2 on PAC Status, which requires only hourly rounds. He stated that he was aware that the patient had been able to consume toilet water and pull a 50 lb light fixture off the wall. He stated that he was not aware that the nursing staff had placed the patient on Close Watch. He stated that nursing did not discuss in the treatment team meetings any need for the patient to be on Close Watch or 1:1.

RN #9, the Nurse Manager of the Child and Adolescent Unit, confirmed during an interview conducted on 4/5/12 at 1405, that the MD order "1:1 while asleep" meant that Pt #4 would be supervised 1:1 from 1900 through 0700, since patients on the Children's Unit are in their rooms in bed from 2000 through 0700. In addition, Pt #4 was not to be in her room alone with any peer. RN #9 recalled that she had informed the staff of the patient's requirement for supervision and intent of the order. She confirmed that a Psych Tech was not assigned on 1/29/12 from 1900 through 2300 to supervise Pt #4 on a 1:1 basis as required and that Pt #4 had been allowed in her room alone with her roommate (Pt #3).

Based on document review, review of medical records and interviews, it was determined that the hospital failed to analyze the causes of adverse patient events, implement preventive actions and mechanisms that include feedback and learning throughout the hospital as evidenced by:

1. failing to identify in the review of an adverse patient event (Pt # 3) that a physician's order for 1:1 supervision of Pt # 4 was not implemented and that the order required interpretation;

2. failing to identify in the review of an adverse patient event (Pt #1) that policy/procedure for fall risk assessment was not followed and required clarification;

3. failing to identify patient safety and privacy issues for patients attending the "OSCA" Program; and

4. failing to identify the patient safety issues related to the management of alcohol withdrawal by medical staff and nursing staff.

Findings include:

1. Review of facility report documentation regarding (Pt #3) revealed: "...Description of actions taken to prevent recurrence: (Pt #3) was examined and there was no evidence of assault...Both girls were separated and (Pt #4) was initially placed in a fold away bed in the milieu...A 1:1 sitter...provided...Then she was given a private room...(Pt #4) has identified predatory issues that are being addressed in her treatment...Additionally, staff will be receiving education predatory behavior...Boundary setting and supervision of these patients will also be a significant part of this training...."

Cross reference Tag A 395 for information regarding Pt #4.

MD #5 confirmed during interview conducted on 4/5/12 at 1603, that Pt #4 had very poor impulse control and was not able to control herself. On 1/23/12, MD # 5 had placed the patient on 1:1 supervision for 24 hours per day. She could not recall why she changed the order to "1:1 while asleep" on 1/29/12, but stated that the nurse called her for the order. She stated that her intent of the order was that the patient was to be supervised 1:1 during sleeping hours and whenever the patient was in her room with another patient.

RN #9, the Nurse Manager of the Child and Adolescent Unit, confirmed during an interview conducted on 4/5/12 at 1405, that the MD order "1:1 while asleep" meant that Pt #4 would be supervised 1:1 from 1900 through 0700, since patients on the Children's Unit are in their rooms in bed from 2000 through 0700. In addition, Pt #4 was not to be in her room, unsupervised, with any peer. RN #9 recalled that she had informed the staff of the patient's requirement for supervision and intent of the order. She confirmed that a Psych Tech was not assigned on 1/29/12 from 1900 through 2300 to supervise Pt #4 on a 1:1 basis as required and that Pt #4 had been allowed in her room, unsupervised, with her roommate.

RN #9 also confirmed that the follow-up education for staff to prevent recurrence did not include the fact that the physician's order was not implemented for supervision of Pt #4 and did not focus on interpretation of the order to mean that Pt #4 was not to be in her room, unsupervised, with a peer.

2. Review of facility report documentation regarding Pt # 1 revealed: "...Description of actions taken to prevent recurrence: This case will be reviewed during the Nursing Unit meeting to identify additional fall precautions measures that may be implemented for patients who may be heavily sedated during hours of sleep...."

Cross reference Tag A 395 #2 for information regarding Pt #1.

RN # 42 stated during interview conducted on 4/5/12 at 0828, that when she assesses a patient for fall risk, she doesn't have the physician order sheet and doesn't know exactly what medications the patient will be receiving. She knew that she would be giving Pt #1 a psychotropic and an antihypertensive. During the interview, she reviewed the medications that she administered to the patient. She didn't know how to score Valium or Methadone. She was aware that Lyrica is sedating and a Schedule V drug, but she did not know how to score it. She stated that she thought she scored one point for each category of medication, not one point for each medication within a category. She confirmed that the hospital had not clarified the scoring of medications. She confirmed that she did not place the patient on 15 minute checks as required by policy. She stated that she thought that 15 minute checks were required for patients in the High Fall Risk category. She stated that the policy/procedure had been changed and she had not received training on the changes.

RN #7, the Nurse Manager of the Adult Chemical Dependency Inpatient Services, stated during an interview conducted on 4/5/12 at 1530, that she would score Lyrica, Methadone and Valium as sedatives and assign a score of 3 for Pt #1's Medication Risk Factor. She was unaware that patients scored as Moderate Fall Risk required 15 minute checks. She believed that 15 minute checks were required for High Fall Risk. She also reviewed the orientation materials during the interview and confirmed that the Nursing Orientation materials for Fall Risk Assessment contain instructions to place patients at High Risk for falls on 15 minute checks. It did not contain instructions to place patients at Moderate Risk for falls on 15 minute checks. She confirmed that the orientation instructions do not correspond with the policy/procedure.

Review of the Action Plan contained in the Meeting Minutes of the AP 3 and AP 4 Units, conducted on 2/22/12 by RN # 7 revealed that it did not contain information regarding scoring of medications and/or the requirement of policy/procedure to place patients assessed as Moderate Fall Risk on 15 minute checks.

3. Cross reference Tag A 143 regarding "OSCA" patients' privacy issues.

Cross reference Tag A 144, #2 regarding "OSCA" patients' bathroom safety issues.

4. Cross reference Tag A 0049 for medical staff issues related to management of patients admitted for alcohol dependence and withdrawal.

Cross reference Tag A 0386 for nursing services' issues related to the care of patients admitted for alcohol dependence and withdrawal.

Based on review of the Medical Staff Rules and Regulations, medical record, and staff interview, it was determined the medical staff failed to provide information to the patient's family for an autopsy for the unexpected death of the patient.

Findings include:

Patient #12's medical record revealed the patient was admitted to the facility on 02/28/12 with mood swings, panic attacks, agoraphobia, depression, and reoccurring flashbacks.

The patient's past medical history included tendonitis and pain in right ankle, shortness of breath (SOB) and insomnia. The history and physical revealed the patient's assessment included the following: chronic obstructive pulmonary disease (COPD), rule out sleep apnea syndrome, insomnia, morbid obesity, and hypercholesterolemia.

Patient #12 was found on 03/07/12 at 0715 hours, cyanotic, apneic, and pulseless. A code arrest was initiated, however, the resuscitation was unsuccessful.

The discharge summary revealed the patient "died from natural causes and complications from his COPD, hyperlipidemia, and morbid obesity."

Medical Staff Rules and Regulations requires: "...All unusual deaths...shall be reported...If the Medical examiner determines this is not a Medical Examiner case...will provide information...to assist...obtaining the requested autopsy...."

The Director of Quality, Risk and Education confirmed during an interview conducted on 04/05/12, that "routinely," the patient's family is given a hospital handout titled "Autopsy Information For Families" to assist the family in making a decision for autopsy.

There was no documentation found in the patient's medical record that the facility provided the patient's next of kin with the autopsy information required by Medical Staff Rules and Regulations. The Director of Quality confirmed the above findings.

Based on review of hospital policies/procedures, hospital documents, medical records, personnel records and interviews, it was determined the hospital failed to provide an organized nursing service 24-hours per day with an adequate number of registered nurses and competent nursing staff to assess patients' care needs and deliver, assign and supervise the care required by each patient as evidenced by:

(A 386) failing to require a well-organized nursing service plan with documented delineation of responsibilities for patient care;

(A 392) failing to provide the nursing care needed by a patient;

(A 395) failing to require that a registered nurse provide the supervision and evaluation of care needed by each patient; and

(A 404) failing to require that drugs be administered in accordance with the orders of the practitioner responsible for the patient's care.

The cumulative effect of these systemic problems resulted in the hospital's failure to provide an adequate, organized nursing service.

Based on review of hospital policies/procedures, hospital documents, medical records, personnel records and interviews, it was determined that the hospital failed to have a well-organized nursing service plan with documented delineation of responsibilities for patient care as evidenced by:

1. failing to have documented policies/procedures related to nursing protocols for patients receiving medication for symptoms of withdrawal as evidenced in 3 of 3 patient records reviewed (Pts #1, 8 and 9); and

2. failing to have a documented process to ensure that RN's have the necessary competencies to provide services to 3 of 3 patients admitted with alcohol dependence.

Findings include:

Review of the hospital document titled St. Lukes Behavioral Health Center Program Description revealed: "...Adult Chemical Dependency...This program serves those individuals ages 18 and older requiring detoxification and treatment for alcohol, stimulants, opiates, prescription drugs, illicit drugs or methadone. The program provides a 22-bed secure, inpatient program which provides a safe and therapeutic environment to assist in the assessment and stabilization of acute detoxification and treatment of severe substance abusing individuals...."

Cross reference Tag A 0049 for information regarding the order sets for administration of Valium for withdrawal symptoms; information regarding Pts #1, 8 and 9, including the dosages of Valium administered to each patient and interviews conducted with RN's #30 and 7 and MD #1.

1. The Director of Quality, Risk Management and Education confirmed during an interview conducted on 4/6/12, that the facility was unable to provide policies/procedures related to detoxification of patients.

2. Review of Pt #1's medical record revealed:

RN # 42 assessed his withdrawal symptoms and administered Valium on 1/26/12, at 0006.

Review of Pt #8's medical record revealed:

RN #27 assessed his withdrawal symptoms and administered Valium on 3/27/12, at 1759 and 2252;
RN #34 assessed his withdrawal symptoms and administered Valium on 3/28/12, at 0223 and 0651;
RN #26 assessed his withdrawal symptoms and administered Valium on 3/28/12, at 1028 and 1254;
RN #28 assessed his withdrawal symptoms and administered Valium on 3/29/12, at 1211.

Review of Pt #9's medical record revealed:

RN #42 assessed his withdrawal symptoms and administered Valium on 3/27/12, at 0523;
RN #30 assessed his withdrawal symptoms and administered Valium on 3/27/12, at 1432;
RN #27 assessed his withdrawal symptoms and administered Valium on 3/27/12, at 1647 and 2103 and on 3/28/12, at 2036;
RN #28 assessed his withdrawal symptoms and administered Valium on 3/28/12, at 1000 and 1536;
RN # 32 assessed his withdrawal symptoms and administered Valium on 3/29/12, at 0649;
RN #33 assessed his withdrawal symptoms and administered Valium on 3/29/12, at 1707.

Review of RN #42's personnel file revealed that her competency to assess and interpret alcohol withdrawal symptoms was last assessed in 2010;
Review of RN #34's personnel file revealed that her competency to assess and interpret alcohol withdrawal symptoms was last assessed in 2010;
Review of the personnel files of RN's #26, 27, 28, 30, 32 and 33 revealed that they did not contain documentation of competency to assess and interpret alcohol withdrawal symptoms.

The Director of Quality, Risk Management and Education stated on 4/6/12, that RN competency to assess and interpret alcohol withdrawal symptoms was to be evaluated annually.

The Nurse Manager of the Inpatient Chemical Dependency Program stated during an interview on 4/4/12, that RN competency to assess and interpret alcohol withdrawal symptoms is not an annual competency. She stated that competency is determined at the time of hire and that RN's receive significant training. She was unable to provide documentation of the training, other than the orientation packet which included definitions of Mild, Moderate, and Severe Withdrawal. The packet did not include definitions of "Mild to Moderate," or "Moderate to Severe." It also did not contain guidelines for frequency of assessment. She confirmed that the hospital has no specific clear criteria for nurses to use in assessing alcohol withdrawal symptoms.

Based on review of hospital documents, medical records and staff interviews, it was determined the patient was found unresponsive and cyanotic; .hospital personnel failed to document Patient #12's breathing on the hourly rounding sheet.

Findings include:

The hospital document titled "Psych Tech Orientation" requires: "...Patient room check...at least every hour...You are to GO INTO the room make sure...ONE patient per bed...they are BREATHING. Chart on round sheet...."

The patient's hourly rounding sheet is divided into six separate lines to include six separate patients and their room numbers. There is nine (9) rows for hourly documentation (time line of 12 am through 7 am) for location and activity codes of the patient and one large box for comments for each patient. The location key is as follows: R = room, M = milieu, K = kitchen, etc. The activity key code is as follows: 1 = working on packet, 10 = sleeping, 13 = awake, etc. There is a line for staff initials below each time.

Patient #12's hourly rounds dated 03/07/12, revealed (R/10) the patient was asleep in his room. The comment section shows a number 8, however, there was no additional documentation describing the patient's breathing/respirations.

Behavioral Health Technician (BHT) #38 and RN #10, confirmed during an interview conducted 04/05/12, the number 8 in the comment section was the total number of hours the patient slept during the night.

The BHT remembers the patient was propped on pillows and was covered with a blanket. The BHT confirmed he checks the patient's face using a flash light directed at the wall, careful to not shine the light directly into a patient's face and is careful not to wake the patient. The BHT confirmed he does not check vital signs unless requested by the nurse.

RN #10 confirmed she did hourly rounds on the patients at 0400 and 0600 hours during the night. The nurse confirmed she also uses a flashlight and assesses the patient's breathing by standing over the patient and listening and watching for breathing. The RN confirmed the patient's death was unexpected.

The Multidisciplinary treatment plan Nurses Notes dated 03/07/12 at 0600 hours, revealed the patient "slept through the night respirations even." The Multidisciplinary Notes at 0715 revealed the patient was found unresponsive, code blue called, and patient found lying on his stomach.

The Resuscitation Record revealed at 0712 hours Cardio Pulmonary Resuscitation (CPR) was started. At 0721 the code team arrived. At 0736 CPR was terminated.

The Code Blue Summary dated 03/07/12 at 0730 hours revealed: patient found cyanotic, apneic, and pulseless; respirations per BVM (bag valve mask); CPR in progress; pupils fixed and dilated; tongue edematous protruding from clenched jaw; attempts to secure airway unsuccessful due to clenched jaw; patient appears mottled, pulseless and apneic throughout resuscitation; time of death declared at 0736.

Based on review of policy/procedure, medical records, and interviews, it was determined that the hospital failed to require that an RN supervise and evaluate the nursing care of each patient as evidenced by:

1. failing to evaluate the supervision needs of 1 of 2 patients admitted to the Psychiatric Intensive Care Unit (Pt #2) and failing to provide required supervision/observation for 1 of 1 minor patient who touched her roommate inappropriately during "room time" (Pt #4); and

2. failing to implement Moderate Fall Risk interventions as required by policy for 1 of 1 patient who sustained a head laceration during a fall.

Findings include:

1. Review of the hospital policy/procedure titled Special Observation Precautions revealed: "...Policy...Patients who are assessed as requiring additional observation/interventions to maintain a safe and/or therapeutic status will be placed on Special Observation Precautions...Procedure...A. The multi-disciplinary treatment team and ongoing nursing will assess the patients (sic) need for Special Observation based on the following criteria:...Acute psychosis resulting in danger to self/danger to other behaviors...Patient acutely disruptive to the milieu requiring continual limit setting/cues from staff...Patient exhibiting sexual acting out behaviors...B. The RN will contact the physician to obtain order for 1:1, which is defined as follows:...1. 1:1...One staff member is assigned to the patient, and shall be within arms reach of the patient at all times...C. A physician order may be obtained or nursing judgment may be used to implement Close Watch or PIC status which is defined a (sic):...Close Watch:...Patient will be checked every 15 minutes for safety/appropriate behavior...D. Documentation:...Patients with Special Observation Precautions will be charted on every 15 minutes using the Special Observation Precautions Assessment Sheet...Patients assigned to PIC status will automatically be observed and documented on every 15 minutes using the Special Observations Precautions Assessment form...."

Review of medical record:

Pt. #2 had been missing from her residential placement since March 2, 2012. She was found by police, wandering the streets and was taken to the Urgent Psychiatric Center (UPC). She was hearing voices, telling her to hurt people and displayed aggressive behavior, such as throwing a pitcher of iced tea on a peer and throwing hot coffee at staff.

She was admitted on 3/6/12, with severe psychotic symptoms; transferred from the UPC.

On 3/6/12, at 1645, an RN recorded telephone admission orders from Physician #1, which included placing the patient on "Adult Psychiatry Acute Status" (PAC). She was placed in the Psychiatric Intensive Care Unit (PIC). Nursing placed the patient on "Close Watch," requiring documentation every 15 minutes. The patient continued to be on "Close Watch" on 3/27/12, when, at 2157, an RN documented: "...Pt observed by peers drinking toilet water out of cup. Cup surrendered by pt & redirectable. Also observed coming out of peer's room. Re-oriented to her own bedroom...."

On 3/27/12 and 3/28/12, the physician documented in the progress notes: "...No Special Precaution Orders...."

On 3/28/12, the patient continued to be on "Close Watch" per nursing judgment. At 2330, an RN documented: "...Pt requiring multiple redirection. Intrusive to peers, for example taking food from peers. Pt pulled light fixture above roommate's bed out of wall...pt moved to private room where can be closely monitored...."

On 3/29/12, at 1120, the physician documented in the progress notes: "...Pt was psychotic & pulled off a 50 lb light fixture last night, very psychotic...No Special Precaution Orders...."

On 3/29/12, at 1600, the Lead Nurse Manager confirmed that the patient was able to consume toilet water, enter another patient's room and pull a light fixture off the wall while on "Close Watch." She also confirmed that the patient's treatment plan did not address the patient's requirement for supervision, or any consideration to provide for closer supervision.

On 4/3/12, at 1200, MD #1 confirmed that he admitted Pt #2 on PAC Status, which requires only hourly rounds. He stated that he was not aware that the nursing staff had placed the patient on "Close Watch." He stated that nursing did not discuss in the treatment team meetings any need for the patient to be on Close Watch or 1:1.

Review of medical records:

Pt #4 was admitted on 1/8/12 with a diagnosis of: "...mood disorder; not otherwise specified; rule out bipolar disorder...." Prior to her admission, she had disclosed that her adoptive grandfather had been molesting her for the past year. She was placed in a shelter by the police and was eventually released to her home. She had become increasingly agitated and aggressive; was making threats towards her family; exposing her genitals and becoming increasingly sexually aggressive toward her siblings. She had been sexually acting out for one to two years. Her adoptive grandfather was arrested on January 4, 2012, and was incarcerated at the time of her admission. The physician admission orders included: "...Special observation-Close Watch...."

On 1/10/12, MD #5 wrote: "...RN...informed me that pt continues to be inappropriate sexually, telling peers she loves them and asking them to show their private parts...sexually preoccupied...."
On 1/16/12, MD #5 wrote: "...pt is inappropriately touching her private part near her door (with) legs apart...."
On 1/19/12, MD #5 wrote: "...Pt remains to have poor boundaries. She went into a boy's room & took him into his bathroom & tried to kiss him...."
On 1/20/12, MD #5 wrote: "...Remains sexual...likes to follow the boy she attempted to kiss & still doesn't see this as a problem...."
On 1/23/12. MD #5 wrote: "...quite sexual. per report, she kissed her roommate & yet pt denies...Now 1:1...." MD #5 wrote an order on 1/23/12: "...1:1 X 24 hr. Staff should stay inside the room between beds at all times while pt is in the room...."

MD #5 wrote orders each day for the patient to remain on 1:1, including 1/24/12, through 1/28/12. On 1/29/12, at 1140, MD #5 wrote an order: "...1:1 X 24 hrs...." On 1/29/12, at 1308, RN #45 recorded a telephone order from MD #5: "...order clarification 1:1 while asleep...." On 1/30/12, at 1910, MD #5 wrote an order: "...1:1 X 24 hrs...."

On 1/29/12 at 0910, an RN wrote: "...Pt remains on a 1:1 status...Pt is very intrusive with peers and requires a lot of redirection from staff this morning...denies any desire to act out sexually at this time...."
On 1/29/12 at 1730, an RN wrote: "...Pt has been appropriate with peers but often requiring a lot of staff redirection as far as boundaries. Pt 1:1 discontinued today...."
On 1/29/12 at 2300, an RN wrote: "...1:1 while in bedroom thru noc...."
On 1/30/12 at 1300, an RN wrote: "...Pt conts on 1:1 during sleep hours...Pt compliant (with) being (with) staff at all times & staying out of room...."
On 1/30/12 at 1800, an RN wrote: "...pt's roommate is c/o (complaining of) pt touching her while she napped yesterday (1/29/12)...holding her nose, causing roommate to gag, & awaken. Pt confirms c/o, 'I don't know why I did, I was just playing doctor, she didn't die, she is a really hard sleeper.'...at the same time, pt shows (no) insight...."

Pt #3 was admitted on 1/25/12 with command auditory hallucinations, suicidal ideation and self mutilation by cutting. She was the roommate of Pt #4 on 1/29/12 and was on "Close Watch."

On 1/30/12 at 1800, an RN documented: "...Describes mood as 'concerned' r/t (related to) 'What happened yesterday.' Pt reports during 'Room Time' two peers in the adjacent room peaked into pt's room and observed pt's roommate touching pt's leg. When redirected by peers, roommate stated, 'It's ok, I'm just doing her hair.' Pt states she has no recollection of this event because she was asleep. pt states she then felt something/someone plugging her nose, felt as though she could not breath, kicked the wall and awoke to discover roommate had been squeezing pt's nose closed. pt reports she then went into the bathroom of her dorm room and noticed a bra strap off her shoulder and her entire bra down around her stomach...."

Review of hospital document titled Daily Patient Assignment Sheet for "CAS" (Child and Adolescent Services) revealed: On 1/29/12, during the 0700-1500 shift, a Psych Tech was assigned 1:1 to Pt #4. During the 1500-2300 shift, a Psych Tech was not assigned 1:1 to Pt #4. Review of the Special Observation Precautions Assessment Sheets for both Pts #4 and 3 revealed that both patients were in their room on beds on 1/29/12 from 2130 through 2345.

Review of hospital document submitted to Arizona State Office of Behavioral Health Licensure revealed: "...She...stated 'right at room time, right we (sic) went to our rooms,' which in the unit schedule would be 1500...."

RN #49 stated during interview conducted on 4/5/12 that the order "1:1 while asleep" means that a patient is to have 1:1 supervision overnight and when in room, unsupervised, with a roommate or any other peer.

RN #45 stated during interview conducted on 4/5/12 at 1327, that the MD order "1:1 while asleep" was intended to keep Pt #4's roommate safe during the night; to watch Pt #4 during the night. She stated that she would not have allowed Pt #4 to be in her room, unsupervised, with her roommate or any other peer. Pt #4 would either be required to stay out of her room or be supervised 1:1 if in her room with a peer at any time. RN #45 was unsure how the Techs understood the order.

RN #9, the Nurse Manager of the Child and Adolescent Unit, confirmed during an interview conducted on 4/5/12 at 1405, that the MD order "1:1 while asleep" meant that Pt #4 would be supervised 1:1 from 1900 through 0700, since patients on the Children's Unit are in their rooms in bed from 2000 through 0700. In addition, Pt #4 was not to be in her room, unsupervised, with any peer. RN #9 recalled that she had informed the staff of the patient's requirement for supervision and intent of the order. She confirmed that a Psych Tech was not assigned on 1/29/12 from 1900 through 2300 to supervise Pt #4 1:1 as required and that Pt #4 had been allowed in her room, unsupervised, with her roommate.

MD #5 confirmed during interview conducted on 4/5/12 at 1603, that Pt #4 had very poor impulse control and was not able to control herself. On 1/23/12, she had placed the patient on 1:1 supervision for 24 hours per day. She could not recall why she changed the order to "1:1 while asleep" on 1/29/12, but stated that the nurse called her for the order. She stated that her intent of the order was that the patient was to be supervised 1:1 during sleeping hours and whenever the patient was in her room with another patient.

2. Review of the hospital policy/procedure titled Fall Prevention Program revealed: "...Purpose: To promote safety by: Identifying patients at risk of falls by use of falls risk predictors, including patient medication regimen...Admitting Nurse Responsibilities...Completing patient fall risk assessment...Initiate appropriate falls risk protocol...Interventions...Interventions are chosen based on the level and severity of risk factors identified...Patient with a Moderate or High Risk will have Fall Precautions implemented, in addition to no/Low Fall Risk Precautions...Moderate Risk...Falls Risk Score = 6-9...15 minute safety checks...."

Review of the form titled Adult Fall Risk Assessment Tool revealed that it contained several Risk Factors that a nurse scores according to criteria in columns with numerical headings: "...0...1...2...." The Risk Factor Medications is scored 0 if the patient is on no medications. It is scored 1 for the following: "...On psychotropic, sedative drugs, cardiac meds, hypnotics, antihypertensives, laxatives, anticoagulants or diuretics ONE POINT FOR EACH...." The column identified with a 2 for Medications contained the following: "...Increase dose/or multiple number of psychotropics, sedative drugs, cardiac meds, hypnotics, anticoagulants or antihypertensives. TWO POINTS FOR EACH...."

Review of medical record:

Pt #1 was admitted on 1/25/12, for alcohol and opiate withdrawal syndrome. On 1/26/12 at 0035, RN #42 documented: "...Admit note...At 0006, Valium 15 mg, Bentyl 20 mg, TTS 1 patch (Clonidine), & scheduled methadone 10 mg given...." At 0006, RN #1 charted on the Medication Administration Record the following medications: Clonidine 0.1 mg, Methadone HCl 10 mg, Pregabalin (Lyrica) 75 mg, Risperidone 1 mg, Diazepam 15 mg, and Dicyclomine 20 mg.

On 1/26/12 at 0105, an LPN noted: "...Pt observed resting (with) eyes closed respirations even/unlabored (with) no s/s distress...."

On 1/26/12 at 0200, an LPN noted: "...Pt in bed @ 0200 resting (with) eyes closed, respirations even/unlabored (with no s/s of distress noted. Will re (check) @ 0300 for re-medicating for ETOH/opiate w/d...."

On 1/26/12 at 0210, an LPN noted: "...pt observed on floor, eyes rolled back in head, d/t fall or poss Sz (seizure). Laceration on back of heald (sic)...."

Review of the Adult Fall Risk Assessment Tool completed by RN #2 revealed that the patient was rated a score of 6 with a risk status of Moderate. The RN documented a score of 2 for Medication Risk Factor. The medical record did not contain documentation that the patient was placed on 15 minute safety checks.

RN # 42 stated during interview conducted on 4/5/12 at 0828, that when she assesses a patient for fall risk, she doesn't have the physician order sheet and doesn't know exactly what medications the patient will be receiving. She knew that she would be giving Pt #1 a psychotropic and an antihypertensive. During the interview, she reviewed the medications that she administered to the patient. She didn't know how to score Valium or Methadone. She was aware that Lyrica is sedating and a Schedule V drug, but she did not know how to score it. She stated that she thought she scored one point for each category of medication, not one point for each medication within a category. She confirmed that the hospital had not clarified the scoring of medications. She confirmed that she did not place the patient on 15 minute checks as required by policy. She stated that she thought that 15 minute checks were required for patients in the High Fall Risk category. She stated that the policy/procedure had been changed and she had not received training on the changes.

RN #7, the Nurse Manager of the Adult Chemical Dependency Inpatient Services, stated during an interview conducted on 4/5/12 at 1530, that she would score Lyrica, Methadone and Valium as sedatives and assign a score of 3 for Pt #1's Medication Risk Factor. She was unaware that patients scored as Moderate Fall Risk required 15 minute checks. She believed that 15 minute checks were required for High Fall Risk. She also reviewed the orientation materials during the interview and confirmed that the Nursing Orientation materials for Fall Risk Assessment contain instructions to place patients at High Risk for falls on 15 minute checks. It did not contain instructions to place patients at Moderate Risk for falls on 15 minute checks. She confirmed that the orientation instructions do not correspond with the policy/procedure.

Based on review of hospital policies/procedures, hospital document, medical records and interviews, it was determined that the hospital failed to require that drugs be administered in accordance with the orders of the practitioner responsible for the patients' care for 3 of 3 patients admitted with alcohol dependence (Pts # 1, 8 and 9).

Findings include:

Review of the hospital policy/procedure titled Physician's Orders: (Receiving, Transcription and Verification) revealed: "...All orders will be verified by the RN to ensure accuracy. The nurse will ensure the following information is included in each medication order:...Diagnosis, condition, or indication of use of medication on first time of order...Clarification of...incomplete, or unclear orders...."

Cross reference Tag A 0049 for information regarding the order sets for administration of Valium for withdrawal symptoms; information regarding Pts #1, 8 and 9, including the dosages of Valium administered to each patient and interviews conducted with RN's #30 and 7 and MD #1.

The physician orders for administration of Valium for withdrawal symptoms do not include a definition of withdrawal symptoms to use to determine whether a patient's symptoms are mild, mild to moderate, moderate to severe, or severe in order to determine the dose of Valium to administer in accordance with the order set.

Based on review of policies/procedures, observations, record review and staff interviews, it was determined that the hospital failed to be constructed, arranged, and/or maintained to ensure patient safety.

Findings include:

K018: the facility failed to maintain corridor doors to resist the passage of heat/smoke;

K027: the facility failed to maintain self closing doors in a smoke barrier;

K038: the facility did not keep the required signs posted at the exit doors equipped with special operating features and failed to maintain the special locking exit doors;

K047: the facility failed to maintain illuminated exit sign;

K050: the facility failed to conduct the required fire drills, failed to provide a written plan for the protection of all patients in time of a fire or emergency and train all staff on life safety procedures and devices;

K062: the facility failed to keep automatic sprinkler heads free of lint and paint and the facility did not assure that all parts of the sprinkler system were in accordance with the UL Listing;

K066: the facility failed to follow the smoking policy for designated smoking areas for the facility;

K076: the facility failed to mount receptacle outlets five feet above the floor in the oxygen storage rooms;

K147: the facility allowed the use of a multiple outlet adapters, power strips and did not use the wall outlet receptacles for appliances; and

The hospital was found to have a Condition level citation identified for Life Safety Code (LSC).

Additionally:
Cross reference Tag A 144 #1 and #2 regarding failure to provide care in a safe setting for Pt #29 and adolescents in the "OSCA" program.

The cumulative effect of these systemic problems resulted in the hospital's failure to provide a physical environment which ensures the safety of each patient.