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Based on document review and interview, the hospital did not have an effective governing body legally responsible for the conduct of the hospital as an institution.

The Governing Body failed to appoint members of the medical staff. See A 046.
The Governing Body failed to approve all bylaws. See A 048.
The Governing Body failed to ensure the medical staff were adequately monitoring the systems for physical health review of patients. See A 049.

Based on document review and interview, in 3 of 3 reviewed cases, the governing body failed to appoint members of the medical staff. Findings include:

<1> 4-16-2010 review of CMS letter dated 2-02-2009 from Region V, Non-Long Term Care Certification & Enforcement Branch Manager to the BCA StoneCrest Center Administrator revealed that Behavior Centers of America's ownership of the hospital became effective 11-01-2008.

<2> Minutes for Governing Body meetings held on 11-17-2008, 6-11-2009, 8-10-2009, 12-10-2009, and 1-24-2010 were reviewed on 4-29-2010. Reviewed Governing Body minutes did not include any documentation substantiating that the Governing Body made any decisions on appointing or approving clinical privileges for 3 new physicians ( Dr. #2, Dr. #4, and Dr. #5) who submitted application for staff privileges after 11-01-2008.

<3> The credential files of Dr. #2, Dr. #4, and Dr. #5 were reviewed on 4-29-2010. Reviewed credential files did not include any documentation substantiating that the hospital's Governing Body took affirmative action to approve the appointment of Dr. #2, Dr. #4 and Dr. #5 to the hospital's medical staff.

The hospital's medical director, interviewed 4-29-2010 @ 0915 hours stated that Dr. #2, Dr. #4, and Dr. #5 respectively employment at the hospital respectively February 2009, June 2009, and June 2009.

Based on document review and interview, the governing body failed to approve medical staff bylaws and other medical staff rules and regulations. Findings include:

<1> Medical staff bylaws, dated 11-01-2008, were reviewed on 4-29-2010. The hospital medical director, interviewed 4-29-2010 @ 0915 hours, confirmed that the bylaws dated 11-01-2008 were still applicable to the hospital's medical staff.

<2> Minutes for Governing Body meetings held on 11-17-2008, 6-11-09, 8-10-09, 12-10-2009, and 1-24-2010 were reviewed on 4-29-2010. Reviewed Governing Body minutes did not include any documentation substantiating that the Governing Body approved the medical staff bylaws dated 11-01-2008.

Based on document review and interview, the governing body failed to ensure that the medical staff was accountable to the governing body for the quality of care provided to patients. Findings include:

<1> Review of the medical records of pt #37 and pt #38 who expired after transfer/discharge from BCA StoneCrest revealed that:

(a) Pt. # 37, a 37 year old male was admitted involuntarily to BCA StoneCrest on 8-07- 2009 as: (i) he was not eating, sleeping or attending to his hygiene, (ii) he was responding to internal stimuli, (iii) his thoughts were disorganized, and (iv) the patient was aggressive towards his sister.

On 8-25-09 at approximately 0105 hours the patient was transferred to St. John Hospital & Medical Center's Emergency Department as the patient became diaphoretic, hyperventilating, was incontinent of bowel and bladder, had a pulse oxygen level of 81% on room air, his blood pressure ranged from 121/85 to 97/66, had a heart rate of 135, respirations were 28, wheezing was auscultated on RUL and RLL with a blood sugar of 152. The patient expired at St. John Hospital & Medical Center on 8-25-2009 at approximately 0530 hours. Reportedly, the patient's death was due to an embolism.

(b) Patient # 38, a 27 year old male, was involuntarily admitted to the hospital on 7-18-2009 due to complaints of depression with a suicide attempt by overdose with Seroquel. The patient complained of loud, tormenting voices that commanded him to kill himself. He complained of being tired of living with voices. The patient was discharged to out-patient care on 7-27-2009.
Reportedly, the patient's mother notified her son's aftercare agency that the patient hung himself on 7-29-2009.

<2> Minutes for Governing Body meetings held on 11-17-2008, 6-11-2009, 8-10-2009, 12-10-2009, and 1-24-2010 were reviewed 4-29-2010

Review of these Governing Body minutes did not reveal or substantiate that the Governing Body receive any results or discussion of a formal peer review of the quality of psychiatric or medical care provided to pt. #37 and pt. #38.

<3> The hospital's medical director, interviewed 4-29-2010 @ 0915 hours, stated that a formal peer review of a patient's case would be conducted if the patient was involved in a "sentinel event". Review of the hospital's Policy #1.87 entitled "Response to Sentinel Event Investigation by JCAHO" defines "sentinel event" as an unexpected incident involving death or serious physical or psychological injury, or the risk thereof". The interviewed medical director acknowledge that the death's of Pt. #37 and Pt. #38 were not expected and that a formal documented physician peer review of the quality of psychiatric and medical care provided to the two deceased patients was not conducted.

<4> The interviewed medical director also acknowledged that since the summer of 2009 he no longer reviewed the medical care provided to patients admitted to BCA StoneCrest, even though there were instances were patients had to be transferred to a medical hospital due to an emergent or emergency medical condition arising after a patient's admission to BCA StoneCrest.

Based on medical record review and document review, it was determined that the facility failed to adequately promote the rights of patients. Findings include:

The facility failed to inform patients of their rights in advance of providing care [see A 117].
The facility failed to provide information for filing a complaint to patients [see A 118]
The facility failed to ensure a periodic review and approval of the grievance process [see A 119]
The facility failed to ensure that the grievance process would include timely resolution [see A 120]
The facility failed to consistently establish whether or not patient's had or wished to have advance directives [See A 132]
The facility failed to determine if patient's wished family or representative to be notified of their admission [see A 133
The facility failed to incorporate medical assessments in the care plan [ See A 144]
The facility failed to ensure that restraints and/or seclusion orders were appropriate when care plans changed or that a training program for restraint use was in place [See A 166, A 176, A 178, A 202, A 205]
The facility failed to ensure that a restrained patient was properly monitored [See A 175]
The facility failed to develop a restraint associated death policy that contained all necessary requirements [See A 214]

Based on medical record review and interview, the hospital failed to inform 3 (Patient # 40, 42, and 44) of 4 current Medicare patient beneficiaries or representative as applicable of the patient's discharge appeal rights as stated in "An Important Message from Medicare." Findings include:

<1> Review of Medicare beneficiary patient medical record #40, #42 and #44 revealed that the "An Important Message from Medicare" was not documented and signed by the patient or patient representative.

<2> The social worker assigned to the geriatric unit on which patient # 40, #42, and #44 resided was interviewed on 4-30-2010 at approximately 1030 hours. The social worker stated that she was assigned to the unit in the last week and was aware of the requirement that the hospital to provide to an admitted Medicare patient a copy of the "An Important Message from Medicare" and would take steps to ensure that Medicare patient beneficiaries would receive the required notice .

Based on interview, document review, and observation, the hospital failed to inform admitted patients whom to contact to file a grievance. Findings include:

<1> Observations on the hospital's psychiatric units on 4-29-2010 and 4-30-2010 revealed that signage was posted for filing a grievance with the hospital's recipient rights advisor, but no signage was posted informing patients of the CMS 800 complaint hot line or information regarding filing a complaint/grievance with CMS.

<3> On 4-30-2010 an unused admission packet was examined. While the admission packet included information regarding Michigan Mental Health Code patient rights information, there was no information in the admission packet informing an admitted patient of his/her right to file a grievance with CMS or noting the CMS 800 complaint hot line, the complaint mailing address, or the web site at which complaint information may be submitted.

Based on document review, and interview, the governing body failed to ensure that it approved and was responsible for the effective operation of the grievance process, Findings include:

<1> Minutes for Governing Body meetings held on 11-17-2008, 6-11-2009, 8-10-2009, 12-10-2009, and 1-24-2010 were reviewed on 4-29-2010.

<2> Reviewed Governing Body minutes did not include any documentation substantiating that the Governing Body approved the hospital's grievance policies entitled (a) Establishment an Office of Recipient Rights - #904.05, and (b) Complaint and Appeal Process - #901.01.

<3> Michigan Compiled Laws 330.1755(6) requires that by December 30th of each year the hospital director submits to the hospital's governing body for their review and follow up (as indicated) an annual report (the annual reporting period is from October 1 to September 30) regarding the disposition of received complaints/grievances and associated patient rights protection activities conducted by the hospital's recipient rights office to ensure continuing compliance with State and Federal patient rights statutes.

The hospital's recipient rights advisor, interviewed 4-30-2010, confirmed that she had prepared the required recipient rights annual report for the 2008/2009 reporting period and in early December 2009 in the absence of the hospital director submitted the annual report to one of the hospital ' s governing body members. Reviewed Governing Body minutes did not include any reference or documentation substantiating that the Governing Body reviewed the 2008/2009 annual recipient rights report at its 12-10-2009 or 1-24-2010 meeting.

Based on document review and interview, the hospital failed to ensure that the grievance process included a mechanism for timely referral of a Medicare beneficiaries concerns regarding quality of care to the appropriate Utilization and Quality Control Quality Improvement Organization. Findings include:

<1> Hospital recipient rights advisor, interviewed 4-30-2010 was asked whether the Recipient rights Office advises a Medicare beneficiary of his/her right to have his/her complaint/grievance regarding a quality of care concern referred to the local Quality Improvement Organization. The rights advisor said that such a notice is not provided to a Medicare beneficiary when a complaint/grievance is received or when notice of the hospital's investigative findings or interventions are sent to patient

<2> On 5-03-2010 the hospital's Complaint and Appeal Process policy (#901.01.) was reviewed. Review revealed that the policy does not include any reference regarding the requirement that if a Medicare beneficiary patient has a quality of care concern, the patient has the right to request that the hospital refer the patient's quality of care concern to the Michigan Quality Improvement Organization (i.e. the Michigan Peer Review Organization).

Based medical record review and document review, the hospital failed to ensure in 9 of 14 sampled cases that at the time of admission an admitted patient was queried as to whether he or she had completed an advance directive and be informed of his/her right to formulate an advance directive. Findings include:

<1> Medical record review revealed that in 9 (Patient # 40, #47, #48, #51, #52, # 53, #54, #56, # 57 ) of 14 cases sampled for compliance with the requirement that an admitted patient was asked whether s/he had an advance directive, the section of the admission registration form that addresses this question was was left blank. No information was noted in these 9 cases as to whether the patient was asked if s/he wanted to receive information regarding his/her right to complete an advance directive.

<2> The 5-03-2010 review of hospital policy #1.77 titled "Advance Directives" revealed that staff query to an admitted patient at the time of admission registration is limited to asking whether the patient had a "medical advance directive" and did not include any reference to asking a patient as to whether the patient had a "psychiatric advance directive".

Based on medical record and document review, in 7 of 7 sampled cases the hospital failed to ensure that an admitted patient's family member or representative of the patents's choice and the patents's own physician were notified promptly of the patient's admission to the hospital. Findings include:


<1> Medical record review revealed that in 7 (Patient # 47, #48, #51, #52, #53, #54, #57) of 7 sampled cases documentation did not substantiated that that an admitted patient was asked whether s/he wanted a family member/designated representative or her/his physician notified of her/his admission to the hospital.

<2> The 5-03-2010 review of hospital Admission Check list revealed that it did not include any provisions for asking an admitted patient whether the patient wanted a family member/designated representative or the patient's physician notified of the patient's admission to BCA Stonecrest.

Based on observation interview and record review, the nursing staff failed to monitor and assess the patients, to ensure a safe environment for 5 of 5 patients (charts) reviewed (#8, #11,#14, #15,and #24). Findings include:

Patient #8 received physician order on 04/02/10 at 2035 to "...give Regular insulin (6 units) for blood sugar of 545. Recheck blood sugar in 3 hours..." There is no documentation that the blood sugar was rechecked per the physicians order. Policy 2.10 states: "Every patient who is admitted to BCA StoneCrest Center with a known diagnosis of diabetes will have their blood sugar tested by glucometer upon admission to the unit." It also states that the facility will "Monitor glucose level as ordered by the physician."

Patient # 11 did not receive proper patient observation according to the physician order. The patient was to be monitored every 15 minutes. There was no documentation that the patient was monitored on 03/16/10 from 0515 until 0545.

Patient #14 was admitted on 03/17/10 and discharge on 03/29/10. The physician wrote an order on 03/17/10 at 1520 for " ... v.s. (vital signs) x (times) 2 day, please chart BP (blood pressure) ... " There was no documentation that the vital signs were taken on 03/19/10.

Patient #15 was admitted on 04/13/10 and discharge on 04/20/10. There was no documentation to show that the vital signs were being monitored on the patient from 04/13/10 until 04/20/10 and then from 04/21/10 until 04/23/10. According to policy titled Nursing Policy 2.18.11 titled " Vital Signs " " vital signs are to be taken daily on all patients or as ordered by the physician and recorded on the individual patient flow sheet. "

Patient #24 was admitted on 03/19/10 and discharged on 03/24/10. There was no documentation to show that the vital signs were being monitored on the patient since 03/21/10. According to policy titled Nursing Policy 2.18.11 titled " Vital Signs " states "Vital signs are to be taken daily on all patients or as ordered by the physician and recorded on the individual patient flow sheet."

These findings were verified by the Director of Nursing on 04/28/10 at 1400.

Based on medical record review and document review, the hospital failed to ensure in 5 of 6 sampled cases that the use of restraint or seclusion was in accordance with a written modification to the patient's plan of care. Findings include:

<1> The 5-03-2010 review of nursing policy entitled "Restraint and Seclusion" (Section 2.20, Number 01) revealed that while Procedure Section 12(b) of the policy stated that follwing the use of restraint or seclusion "The plan of service will be reviewed and modified to reduce the need for restraint or seclusion", the policy did not specify a time frame in which the treatment plan should be reviewed and modified nor specify who should participate and be involved in the review and modification of the patient's treatment plan.

<2> Medical record review revealed that in 5 (patient #49, #50, #53, #54, #55) of 6 sampled cases that involved the use of seclusion or restraint, reviewed treatment plans did not substantiate that following the use of seclusion/restraint, the patient's treatment plan was formally reviewed and modified to reduce the need for restraint or seclusion utilization.

Based on document review, medical record review, and interview, the hospital failed to ensure in 1 (patient # 46) of 6 sampled cases that the condition of a restrained patient was monitored by a trained staff person who had completed the hospital's training program regarding the assessment and monitoring of a secluded or restrained patent. Findings include:

<1> The 4-30-2010 review of nursing policy entitled "Restraint and Seclusion (Section 2.20, Number 01)" and Hospital nursing policy regarding Restraint (Section 2:20, Number: 02) revealed that while these policies makes reference to a MHA (mental health assistant) conducting 15 monitoring checks of a secluded or restrained patient, no reference was made to the involvement of a unit clerk in conducting such checks.

<2> Medical record review of patient # 46 revealed that on 4-22-2010 at approximately 1000 hours the patient was restrained and was monitored at 15 minute intervals. As the identity of the individual conducting the 15 minute monitoring checks could not be determined due to the writer's illegibility of her signature, registered nurse (RN) # 10, interviewed on 4-29-2010 at approximately 1400 hours, was asked to identify this individual. RN # 10 stated that it was the unit clerk who conducted the 15 minute monitoring checks of restrained patient #46. When asked whether unit clerks were trained to conduct the 15 minute checks and assessment of restrained and secluded patient's, RN #10 stated that to the best of her knowledge unit clerks were not trained in the monitoring and assessment of a secluded/restrained patient and it was not customary practice for a unit clerk to do this this clinical activity. In the case at hand, RN #10 recalled that the nursing office had directed that the unit clerk conduct the 15 minute monitoring checks due to the unavailability of other registered nurses mental health assistants to provide coverage on the unit.

<3> On 4-30-2010 the circumstances of the 4-22-2010 episode of the unit clerk's role in the monitoring of restrained patient # 46 was discussed with the hospital's Director of Nursing (DON). The DON was requested to provide a copy of the unit clerk's training records relative to the monitoring and assessment of a restrained/secluded patient. Later that day at approximately 1500 hours the DON reported that the unit clerk in question has not received any training in the monitoring and assessment of a restrained patient and confirmed that the nursing shift supervisor in the nursing office had erroneously assigned the monitoring and assessment responsibilities to the unit clerk.

Based on document review, the hospital failed to ensure that hospital policy specified physician training requirements for physician's authorized to order restraint and seclusion. Findings include:

The 4-30-2010 review of the hospital's policies regarding seclusion and restraint and entitled "Restraint and Seclusion (Section 2:20, Number: 01) and "Physical Restraint (Section 2:20, Number: 02)" revealed that the policies did not specify physician training requirements for those physician's authorized to order restraint or seclusion.

Based on document review, medical record review, and interview, the hospital failed to ensure that in 1 of 6 sampled cases in which seclusion or restraint was utilized for the management of violent or self-destructive behavior that jeopardized the immediate physical safety of the patient, the patient was seen face-to-face within 1-hour after the initiation of the intervention by a trained physician or a registered nurse or physician assistant. Findings include:

<1> The 4-30-2010 review of the hospital's nursing policies regarding seclusion and restraint and entitled "Restraint and Seclusion (Section 2:20, Number: 01) and "Physical Restraint (Section 2:20, Number: 02)" revealed that "...A face to face evaluation by a physician, physician assistant or registered nurse must be completed within one (1) hour for any time spent in restraint or seclusion even if the patient recovers quickly from an aggressive/violent episode and is released early...."

<2> Review of patient #55 medical record revealed that on 3-30-2010 the patient was restrained from 0245 to 345 hours. The required 1 hour face to face assessment was conducted by a registered nurse at 0245 hours on 3-30-2010.

<3> The hospital's Director of Nursing (DON), interviewed on 4-30-2010, was asked to provide a copy of the training program regarding the assessment of a secluded or restrained patient that would qualify a registered nurses or physician assistant to conduct the face to face examination required at 42 CFR 482.13(e)(12). The DON stated that the hospital has not yet promulgated the training program that would qualify a registered nurse or physician assistant to complete the 1 hour required face to face assessment of a restrained or secluded patient. In the above noted case of patient # 55 which was discussed with the DON, the DON stated that the required face to face examination should have been completed by a physician rather than a registered nurse.

Based on document review and interview, the hospital failed to ensure that appropriate staff received education and training in how to recognize and respond to signs of physical and psychological distress . Findings include:

<1> On 4-30-2010 the following training documents regarding crisis prevention, intervention and seclusion/restraint were reviewed
(i) Participant Workbook for the Nonviolent Crisis Intervention Training Program, published by the Crisis Prevention Institute.
(ii) Refresher Workbook for Review of the Nonviolent Crisis Intervention Training Program published by the Crisis Prevention Institute,
(iii) Hospital nursing policy regarding Restraint and Seclusion (Section 2:20, Number: 01)
(iv) Hospital nursing policy regarding Restraint (Section 2:20, Number: 02)
(v) Restraint/Seclusion power point inservice presentation prepared by Behavioral Centers of America Corporate Central Office.

<2> The 4-30-2010 review revealed that while the above referenced reviewed documents noted the dangers of restraint related positional asphyxia, the psychological danger in using restraints that may be frightening and even traumatic for a restrained patient, and cautions in applying restraints to prevent physical injury, none of the reviewed documents specifically discussed the recognition signs and symptoms of physical and psychological distress associated with the use of restraint or seclusion or what steps should be taken if the patient appeared by be experiencing psychological distress while secluded or restrained.

Based on document review, medical record review, and interview, the hospital failed to ensure that in 1 of 1 sampled cases in which a registered nurse conducted the 1 hour face to face assessment required at 42 CFR 42 CFR 482.13(e)(12) had completed a formal education program regarding monitoring the physical and psychological well-being of the patient who is restrained or secluded. Findings included:

<1> The 4-30-2010 review of the hospital's nursing policies regarding seclusion and restraint and entitled "Restraint and Seclusion (Section 2:20, Number: 01) and "Physical Restraint (Section 2:20, Number: 02)" revealed that "...A face to face evaluation by a physician, physician assistant or registered nurse must be completed within one (1) hour for any time spent in restraint or seclusion even if the patient recovers quickly from an aggressive/violent episode and is released early...."

<2> Review of patient #55 medical record revealed that on 3-30-2010 the patient was restrained from 0245 to 0345 hours. The required 1 hour face to face assessment was conducted by a registered nurse at 0245 hours on 3-30-2010.

<3> The hospital's Director of Nursing (DON), interviewed on 4-30-2010, was asked to provide a copy of the training program regarding the assessment of a secluded or restrained patient that would qualify a registered nurses or physician assistant's to conduct the face to face examination required at 42 CFR 482.13(e)(12). The DON stated that the hospital has not yet promulgated the training program that would qualify a registered nurse or physician assistant to complete the 1 hour required face to face assessment of a restrained or secluded patient.

Based on document review, the hospital failed to ensure that it promulgated a policy/procedure with the appropriate reporting requirements associated with a patient's death. Findings include:

<1> The 4-30-2010 review of the hospital's Restraint and Seclusion policy(Section 2:20, Number: 01) and Restraint policy (Section 2:20, Number: 02) revealed that in regards to a patient's death the respective policies only required that "The hospital must report to the JCAHO and the DCH/BHS Psychiatric Licensing Office any death that occurs while a resident is in seclusion or where it is reasonable to assume that a patient's death is a result of seclusion."

<2> The respective reviewed policies did not include any of the following requirements:

(a) CMS is to be notified of a patient's death when the death occurred under any one of the following circumstances:
(i) Each death that occurs while a patient is in restraint or seclusion.
(ii) Each death that occurs within 24 hours after the patient has been removed from restraint or seclusion.
(iii) Each death known to the hospital that occurs within 1 week after restraint or seclusion where it is reasonable to assume that use of restraint or placement in seclusion contributed directly or indirectly to a patient's death. "Reasonable to assume" in this context includes, but is not limited to, deaths related to restrictions of movement for prolonged periods of time, or death related to chest compression, restriction of breathing or asphyxiation.

(b) The patient death notification is to be reported to CMS by telephone no later than the close of business the next business day following knowledge of the patient ' s death.

(c) Staff document in the patient's medical record the date and time the death was reported to CMS.

Based on record review and interview, it was determined that data collection for the Quality Assessment & Process Improvement program components was not ongoing. Findings include:

During record review on 4/28/10 at 1300 it was determined that the forms titled "Performance Improvement Monthly Tool" dated 3/30/10 and 04/09/10 were not completed.

During record review was determined that the form titled "Diabetic Log" was not kept current.

During record review it was determined that the form titled 'PERFORMANCE IMPROVEMENT/UTILIZATION REVIEW"(Nursing Services Review) was not being kept current.

The Director of Nursing confirmed that the QAPI data collection was not current on 04/29/10 at 1100.

Based on document review and interview, the hospital failed to ensure that it had organized medical staff that operated under bylaws approved by the governing body and is responsible for the quality of medical care provided to patients by the hospital.

The hospital was not conducting adequate appraisals of staff. See A 340.
The hospital medical staff bylaws had not been accepted. See A 353 and A 354.
The hospital lacked appropriate content for medical history, physicals and examinations. See A 358 and A 359.

Based on document review and interview, the hospital failed to ensure that medical staff periodically, conducted appraisals of its members. Findings include:

<1> The hospital's medical director, interviewed 4-29-2010 at 0915 hours, stated that physician peer review was conducted periodically that consisted of an audit of randomly selected medical records. Review of completed audit work sheets revealed that the audit questions primarily focused on compliance with medical record documentation requirements. In response to whether audit findings were tabulated and summarized for each psychiatric and medical physician, the medical director stated that no such formal data base is maintained.

<2> The interviewed medical director acknowledged that since the summer of 2009 he no longer reviewed the medical care provided to patients admitted to BCA StoneCrest, even after patients needed to be transferred to a medical hospital due to an emergent or emergency medical condition arising after a patient's admission to BCA StoneCrest.

<3> In response to the question as to when a formal physician peer review would be scheduled and conducted, the interviewed medical director stated that a formal documented peer review of a patient's case and associated physician would be conducted if the patient was involved in a "sentinel event". Review of the hospital's Policy #1.87 entitled "Response to Sentinel Event Investigation by JCAHO" defines "sentinel event" as an unexpected incident involving death or serious physical or psychological injury, or the risk thereof".

The interviewed medical director acknowledge that physician peer review of the quality of provided psychiatric and medical care were not conducted and documented in regards to the deaths of patient #37 and patient #38 whose deaths were unexpected. Review of the respective patient's medical records revealed that:

(a) Pt. # 37, a 37 year old male was admitted involuntarily to BCA StoneCrest on 8-07- 2009 as: (i) he was not eating, sleeping or attending to his hygiene, (ii) he was responding to internal stimuli, (iii) his thoughts were disorganized, and (iv) the patient was aggressive towards his sister.

On 8-25-09 at approximately 0105 hours the patient was transferred to St. John Hospital & Medical Center's Emergency Department as the patient on presented BCA StoneCrest registered nurse as diaphoretic, hyperventilating, was incontinent of bowel and bladder, with a pulse ox of 81% on room air, blood pressure ranged from 121/85 to 97/66, heart rate was 135, respirations were 28, wheezing auscultated on RUL and RLL. and blood sugar 152. The patient reportedly expired from an embolism at St. John Hospital & Medical Center on 8-25-2009 at approximately 0530 hours .

(b) Patient # 38, a 27 year old male, was involuntarily admitted to the hospital on 7-18-2009 due to complaints of depression with a suicide attempt by overdose with Seroquel. The patient complained of loud, tormenting voices that commanded him to kill himself. He complained of being tired of living with voices. The patient was discharged to out-patient care on 7-27-2009. Reportedly, the patient's mother notified her son's aftercare agency that the patient hung himself on 7-29-2009.

Based on document review and interview, the medical staff failed to adopt medical staff bylaws. Findings include:

<1> On 4-29-2010 the hospital's current medical staff bylaws, dated 11-1-2008, were reviewed. The reviewed bylaws did not include any notation as to when these bylaws were approved or adopted by the medical staff.

<2> During an interview with the medical director on 4-29-2010 at 0915 hours, the bylaws were reviewed . In response to the question of when the bylaws dated 11-1-2008 were formally approved or adopted by the medical staff, the medical director stated that he could not recall.

<3> The 4-30-2010 review of medical staff minutes revealed that the minutes did not include any reference to the adoption or approval of the medical staff bylaws dated 11-1-2008.

Based on document review and interview, the governing body failed to approve medical staff bylaws and other medical staff rules and regulations. Findings include:

<1> Medical staff bylaws, dated 11-01-2008, were reviewed on 4-29-2010. The hospital medical director confirmed that the bylaws dated 11-01-2008 were currently applicable to the hospital's medical staff during interview on 4-29-2010 at 0915 hours.

<2> The 4-29-2010 review of the minutes for Governing Body meetings held on 11-17-2008, 6-11-09, 8-10-09, 12-10-2009, and 1-24-2010 revealed that the reviewed minutes did not not include any documentation substantiating that the Governing Body approved the medical staff bylaws dated 11-01-2008.

Based on document review and interview, the hospital failed to ensure that the hospital bylaws included the requirements that: (a) a medical history and physical examination must be completed and documented for each patient no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services, and (b) the medical history and physical examination must be completed and documented by a physician or other qualified individual in accordance with State law and hospital policy. Findings include:

<1> Medical staff bylaws, dated 11-01-2008, were reviewed on 4-29-2010. The hospital medical director, interviewed 4-29-2010 at 0915 hours, confirmed that the bylaws dated 11-01-2008 were currently applicable to the hospital's medical staff.

<2> Review of the medical staff bylaws revealed that the bylaws did not include the requirements that (a) a medical history and physical examination must be completed and documented for each patient no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services, and (b) the medical history and physical examination must be completed and documented by a physician or other qualified individual.

Based on document review and interview, the hospital failed to ensure that the hospital bylaws included the requirements that (a) an updated examination of the patient, including any changes in the patient's condition, be completed and documented within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services, when the medical history and physical examination is completed within 30 days before admission or registration, and (b) the updated examination of the patient, including any changes in the patient's condition, must be completed and documented by a physician, or other qualified licensed individual in accordance with State law and hospital policy

<1> Medical staff bylaws, dated 11-01-2008, were reviewed on 4-29-2010. The hospital medical director, interviewed 4-29-2010 at 0915 hours, confirmed that the bylaws dated 11-01-2008 were currently applicable to the hospital's medical staff.

<2> Review of the medical staff bylaws revealed that the bylaws did not include the requirement that: (a) an updated examination of the patient, including any changes in the patient's condition, be completed and documented within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services, when the medical history and physical examination is completed within 30 days before admission or registration, and (b) the updated examination of the patient, including any changes in the patient's condition, must be completed and documented by a physician, or other qualified licensed individual.

Based on record review and document review, it was determined that the nursing services were not organized to ensure that care plans were kept current [See 396].

This Condition was found to be NOT MET in conjunction with the survey which concluded January 7, 2010.

Based on record review, policy review and interview the facility failed to ensure that the nursing staff develops and keeps current nursing care plans in 4 of 14 charts reviewed.(Patient ' s #13, #20, #28 and #29) Findings include:

Patient #13 ' s chart did not contain a care plan.

Patient # 20 ' s care plan did not contain the signature of the patient and the physician.

Patient #28 ' s care plan only contained the signature of the Social Worker and Activity Therapy.

Patient # 29 ' s care plan did not contain the signature of the patient and the physician.
During review of the policy titled " Interdisciplinary Treatment Team " the policy states that ... " The psychiatrist, registered nurse, social worker, and activity therapist will continue to identify problems and develop interventions within the first 24 hours of inpatient treatment ... "

The Director of Nursing confirmed that the facility did not follow the care plan policy on 4/28/10 at 1500.

Based on staff interview, and record review, it was determined the facility failed to ensure that all discharged inpatient's clinical records were complete, including an authenticated signature from the attending physician. Findings include:

During an interview with the chief financial officer and manager of of medical records on 4/27/10 at 1:00 pm , it was identified there were 29 incomplete inpatient clinical records that were awaiting signatures from the physician 30 days following the patient's discharge from the hospital.

Based on observation the agency failed to ensure drugs were locked when appropriate. Findings include:

During the observation tour of the pharmacy on 4/28/10 at approximately 11:20 am, it was noted the stock of "Ativan" was not locked within the pharmacy refrigerator.

Based on observation and interview it was noted outdated medication was available for patient use. Findings include:

During the observation tour of the pharmacy on 4/28/10 at approximately 11:20 am, it was noted in the narcotic locked cabinet the following outdated medications; Concertra 15 doses (exp. 3/20/10), Adderall 56 doses (exp. 3/20/10), and Metadate 58 doses (exp. 3/20/10). The findings were discussed the director of pharmacy on 4/28/10.

Based on interview and document review the facility failed to ensure drug administration errors, adverse drug reactions, and incompatibilities were part of the hospital wide quality assurance program. Findings include:

During the course of interviewing the director of pharmacy on 4/28/10 at approximately 11:00 am, it was confirmed that the pharmacy did not participate in the hospital wide quality assurance program.

Based on employee records reviewed the facility failed to ensure the director of food services was qualified by training. Finding include:

There was no documented evidence the director of food services was qualified to manage the facility's food services.

The facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the Life Safety Code deficiencies identified. See A-710.

Based on observation, interview, and record review the facility failed to properly maintain the physical plant which could affect the safety and well-being of the patients.

Findings include:

On 4/29/10 by observation, record review, and interview with the facility manager, it was determined that the air handling systems were not on a preventive maintenance schedule. Many of the air handlers did not have final filters installed. The monometers reading across the filter beds were not all functioning properly. No coherent schedule or policy for routine inspections of air handling units was found.

On 4/29/10 by record review and interview with the facility manager, it was determined that the testable backflow preventers were not being tested and inspected on a routine schedule and there was no record of location or number of devices.
On 4/29/10 by observation it was discovered that the several plumbing vents located on the south tower roof had been capped. The plumbing system may not function properly with this modification.On 4/29/10 by observation and interview with the facility manager it was discovered that the only elevator serving the parking garage was not in operation.

Based upon on-site observation and document review by Life Safety Code (LSC) surveyors on April 27-29, 2010, the facility does not comply with the applicable provisions of the 2000 Edition of the Life Safety Code.

See the K-tags on the CMS-2567 dated April 29, 2010, for Life Safety Code.

Based on observation the facility failed to provide secure and adequate facilities for its services.

On 4/29/10 by observation it was discovered that the facility failed to properly secure ceiling tiles in spaces where patients had limited supervision which could inhibit possible escape or suicide. These spaces included in the alcove to patient rooms S432 and S434 and the unisex toilet room adjacent to the activity space on 4 South.

Based on observation the facility failed to provide proper lighting in dietary areas and routine cleaning of the ventilation system.

On 4/29/10 by observation it was discovered that the facility failed to provide adequate lighting in dietary areas. Multiple lights were not working in the dishwashing area and 1 of 2 lights provided in both the walk-in refrigerator and walk-in freezer were not working.

On 4/29/10 by observation it was discovered that the facility failed to routinely clean the ventilation grills. Throughout the facility a heavy layer of dust was seen on return and exhaust ventilation grills.