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Based on record review and interview the hospital failed to ensure:
1) a policy was developed and implemented regarding 'staff to patient' abuse/neglect.
2) all staff were educated/trained regarding 'staff to patient' abuse/neglect.
These findings were hospital wide with no evidence of any employee having been trained/educated in 'staff to patient' abuse/neglect. Findings:

1) Review of the hospital policy titled, "Abuse and Neglect, last revised 12/21/2008" presented by the hospital as their current policy revealed in part, "Patients/clients entering the program who exhibit evidence of abuse or neglect will be assessed immediately and the suspicion will be reported to the proper county Division of Family Services within 24 hours of the receipt of this information. . . " Review of the entire policy revealed no documented evidence of addressing abuse/neglect that occurred within the hospital to include 'staff to patient' abuse.

During a face to face interview on 5/18/2011 at 10:45 a.m., Director of Quality S1 confirmed the above findings. S1 further indicated she had been unable to find any hospital policy that addressed abuse of patients that occurred within the hospital to include 'staff to patient' abuse.

2) Review of personnel folders for Recreational Therapist S21, Recreational Therapist S22, Mental Health Technician S20, and Licensed Practical Nurse S8 revealed no documented evidence of having been trained on the procedure for addressing patients' allegations of abuse that occurred within the hospital or witnessed patient abuse that occurred within the hospital to include 'staff to patient' abuse.

During a face to face interview on 5/18/2011 at 10:45 a.m., Director of Training/Education S23 indicated all staff at the hospital had been trained on Abuse during Hospital Orientation and during Annual Mandatory Training. S23 further indicated the training centered around identifying and assessing patients that had been abused outside the hospital and ensuring the abuse/neglect was reported to the appropriate authorities. S23 indicated there had been no training provided to staff regarding abuse/neglect that occurred within the hospital to include 'staff to patient' abuse/neglect."

During a face to face interview on 5/18/2011 at 8:55 a.m., Activity Therapist S22 indicated she had witnessed a former employee (S5) call a patient a "B_ _ _ h" and make physical gestures that appeared to be mocking or making fun of homosexuals. S22 indicated she (S22) had made a verbal report of the incident to Program Manager S2 (date/time/year/patient's name unknown). S22 indicated she (S22) had been instructed to document the incident by Program Manager S2; however, she (S22) refused to do so because she (S22) felt any firing of the employee (S5) should not be based on a report that had been filed by her (S22). S22 indicated she (S22) had ongoing conflict with the former employee (S5). S22 indicated S5 had resigned some time after the incident for unrelated issues (Resignation Date 10/18/2010).

During a face to face interview on 5/17/2011 at 1400 (2:00 p.m.), Mental Health Technician S20 indicated she (S20) had heard Mental Health Technician S5 call a patient "Picky Head" in front of there peers. S20 further indicated it had been a child that had very low self esteem and the child cried for some time after S5 made the comment. S20 indicated she (S20) had informed the Charge Nurse on duty but had no knowledge as to whether the Charge Nurse spoke with Mental Health Technician S5 or not. S20 indicated she (S20) had no recall of the patient's name, the Charge Nurse's name, or the time frame of the event.
S20 further indicated she (S20) had witnessed Mental Health Technician S5 being inappropriate with other patients. S20 described the incident as a time when Mental Health Technician S5 had been talking to a group of patients about changing their lives to avoid going to prison. S20 indicated S5 had been making physical gestures imitating homosexual behavior and sticking out his tongue. S20 indicated his (S5's) mannerisms seemed to be making fun of homosexual behavior and it had made her (S20) very uncomfortable. S20 indicated some of the children had expressed the same discomfort. S5 indicated other children had thought it was funny. S20 indicated she (S20) had never reported the incident to anyone. S20 indicated staff were supposed to report misconduct. S20 indicated she had never known any action to be taken regarding misconduct, so she decided not to report the incident. S20 indicated she had no recall of the time frame of the incident or the names of any patients witnessing the incident. S20 further indicated Mental Health Technician S5 no longer worked at the hospital.

During a face to face interview on 5/18/2011 at 1250 (12:50 p.m.), Program Manager S2 indicated he (S2) had been unable to get Activity Therapist S22 to document any incidents regarding the behaviors of Mental Health Technician S5. S2 indicated there had been an ongoing conflict between S5 and S22. S2 indicated it had been an ongoing "He said. She said." conflict. S2 indicated the complaints had been about Activity Therapist indicating S5 had repeatedly challenged their job performance of Activity Therapy and belittled them in from of peers. S2 further indicated S5 had repeatedly complained that the Activity Therapist were not performing Activity Therapy appropriately. S2 indicated he (S2) had no recall of any specific patient complaint regarding S5; however, it had been his (S2) practice to attend to patient complaints promptly. S2 indicated patients' typical complaints had been about issues that could promptly be resolved and he (S2) had no documentation of the interactions. S2 indicated Mental Health Technician S5 had resigned on October 18, 2010 in lieu of being terminated for abandoning his assigned duties and for interfering with staff's performance of duties (Confirmed with Record Review).

Based on record review and interview the hospital failed to ensure all departments were monitored for Quality by failing to have any Quality Indicators identified for the Activity Therapy Department in the Behavioral Psychiatric In-Patient Off Site Campus for 3 of 3 units reviewed (Adolescent 2nd floor, Adolescent 3rd Floor, and Children's 3rd Floor). Findings:

Review of the hospital's "Performance Improvement Plan 2011" presented by the hospital as their current plan revealed in part, "The Plan serves as a strategy for measuring the efficacy of key processes and services, identifying changes that enhance performance, and monitoring performance to ensure improvement sustainability. . . The goal of the Children's Hospital Performance Improvement Plan is to establish, maintain, and support an organization-wide performance improvement program. . ."

Program Manager S2 and Director of Quality S1 were unable to produce any Quality monitoring (measuring, analyzing, and tracking of quality indicators) for Activity Therapy Services provided at the Behavioral Psychiatric In-Patient Unit/ Off Campus Hospital.

During a face to face interview on 5/18/2011 at 9:40 a.m., Program Manager S2 and Director of Quality S1 confirmed there had been no measuring, analyzing, and tracking of quality indicators regarding services provided by Activity Therapy at the Off Site Campus's Behavioral Psychiatric In-Patient Unit. S2 indicated he (S2) had Quality Indicators for other Services provided in the Behavioral Psychiatric In-Patient Unit; however, had never identified or monitored Quality Indicators for Activity Therapy.

Based on record review and interview, the hospital's QAPI (Quality Assurance Performance Improvement) program failed to ensure the effective implementation of performance improvement activities by failing to accurately analyze the cause of an adverse patient event (suicide attempt/gesture of Patient #6) and implement actions and mechanisms that include feedback and learning throughout the hospital. Findings:

Patient #6: Medical record review revealed the patient was admitted to the behavioral health unit of Children's Hospital on 3/12/10. Review of the Psychiatric Evaluation revealed the patient had multiple psychiatric hospitalizations. Documentation revealed that Patient #6's Axis 1 diagnoses included Psychosis NOS (Not Otherwise Specified); R/O (Rule Out) BP (Bipolar Disorder); R/O Schizophrenia. Review of the Physician's Order Sheet revealed an order dated 3/24/10 at 10:30 a.m. for "Change status to VC" VC (Visual Contact). Review of the "Treatment Team Progress Notes" revealed an entry dated 3/31/11 at 8:30 p.m. that read "Upon checking in on patient, nurse (S) saw the patient standing on a desk with a bed sheet tied to his neck. The bed sheet was also tied to a vent near the ceiling. The patient stated 'I'm trying to kill myself'. Nurse (S) and MHT (E) escorted the patient to the ground without resistance. The patient was then escorted to the quiet room where he fell asleep. MHT (name) is with patient at current time. Will continue to monitor for safety". Review of the medical record including the physician's orders revealed that Patient #6 was to be on a "VC" observational status at the time of being found standing on a desk with a sheet tied around his neck and tied to a vent near the ceiling on 3/31/10. There was no documentation to indicate that the "VC" order dated 3/24/10 had been discontinued or changed prior to 3/31/10 at 8:30 p.m.

The hospital's policies/procedures were reviewed. No policy/procedure was found during this review to define "CO" (Close Observation) status or to define "VC" (Visual Contact) status.

The Nurse Manager/Program Director of Behavior Health Services (S2) was interviewed on 5/18/11 at 10:30 a.m. S2 reported that he was unable to provide a policy/procedure defining "CO" (Close Observation) or "VC" (Visual Contact).

The Nurse Manager/Program Director of Behavior Health Services (S2) was interviewed on 5/17/11 at 2:30 p.m. S2 reviewed the medical record of Patient #6. S2 confirmed that Patient #6 was ordered to be on a "VC" (Visual Contact) observational status at the time of being found standing on a desk with a sheet tied around his neck and tied to a vent near the ceiling on 3/31/10. S2 reported that patients ordered to be on a "VC" observational status are to be within the line of sight of a staff member at all times. S2 reported the documentation indicated that Patient #6 was not being observed and/or monitored on 3/31/10 as ordered as the patient would not have been found standing on a desk with a sheet tied around his neck and tied to a vent near the ceiling had he been within the line of site of a staff member at all times.

The Director of Quality (S1) was interviewed on 5/17/11 at 2:45 p.m. S1 reported the suicide attempt/gesture of Patient #6 was handled as a "near miss" by the hospital and indicated that a "Root Cause Analysis and Corrective Action Plan" was done relating to this "near miss". S1 presented the "Root Cause Analysis and Corrective Action Plan" for review. Review of the "Root Cause Analysis and Corrective Action Plan" relating to the suicide attempt/gesture of Patient #6 on 3/31/10 revealed the following:
"Patient was wandering around unit punching walls and doors during snack time. Patient was asked to go to his room or the quiet room. Other patients were also sent to their respective rooms. (Name of Patient #6) became increasingly hostile to staff. Security was called and the patient was given an oral dose of Haldol/Ativan/Benadryl. Patient stated he was calm and took the medicines. He went to his room stating 'I'm tired of being here ...I'm tired of this *ing place,,, I'm gonna give ya'll hell.' The patient went to his room and got into bed under the sheet and blanket. He closed his eyes and appeared to be going to sleep. Staff left the room. Ten minutes later, the nurse went to check on the patient and found him standing on top of the desk with a bed sheet around his neck and the other end attached to the A/C vent. Patient stated 'I'm trying to kill myself'. Patient was assisted down by nurse and MHT. Patient was taken to quiet room and placed on 1:1 observation status. MD was notified". Documentation on the "Flowchart of event" was "Policy did not require VC". There was no documentation in the "Root Cause Analysis and Corrective Action Plan" to indicate that the staff members had failed to ensure that Patient #5 was being monitored on a VC status as ordered by the physician at the time of his attempted suicide. S1 confirmed that the "Root Cause Analysis and Corrective Action Plan" failed to identify and capture the fact that staff members had failed to follow physician's orders relating to the ordered VC observational status and failed to identify and capture the fact that the hospital had no policies/procedures that define the observational levels used on the psychiatric unit including "CO" and "VC" observational levels.

20638

Based on record review and interview the hospital failed to ensure the Psychiatric Unit was staffed according to hospital policy 2 of 23 days reviewed for staffing (1101/2010 and 3/31/2010). Findings:
Patient #4: Medical record review revealed the patient was admitted to the behavioral health unit of Children's Hospital on 10/29/10. Review of the Psychiatric Evaluation revealed the patient was admitted for Depression with Suicidal Ideations with a plan to hang himself. Review of the Treatment Team Progress Notes dated 11/01/10 and timed 7:55 p.m. revealed in part, "This RN was doing a routine room check and pt.(patient) was found on the floor of his room with a piece of his T-shirt around his neck, knotted twice. This RN yelled for MHT (Mental Health Tech), who was in hallway and when MHT came to doorway, this RN ran to get scissors and cut the cloth from his neck (because we were unable to remove it otherwise). Pt's face was reddened and when it was removed, pt immediately began crying tears and refused to speak to staff, but was visibly breathing .... "
Review of the documentation related to the unit census on 11/01/10 revealed the total census was 13 on the unit. The unit was staffed with 2 RNs (registered nurses) and 2 MHT (Mental Health Techs). Review of the Hospital's Policy/Procedures titled Staffing revealed with a weekday census of 10- 16 patients, on the 3 p.m. to 11 p.m. shift, 1.5 nurses and 3 MHT should have been working on the evening of the suicide attempt by Patient #4.
An interview was conducted with S2Nurse Manager/Program Director of Behavior Health Services on 05/18/11 at 12:50 p.m. He stated according to the hospital policy ,on the evening of 11/01/10, 4.5 staff members should have been working in the unit therefore the unit was short 0.5 a staff member on the evening of Patient #4's suicide attempt.
Patient #5: Medical record review revealed the patient was admitted to the behavioral health unit of Children's Hospital on 3/23/11. Review of the Psychiatric Evaluation revealed the patient had multiple psychiatric hospitalizations. Documentation revealed that Patient #5's Axis 1 diagnoses included R/O (Rule Out) impulse control D/O (Disorder); ODD; ADHD NOS (Not Otherwise Specified); R/O Sexual Abuse Child; Adjustment D/O with mixed disturbance of emotion & conduct; and Parent Child Relational Issues. Review of the Physician's Order Sheet revealed an order dated 3/30/11 at 7:30 p.m. for "OK for patient to return to CO". (CO=Close Observation) Review of the "Treatment Team Progress Notes" revealed an entry by the MHT (Mental Health Technician) dated 3/31/11 at 10:17 p.m. that read "Pt. attempted to strangle herself with her bed sheet by wrapping it around her throat & tying the other end to her door knob in her closet she has been placed on visual contact & needs to shower in the morning". Review of the medical record revealed no documentation to indicate the Registered Nurse (S10) assigned to Patient #5, or any Registered Nurse, had assessed/evaluated Patient #5's status and/or condition following the patient's attempt to strangle herself with a bed sheet as documented by the mental health technician on 3/31/11.

S10 (Registered Nurse) was interviewed on 5/18/11 at 8:30 a.m. S10 reviewed the medical record of Patient #5. S10 reported that she remembers the mental health technician informing her of Patient #5 having a sheet around her neck with one end of the sheet tied to a door knob. S10 reported that the mental health technician told her he had gotten the sheet off the patient and the patient (Patient #5) was okay. S10 reported that she called the physician and orders were given to place Patient #5 on a "VC" (visual contact) status.

Review of documentation relating to the unit census revealed a total of thirteen (13) patients on the third floor psychiatric unit. Review of documentation relating to nurse staffing revealed that there was one (1) registered nurse and two (2) mental health technicians working on the p.m. shift that began on 3/31/11 on the third floor psychiatric unit. Review of the Behavioral Health policies/procedures relating to staffing revealed that there should have been a total of 1.5 nurses and 3 mental health technicians assigned to the third floor psychiatric unit when the unit census is between 10 - 16 patients. This indicated that the third floor psychiatric unit was understaffed by 1.5 employees on the p.m. shift that began on 3/31/11.

The Nurse Manager/Program Director of Behavior Health Services (S2) was interviewed on 5/18/11 at 10:30 a.m. S2 confirmed that the third floor psychiatric unit was not staffed in accordance with the hospital approved policy/procedure.

17470

Based on record review and interview, the registered nurse failed to ensure the supervision and evaluation of care provided to 2 of 8 sampled patients by failing to assess/evaluate the status and/or condition of a patient (Patient #4 and #5 ) following the patient's attempt to strangle/hang themselves. Findings:
Review of Wisconsin Medical Journal 2003, Volume 102, No. 3 (a resource article regarding Strangulation Injuries provided by the hospital's Director of Quality S1), revealed in part " ... Delayed edema, hematoma, vocal cord immobility and displaced laryngeal fractures all may contribute to an unstable airway following strangulation. If the victim survives the initial assault and the injuries go unrecognized and untreated, delayed life threatening airway obstruction or long term vocal dysfunction may result.. "
Patient #4: Medical record review revealed the patient was admitted to the behavioral health unit of Children's Hospital on 10/29/10. Review of the Psychiatric Evaluation revealed the patient was admitted for Depression with Suicidal Ideations with a plan to hang himself. Review of the Treatment Team Progress Notes dated 11/01/10 and timed 7:55 p.m. revealed in part, "This RN was doing a routine room check and pt.(patient) was found on the floor of his room with a piece of his T-shirt around his neck, knotted twice. This RN yelled for MHT (Mental Health Tech), who was in hallway and when MHT came to doorway, this RN ran to get scissors and cut the cloth from his neck (because we were unable to remove it otherwise). Pt's face was reddened and when it was removed, pt immediately began crying tears and refused to speak to staff, but was visibly breathing .... " Review of the entire medical record revealed no documented evidence of a Registered Nurse's physical assessment immediately after a hanging attempt by Patient #4 or during the hours post hanging attempt for evaluation/assessment of delayed symptoms.
Review of the Safety Report dated 11/01/10, under the section listed as injury type; reddened area was checked, indicating the injury type the patient obtained during his suicide attempt.
An interview was conducted with S2Nurse Manager/Program Director of Behavior Health Services on 05/17/11 at 2 p.m. He stated a complete assessment was not done on the patient after the suicide attempt on 11/01/11 and he would expect a full assessment would be done by a nurse after a suicide attempt.
Patient #5: Medical record review revealed the patient was admitted to the behavioral health unit of Children's Hospital on 3/23/11. Review of the Psychiatric Evaluation revealed the patient had multiple psychiatric hospitalizations. Documentation revealed that Patient #5's Axis 1 diagnoses included R/O (Rule Out) impulse control D/O (Disorder); ODD; ADHD NOS (Not Otherwise Specified); R/O Sexual Abuse Child; Adjustment D/O with mixed disturbance of emotion & conduct; and Parent Child Relational Issues. Review of the Physician's Order Sheet revealed an order dated 3/30/11 at 7:30 p.m. for "OK for patient to return to CO". (CO=Close Observation) Review of the "Treatment Team Progress Notes" revealed an entry by the MHT (Mental Health Technician) dated 3/31/11 at 10:17 p.m. that read "Pt. attempted to strangle herself with her bed sheet by wrapping it around her throat & tying the other end to her door knob in her closet she has been placed on visual contact & needs to shower in the morning". Review of the medical record revealed no documentation to indicate the Registered Nurse (S10) assigned to Patient #5, or any Registered Nurse, had assessed/evaluated Patient #5's status and/or condition following the patient's attempt to strangle herself with a bed sheet as documented by the mental health technician on 3/31/11.

S10 (Registered Nurse) was interviewed on 5/18/11 at 8:30 a.m. S10 reviewed the medical record of Patient #5. S10 reported that she remembers the mental health technician informing her of Patient #5 having a sheet around her neck with one end of the sheet tied to a door knob. S10 reported that the mental health technician told her he had gotten the sheet off the patient and the patient (Patient #5) was okay. S10 reported that she called the physician and orders were given to place Patient #5 on a "VC" (visual contact) status. S10 confirmed that there was no documentation to indicate that Patient #5 was assessed and/or evaluated by a registered nurse following the patient's attempt to strangle herself with a bed sheet.

The hospital's policies/procedures were reviewed. There was no policy/procedure addressing the actions the registered nurse should take following the attempted suicide of a hospitalized patient. In addition, no policy/procedure was found during this review to define "CO" (Close Observation) status.

The Nurse Manager/Program Director of Behavior Health Services (S2) was interviewed on 5/18/11 at 10:30 a.m. S2 confirmed that the third floor psychiatric unit was not staffed in accordance with the hospital approved policy/procedure. S2 confirmed that there was no policy/procedure addressing the actions the registered nurse should take following the attempted suicide of a patient. S2 reported that he was unable to provide a policy/procedure defining "CO" (Close Observation).

26351

Based on record review and interview the hospital failed to ensure nursing care plans (Treatment Plans) were developed and kept current for 3 of 8 sampled patients (#2, #4, #7). Findings:

Patient #2:
Patient #2 was admitted to the hospital on 4/26/2011 and discharged on 5/16/2011 with diagnoses that included Mood Disorder Not Otherwise Specified and Rule Out Conduct Disorder. The patient had been admitted under a Coroner's Emergency Certificate dated 4/27/2011 for jumping out of a car in an attempt to kill himself.

Review of Patient #2's Behavioral Health Service Progress notes dated 5/07/2011 at 1700 (5:00 p.m.) revealed in part, "Pt (patient) reports that he (#2) has been building a relationship (with) a female peer. Pt.(#2) reports that on Thurs (Thursday) 5/05/11 he and a female peer planned to "get together in one of their rooms." Pt. (#2) reports that they kissed and the entire encounter lasted about 10 mins (minutes). Pt (#2) then reports that on Friday 5/06/2011, pt. (#2) was again able to sneak into female peer's room, but this time he reports that the two had consensual sex. "She told me to come tonight into her room, she leaves the door open." Pt. reports that he did not ejaculate inside of her but they did have sex." Further review revealed the patient (#2) had been sent to the Emergency Room, along with the female patient, for a rape exam, the police had been called, and Patient #2 had been transferred to anther unit to separate the two patients. Review of the entire medical record for Patient #2 revealed no documented evidence that Patient #2's Nursing Care Plan/Treatment Plan had been updated to include the Problem of Sexually Inappropriate Behavior. Further record review revealed no documented evidence of updating the Nursing Care Pan/Treatment Plan to include treatment modalities, staff interventions, or measurable goals related to the Problem of Sexually Inappropriate Behaviors for Patient #2 after the incident.

Patient #4:
Medical record review revealed the patient (#4) was admitted to the behavioral health unit of Children's Hospital on 10/29/10. Review of the Psychiatric Evaluation revealed the patient (#4) was admitted for Depression with Suicidal Ideations with a plan to hang himself. Review of the Treatment Team Progress Notes dated 11/01/10 and timed 7:55 p.m. revealed in part, "This RN was doing a routine room check and pt.(patient) was found on the floor of his room with a piece of his T-shirt around his neck, knotted twice. This RN yelled for MHT (Mental Health Tech), who was in hallway and when MHT came to doorway, this RN ran to get scissors and cut the cloth from his neck (because we were unable to remove it otherwise). Pt's face was reddened and when it was removed, pt immediately began crying tears and refused to speak to staff, but was visibly breathing .... " Review of the Safety Report dated 11/01/10, under the section listed as injury type; reddened area was checked, indicating the injury type the patient obtained during his suicide attempt. Review of the Master Treatment Plan with an admit date of 10/29/10 revealed, " 14 y.o (year old) male, depressed with SI (suicidal ideations) attempting to hang self. Parent/child relationship problems, bullying at school, good physical health, average or better intelligence." Under the section labeled Treatment Plan Review, the section was blank.
Patient #7:
Patient #7 was admitted to the hospital on 4/30/2010 and discharged on 5/17/2010 with diagnoses that included Psychotic Disorder Not Otherwise Specified, Disruptive Behavior Disorder Not Otherwise Specified, and Learning Disorder Not Otherwise Specified. Review of Patient #7's Behavioral Health Service Progress notes dated 5/11/2010 at 1345 (1:45 p.m.) revealed in part, "Pt. (patient) eloped from hospital while on an outside activity. He jumped the wall. . . "
Review of Patient #7's entire medical record revealed no documented evidence that a Nursing Care Plan/Treatment Plan had ever been initiated on Patient #7 during his entire hospital stay (4/30/2010 through 5/17/2010) to include no updating of the Treatment Plan after the patient had eloped on 5/11/2010.
An interview was conducted with S2 Nurse Manager/Program Director of Behavior Health Sciences on 05/17/11 at 2 p.m. S2 indicated all patients admitted to the Behavioral Health In-patient Psychiatric Units should have a Treatment Plan and should have the Treatment Plan updated after any change in condition or significant incident. S2 indicated Patient #2's Treatment Plan should have been updated after having inappropriate sexual conduct with another patient. S2 further indicated Patient #4 should have had his Treatment Plan updated after a suicidal gesture on the unit. S2 indicated Patient #7 should have had a Treatment Plan initiated during his hospital stay and then updated after the patient eloped from the unit.
Review of the hospital policy titled, "Treatment Planning, last reviewed 12/21/2008" presented by the hospital as their current policy revealed in part, "Preliminary Treatment Plans are completed within 24 hours of admission based upon the information received through the intake process. By the third day of treatment the rest of the Master Treatment Plan will be completed. This will incorporate the objectives, modalities for achieving the objectives, frequency of intervention, responsible part for each intervention, and projective date of goal achievement. Treatment Team meetings are held at least every week in order to monitor patient's progress, summarize and revise the plan as needed until patient is ready for discharge. However, the treatment plan may be altered at any time a patient's status indicates. . ."

Based on record review and interview the hospital failed to ensure documentation errors were corrected as per hospital policy for 1 of 8 sampled patients (#2). Findings:

Review of the hospital policy titled, "Behavioral Health Medical Record Documentation, last reviewed 12/21/2008" presented by the hospital as their current policy revealed in part, "Correct errors by drawing one single line through mis-statements and note "error" and add initials above the line. Do not erase or use Correction Fluid."

Review of Patient #2's medical record revealed the Code for (Patient) Location on the patient's "24 Hour Rounds Checklist" for the dates of 5/07/2011 at 1800 (6:00 p.m.), 1815 (6:15 p.m.) , 1830 (6:30 p.m.), and 1845 (6:45 p.m.) to be marked out completely with a pen. Further review revealed no documented evidence identifying the 'marked out information' as an error or identifying the author of the 'marked out information.'

During a face to face interview on 5/17/2011 at 1500 (3:00 p.m.), Program Manager S2 indicated errors in documentation should have a single line drawn through them with the notation of error and the initials of the person making the entry. S2 indicated the documentation in Patient #2's 24 Hour Rounds Checklist where information had been completely marked out was not an acceptable practice.