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Based on document review, observational tour, and interview, it was determined that the Hospital failed to ensure children with suicidal and elopement precaution orders were monitored. This endangered 7 of 7 children on 2/5/13 on the second floor boys psychiatric unit.

The cumulative effects of these systemic practices resulted in the Hospital's inability to ensure patient safety. As a result, the Condition of Patient Rights (42 CFR 482.13) was not met.

Findings include:

The Hospital failed to ensure that 15 minute face to face checks were completed for all children with psychiatric diagnoses and physician's orders for close observation safety precaution.
(A-144).

Based on document review, observational tour, and interview, it was determined that for 7 of 7 clinical records reviewed (Pts. #17 - 23), on the second floor boys psychiatric unit, the Hospital failed to ensure that 15 minute face to face checks were completed for all children with psychiatric diagnoses and physician's orders for close observation safety precaution.

Findings include:

1. Hospital policy number RMC-MHU642-03-0208-V06, titled, "Precaution Check Sheet", revised 1/9/13, was reviewed, and required, "2. The assigned staff member(s) caring for the patient during each 8 hour shift must document approximate 15 minute face to face checks."

2. On 2/5/13 at 1:00 PM, an observational tour was conducted on the 2nd floor boys psychiatric Unit. There were 7 boys, 1 Registered Nurse (E #1) and 2 Mental Health Technicians (E #2 & 3) on the unit.

3. Seven of 7 patients (Pts. #17 - 23), on the second floor boy's psychiatric unit on 2/5/13, had orders for close observation every 15 minutes, however, documentation of monitoring was missing for all 7 patients on 2/5/13 from 7:15 AM to 1:00 PM, for 5 3/4 hours. These patients included:

- Pt. #17 was a 16 year old male, admitted on 1/18/13, with a diagnosis of Bipolar Disorder. A physician's order, dated and timed 1/18/13 at 8:50 PM, included close observation precautions (15 minute checks) for suicide, elopement, aggression, and close nursing observation.

- Pt. #18 was a 15 year old male, admitted on 1/20/13, with a diagnosis of Bipolar Disorder. A physician's order, dated and timed 1/20/13 at 5:11 AM, included close observation precautions for suicide, elopement, aggression, and close nursing observation.

- Pt. #19 was a 17 year old male, admitted on 1/30/13, with a diagnosis of Bipolar Disorder. A physician's order, dated and timed 1/30/13 at 4:19 AM, included close observation precautions for suicide, elopement, aggression, and close nursing observation.

- Pt. #20 was a 14 year old male, admitted on 1/29/13, with a diagnosis of Bipolar Disorder. A physician's order, dated and timed 1/29/13 at 10:15 PM, included close observation precautions for suicide, elopement, aggression, and close nursing observation.

- Pt. #21 was a 12 year old male, admitted on 1/30/13, with a diagnosis of Major Depressive Disorder. A physician's order, dated and timed 1/30/13 at 2:51 PM, included close observation precautions for suicide, elopement, aggression, and close nursing observation.

- Pt. #22 was a 14 year old male, admitted on 1/15/13, with a diagnosis of Bipolar Disorder. A physician's order, dated and timed 1/15/13 at 1:19 PM, included close observation precautions for suicide, elopement, aggression, and close nursing observation.

- Pt. #23 was a 13 year old male, admitted on 1/30/13, with a diagnosis of Mood Disorder. A physician's order, dated and timed 1/18/13 at 8:50 PM, included close observation precautions for suicide, elopement, aggression, and close nursing observation.

4. On 2/5/13 at 1:00 PM, an interview was conducted with the Charge Nurse (E #1) on the boy's psychiatric unit. E #1 stated that the Unit was very busy and no one had completed the 15 minute safety checks. E #1 stated that no one was assigned to do safety check and it is a shared duty completed by the unit staff.

5. On 2/5/13 at 1:30 PM, an interview was conducted with the Mental Health Technician (E #2) who completed the 7 patient's precaution check sheets after 1:00 PM. E #2 stated that the unit was very busy and no one was able to complete the precaution check sheets.

6. The Director of Behavioral Services was present during the observational tour and discovery of the incomplete precaution check sheets on 2/5/13 at 1:00 PM. The Director stated that she was surprised that the precaution checks had not been completed and that she would discuss it with the staff.

Based on review of documents and interview, it was determined that in 1 of 3 (Pt #1) clinical records reviewed on the 2nd floor Mental Health Unit (MHU), the Hospital failed to ensure the patients received a complete nursing assessment within 8 hours of admission, as required by policy.

Findings include:

1. The clinical record of Pt #1 was reviewed on 2/5/13 at approximately 11:00AM. Pt #1 was a 16 year old female admitted on 1/16/2013 with a diagnosis of Bipolar Disorder. The clinical record lacked a completed "Adult Body Assessment" and "Patient Property Locator" form as of 2/5/13 at 11:00 AM, 20 days after admission.

2. Hospital policy entitled "Organizational Patient Assessment /Reassessment Plan, " (effective 11/2012) states that, "The assessment will be completed as soon as possible upon arrival to the Patient Care Unit, but shall not exceed established time parameters for each unit (Mental Health Unit to be completed within 8 hours) b. The Initial assessment includes: Patient Belongings and Physical Status."

3. The Unit Manager of MHU, 2nd Floor, stated during an interview on 2/5/13 at approximately 11:00 AM that Pt #1's Body Assessment and Patient Property Locator were both blank and it should have been completed and signed by the RN even if the patient refuses.

Based on document review and interview, it was determined, that for 1 of 3 patients (Pt. #2) on the Adult Mental Health Unit on 2/5/13, the Hospital failed to ensure the care plan thoroughly addressed the patient's needs.

Findings include:

1. Hospital policy Number RMC-MHU642-03-0183-V05, titled, "Interdisciplinary Treatment Plan", revised 3/22/10, included, "The Mental Heath Unit interdisciplinary treatment plan provides a plan for outlining the treatment of the psychiatric patient. The plan will identify patient needs and problems, determine patient treatment goals, plan treatment interventions during hospitalization and coordinate aftercare..."

2. Pt. #2's clinical record was reviewed on 2/5/13 and included that Pt. #2 was a 91 year old female, admitted to the Behavioral Unit on 1/29/13, with diagnoses of Depression, Chronic Kidney Disease, and Chronic Obstructive Lung Disease. A Physician's orders dated 1/29/13, included an isolation cart to be set up for contact precautions for a history of Methicillin Resistant Staphylococcus Aureus and another order dated 1/29/13, for Oxygen per nasal canula as needed for comfort (the number of oxygen liters were not included). The treatment plan face sheet dated 1/30/13, included only 2 problems: Risk of self harm, and Safety. Isolation, oxygen, and urinary renal needs were not included in the care plan.

3. The Director of Behavioral Services confirmed the above findings during an interview on on 2/5/13, at approximately 11:00 AM, and stated that the Care Plan was not complete.

Based on document review and interview, it was determined that the Hospital failed to ensure all medical records were completed within 30 days following patient discharge.

Findings include:

1. The Director of Health Information Management (HIM) presented the surveyor with an attestation letter indicating that as of 2/6/13 there were 141 medical records incomplete, 30 days following the patient's discharge.

2. The above finding was confirmed with the Director of HIM, during an interview on 2/6/13 at approximately 11:15 AM.

CONDITION: Based upon on-site observation, staff interview, and document review during the Life Safety portion of a Medicare Sample Validation Survey conducted on February 5 through 8, 2013, the surveyors finds that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the severity, variety, and number of Life Safety Code deficiencies that were found. Also see A 710

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STANDARD: Based upon on-site observation, staff interview, and document review during the Life Safety portion of a Medicare Sample Validation Survey conducted on February 5 through 8, 2013, the surveyor finds that the facility does not comply with NFPA 101 - 2000, the Life Safety Code

See Life Safety Code deficiencies that were cited (K-tags dated 02/08/13). Also see A 700.

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Based on document review, observational tour, and interview, it was determined, that for 1 of 5 staff (E #4) in Operating Room (OR) Suite 2, 8 of 14 staff and vendors (E # 9 - 16) in OR Suite 5, and 4 of 10 staff (E #5 - 8) in OR Suite 11, on 2/6/13 between 7:00 and 8:30 AM, the Hospital failed to ensure adherence to the "Surgical Attire" policy.

Findings include:

1. Hospital policy, Number RMC-OR660-03-01420-V01, titled, "Surgical Attire", revised 12/13/12, required, "6. All personnel must cover hair, including sideburns and the nape of the neck, when in the semirestricted and restricted areas. 7. All individuals entering the restricted areas must wear a mask when open sterile supplies and equipment are present... 10. Masks will be worn covering the mouth and nose and tied securely... Jewelry including earrings, necklaces, and bracelets will be removed before entering the semirestricted or restricted area..."

2. This was found in the OR Suite 2:

- On 2/6/13 at approximately 7:00 AM, during a tour of OR 2, the circulating nurse (E #4) was observed with approximately 2 inches of hair exposed on the back of the head, below the head covering. This finding was confirmed by the OR Manager during the tour.

3. This was found in the OR Suite 5 between approximately 7:00 AM and 8:30 AM:

- At approximately 7:00 am, E #9 (RN), E #10 (RN), and E #11 (vendor) were present in OR #5 with approximately 1-2 inches of hair exposed from the sides and rear of their head covers.

- At approximately 7:10 am, E #16 (vendor) entered OR #5 with facial hair and sideburns exposed on both sides of his face mask.

- At approximately 7:25 am, E #12 (anesthesiologist) entered OR #5 with approximately 1/2 inch of hair exposed from the front of the head cover.

- At approximately 7:42 am, E #13 (surgeon) entered OR #5 with his surgical mask unsecured at the bottom.

- At approximately 7:50 am, E #14 (surgical technician) entered OR #5 with facial hair exposed on both sides of his face mask.

- At approximately 8:03 am, E #15 (physician assistant) entered OR #5 with his surgical mask unsecured at the bottom.

4. This was found in the OR Suite 11 where sterile supplies were open:

- An Anesthesiologist (E #5) and a Certified Registered Nurse Anesthetist (E #6) were wearing rings.

- E #5 removed a mask from her pocket and used it.

- A Surgeon (E #7) and a Surgical Assistant (E #8) entered the room tying on their masks.

5. The above findings were discussed with the OR Manager and Vice President of Clinical Operations during an interview on 2/6/13 at approximately 8:30 AM.



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