HospitalInspections.org

Based on record reviews, observation, and staff interviews, it was determined the hospital failed to ensure the Governing Body evaluated hospital services related to medical staff, quality management, nursing services, pharmaceutical services, and laboratory services. This deficient practice poses the risk of the Governing Body being unaware of the overall function and management of the hospital and the inability to improve patient care services.

Findings include:

The Condition level deficiency is the result of the standard deficiencies found in the following tags:

A-0048: The Governing Body failed to approve medical staff rules and regulations.

A-0297: The Governing Body failed to ensure performance improvement projects were conducted as part of the quality assessment and performance improvement program.

A-0358: The Governing Body failed to ensure medical staff rules and regulations included medical history and physical examination be completed 24 hours after admission.

A-0395: The Governing Body failed to ensure 15 minute observation was documented for 11 of 20 patients.

A-0454: The Governing Body failed to ensure restraint order was dated and authenticated by ordering physician for one of one patient.

A-0458: The Governing Body failed to ensure history and physical examination was performed within 24 hours after admission for 9 of 20 patients.

A-0491: The Governing Body failed to ensure patients were provided medications that were prepackaged and not requiring additional preparation prior to administration.

A-0492: The Governing Body failed to ensure there was an operational pharmacy overseen by a pharmacist.

A-0501: The Governing Body failed to ensure medications were available when needed by patients at all times.

A-0508: The Governing Body failed to ensure a pharmacist was tracking and reporting medication errors, adverse drug reactions, and incompatibilities to the Quality Assessment and Performance Improvement program.

A-0582: The Governing Body failed to ensure point-of-care testing was provided under a CLIA certificate of waiver.

A-0775: The Governing Body failed to ensure medical staff received infection control training.

A-1690: The Governing Body failed to ensure behavioral health technician received clinical oversight.

The cumulative effect of these systemic deficient practices resulted in the facility's failure to meet the requirement for the Condition of Participation for Governing Body.

Based on the review of records and staff interviews, it was determined that the Medical Staff failed to provide quality patient care as stated in the by-laws as evidenced by:

A0048: The Governing Body failed to ensure the Medical Staff Bylaws included Rules and Regulations.


A035: Medical Staff failed to ensure that patient history and physicals were completed within 24 hours of admission.


A0454: Medical Staff failed to ensure that restraint orders were dated and authenticated.

A0458: Medical Staff failed to ensure patient medical records contained history and physicals within the required timeframe.

The cumulative effect of these systemic problems resulted in the medical staff's inability to ensure the provision of quality patient care.

Based on the review of record, observations, and staff interviews, it was determined that the Hospital failed to ensure that the hospital had a pharmacy that was directed by a pharmacist. This deficient practice poses a potential risk for patients of not receiving necessary and required medications to aide in the patients care and treatment.

Findings include:

A-0491: The Hospital failed to ensure that patients were provided medications that were prepackaged and not requiring additional preparation prior to administration.

A-0492: The Hospital failed to ensure there was an operational pharmacy overseen by a pharmacist.

A-0501: The Hospital failed to ensure that medications were available when needed by patients at all times.

A0508: The Hospital failed to ensure a Pharmacist was tracking and reporting medication errors, adverse drug reactions, and incompatibilities to the Quality Assessment and Performance Improvement program.

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of safe medication administration practices.

Based on review of facility records and interview the Department determined the hospital failed to provide approved Medical Staff Rules and Regulations. This deficient practice poses a health and safety risk when rules governing patient care determined by the Governing Body of the facility are not followed.

Cross reference: A0043, A0338

Findings Include

Hospital document titled "Talus Harbor Behavioral Health Hospital MEDICAL STAFF BYLAWS" revealed: "...Article 13 GENERAL PROVISIONS 13.1 STAFF RULES AND REGULATIONS. Subject to the approval by the board the Medicals Staff shall adopt such Rules and Regulations as may be necessary to implement more specifically the general principles found with these Bylaws. The Rules and Regulations shall relate to the proper conduct of the Medical Staff organization activities and embody a level of practice that is to be required of each Staff member of Allied Health Professional exercising privileges ...."

Observation and Review conducted on 08/30/2023 revealed that the Medical Staff Rules and Regulations were missing from the Medical Staff Bylaws.

Upon request of a copy of the Medical Staff Rules and Regulations on 08/31/2023, none was provided.

Employee # 11 confirmed in an interview dated 03/31/2023 that the Medical Staff Bylaws did not contain the Medical Staff Rules and Regulations.

Based on the review of facility records and interviews, the Department determined the hospital failed to ensure that the facility followed its policies and procedures related to performance improvement studies. This deficient practice poses a potential risk to the health and safety of patients if the data collected is not evaluated in order to implement processes to improve.

Findings Include

Hosptial document titled "Performance Improvement Plan" revealed: " ...1. Overview The purpose of the plan is to ensure the delivery of quality care to all patients. This is accomplished through consistent monitoring of the clinical services of the unit including Outcome measurements ...When opportunities are identified as a result of review and data collection a plan of correction is developed and monitored towards resolution ...The activities of the PI Plan are reported at least quarterly to the Performance Improvement Committee ...II. Functions ...e. A plan will be developed for all areas identifying corrective action, staff responsible, expected target date, and length of time for review ...f. Identify opportunities to improve patient care through implementation of evidenced-based services to improve patient outcome, improve patient safety, improve patient/family satisfaction, and or/services ...."

A hospital document titled "QAPI Committee Talus Harbor at Buckeye-Date": revealed:
The minutes are not dated. Quality Indicators ...Master Treatment Plan Each active medical problem has a long-term goal January 75%, February 90% March 90%. Each active medical problem has a short-term goal January 75%, February 90%, and March 90%. Each active medical problem has an intervention for nursing. January 75%, February 90%, March 90%.

Employee #7 confirmed during an interview conducted on 08/31/2023 that the facility had not conducted any Performance Improvement studies.

Based on record review and staff interview, it was determined the hospital failed to ensure a medical history and physical examination were performed within 24 hours after admission for 9 of 20 patients (Patients #6, #11, #12, #13, #14, #17, #18, #19, #20). This deficient practice poses a potential risk that underlying conditions are missed and patients are not being evaluated after admission.

Cross reference: A0043, A0338, A0458

Findings include:

The medical staff rules and regulations were requested on 08/30/2023. None was provided.

Review of Patient #6's medical record revealed admission date of [08/25/2023], and history and physical examination performed on [08/28/2023].

Review of Patient #11's medical record revealed admission date of [07/24/2023], and history and physical examination performed on [07/28/2023].

Review of Patient #12's medical record revealed admission date of [07/14/2023], and no documentation of history and physical examination was performed.

Review of Patient #13's medical record revealed admission date of [06/27/2023], and history and physical examination performed on [07/05/2023].

Review of Patient #14's medical record revealed admission date of [06/17/2023], and history and physical examination performed on [06/21/2023].

Review of Patient #17's medical record revealed admission date of [07/03/2023], and history and physical examination performed on [07/05/2023].

Review of Patient #18's medical record revealed admission date of [05/03/2023], and no documentation of history and physical examination was performed.

Review of Patient #19's medical record revealed admission date of [05/26/2023], and no documentation of history and physical examination was performed.

Review of Patient #20's medical record revealed admission date of [06/10/2023], and history and physical examination performed on [06/12/2023].

Employee #1 confirmed during an interview conducted on 08/31/2023 that Patients #12, #18, and #19 had no documentation of history and physical examination. They also confirmed Patients #6, #11, #13, #14, #17, #20 did not have history and physical examination performed within 24 hours after admission.

Based on record review and staff interview, it was determined the hospital failed to ensure policies and procedures for nursing services were implemented for 11 of 20 patients (Patients #5, #6, #8, #10, #11, #14, #15, #17, #18, #19, #20). This deficient practice poses a potential risk to the health and safety of patients if there is a lack of monitoring and supervision.

Findings include:

Policy titled, "Nursing Rounds" dated 03/01/2023, revealed: " ...B. Rounds, (15-minute checks) are made a minimum of every fifteen (15) minutes in a varied pattern ...C. The assigned staff member(s) personally locates each patient they are assigned to, documents the rounds exact time (0702, 0712, 0724 etc.), patient's location (Room, Day Room, Bathroom, etc.), and behavior on the Observation Sheet under the appropriate column ....E. In the event a staff member cannot complete their assigned 15-minute rounds, the charge RN must be notified to reassign and ensure hand off communication between staff members ...."

Review of Patient #5's medical record revealed no documentation of 15-minute checks on [08/27/2023] from [0135-0525 hours].

Review of Patient #6's medical record revealed no documentation of 15-minute checks on [08/27/2023] from [0135-0525 hours].

Review of Patient #8's medical record revealed no documentation of 15-minute checks on [08/26/2023] from [2250-2355 hours], and [08/27/2023] from [0135-0525 hours].

Review of Patient #10's medical record revealed no documentation of 15-minute checks on [08/15/2023] from [0005-0655 hours].

Review of Patient #11's medical record revealed no documentation of 15-minute checks on the day of [07/27/2023].

Review of Patient #14's medical record revealed no documentation of 15-minute checks on [06/18/2023] from [0000-0625 hours], and [06/22/2023] from [0205-0825 hours].

Review of Patient #15's medical record revealed no documentation of 15-minute checks on [07/29/2023] from [0000-0145 hours, 1220-1340 hours], [07/30/2023] from [0610-0700 hours, 1105-1200 hours], [07/31/2023] from [0000-0255 hours, 1705-1825 hours], and [08/01/2023] from [0000-0120 hours, 0150-0315 hours].

Review of Patient #17's medical record revealed no documentation of 15-minute checks on [07/04/2023] from [1425-1550 hours, 1625-1810 hours].

Review of Patient #18's medical record revealed no documentation of 15-minute checks on [05/07/2023] from [1705-1855 hours].

Review of Patient #19's medical record revealed no documentation of 15-minute checks on [05/29/2023] from [1850-1955 hours], and [05/30/2023] from [1535-1710 hours, 1720-1820 hours].

Review of Patient #20's medical record revealed no documentation of 15-minute checks on [06/12/2023] from [0410-0510 hours], [06/17/2023] from [1950-2245 hours, 2255-2355 hours], and [06/18/2023] from [0000-0625 hours].

Employee #1 confirmed during an interview conducted on 08/31/2023 that there was missing documentation of 15-minute checks for Patients #5, #6, #8, #10, #11, #14, #15, #17, #18, #19, #20.

Based on record review and staff interview, it was determined the hospital failed to ensure restraint order for one of one patient (Patient #15) was dated and authenticated. This deficient practice poses a potential risk to the patient's health and safety in the event the patient was inappropriately restrained.

Cross reference: A0043, A0338

Findings include:

Policy titled, "Seclusions and Restraints" dated 03/01/2023, revealed: " ...Orders: 1. Restraint and/or Seclusions shall be ordered by a physician or a registered nurse practitioner primarily responsible for the patient's ongoing care authorized by the medical staff ...."

The medical staff rules and regulations were requested on 08/30/2023. None was provided.

Review of Patient #15's medical record revealed a restraint order on [08/07/2023 at 0825 hours]. The order was noted by a registered nurse at 0820 hours. The physician authentication, date, and time were left blank.

Employee #1 confirmed during an interview conducted on 08/31/2023 that the restraint order for Patient #15 was not dated or authenticated by the ordering physician.

Based on record review and staff interview, it was determined the hospital failed to ensure a medical history and physical examination were performed within 24 hours after admission for 9 of 20 patients (Patients #6, #11, #12, #13, #14, #17, #18, #19, #20). This deficient practice poses a potential risk that underlying conditions are missed and patients are not being evaluated after admission.

Cross reference: A0043, A0338, A0358

Findings include:

The medical staff rules and regulations were requested on 08/30/2023. None was provided.

Review of Patient #6's medical record revealed admission date of [08/25/2023], and history and physical examination performed on [08/28/2023].

Review of Patient #11's medical record revealed admission date of [07/24/2023], and history and physical examination performed on [07/28/2023].

Review of Patient #12's medical record revealed admission date of [07/14/2023], and no documentation of history and physical examination was performed.

Review of Patient #13's medical record revealed admission date of [06/27/2023], and history and physical examination performed on [07/05/2023].

Review of Patient #14's medical record revealed admission date of [06/17/2023], and history and physical examination performed on [06/21/2023].

Review of Patient #17's medical record revealed admission date of [07/03/2023], and history and physical examination performed on [07/05/2023].

Review of Patient #18's medical record revealed admission date of [05/03/2023], and no documentation of history and physical examination was performed.

Review of Patient #19's medical record revealed admission date of [05/26/2023], and no documentation of history and physical examination was performed.

Review of Patient #20's medical record revealed admission date of [06/10/2023], and history and physical examination performed on [06/12/2023].

Employee #1 confirmed during an interview conducted on 08/31/2023 that Patients #12, #18, and #19 had no documentation of history and physical examination. They also confirmed Patients #6, #11, #13, #14, #17, #20 did not have history and physical examination performed within 24 hours after admission.

Based on review of records, observation and staff interview, it was determined that the Hospital failed to ensure that patients were provided medications that were prepackaged and not requiring additional preparation prior to administration. This deficient practice poses a risk to the health and safety of patient if there is not a pharmacist on cite to oversee that patients receive proper medication administration.

Cross reference: A0489

Findings include:

Review of list of hospital contracted vendors revealed pharmacy services were provided by APC Pharmacy.

Tour of hospital revealed a locked and unstocked pharmacy.

Observation while on tour revealed a medication room at the nurse's station. Further observation of the medication room revealed multi-dose and single dose vials requiring staff to manually draw up the contents of the medication vials into syringes prior to patient administration.

Employee #5 confirmed on 08/31/2023 that medications were provided by an outsourced pharmacy.

Based on review of hospital documents, observation and staff interviews, it was determined the Hospital failed to ensure there was an operational pharmacy overseen by a pharmacist. This deficient practice poses a risk to the health and safety of patients if medication is not readily available to meet the needs of patients.

Cross reference: A0489

Findings include:

Review of the facility's list of contracts revealed a contract with APC Pharmacy Services

Tour of the facility revealed a locked and unstocked pharmacy area in the facility.

Employee #6 confirmed during an interview conducted on 08/31/2023 that the hospital did not have a functioning pharmacy or a pharmacist on duty.

Based on review of records, observation and staff interview, it was determined the Hospital failed to ensure that medications were available when needed by patients at all times. This deficient practice poses a risk to the health and safety of patients if medications are not readily available when needed.

Cross Reference: A0489

Findings include:

Review of hospital list of contracted vendors revealed the hospital had contracted APC Pharmacy as the contracted pharmacy vendor.

Tour of the hospital revealed a locked and unstocked pharmacy in the hospital.

Employee #6 confirmed on 8/31/2023 that the hospital does not have a pharmacy in the hospital. Employee #6 confirmed that the contracted vendor made medication deliveries three (3) times a day. Employee #6 stated that if a medication was needed in the off hours before a delivery, the facility could call the pharmacy supplier to request the needed medication.

Based on review of records and staff interview, it was determined that the Hospital failed to ensure a Pharmacist was tracking and reporting medication errors, adverse drug reactions, and incompatibilities to the Quality Assessment and Performance Improvement program. This deficient practice poses a risk to the health and safety of patients if the hospital does not monitor medication errors and implement actions to prevent medication errors.

Cross reference: A0489

Findings include:

Multiple requests were made for the hospital Quality Assessment and Performance Improvement Plan during the survey. None was provided by the hospital.

Tour of the hospital revealed a non-operational pharmacy on the hospital premises.

Employee #6 confirmed on 08/31/2023 that the hospital did not have a pharmacist.

Based on record review and staff interview, it was determined the hospital failed to ensure clinical laboratory services were provided by the hospital through a laboratory with a current certificate of waiver issued by the United States Department of Health and Human Services under the 1988 amendments to the Clinical Laboratories Improvement Act (CLIA) of 1967. This deficient practice poses a health risk to patients by not providing clinical laboratory services per CLIA certification guidelines.

Cross Reference: A-0043

Findings include:

Policy titled, "Capillary Blood Glucose" dated 09/03/2022, revealed: " ...Capillary blood glucose monitor (BGM) is one of four waived tests identified by the facility in accordance with the facility's Clinical Laboratory Improvement Amendments of 1988 (CLIA '88) certificate. CLIA waived tests required specific training, competency, quality assurance, and quality control in order to maintain compliance ...."

A copy of current CLIA certificate of waiver was requested on 08/30/2023. A certificate of accreditation for Sonora Quest Laboratories was provided.

Employee #5 confirmed during an interview conducted on 08/30/2023 that the facility performs point-of-care testing such as blood glucose monitoring. Employee #6 confirmed CLIA certificate of waiver with the facility's name and address was not available for review.

Based on review of the facility's employee and credential files, Infection Control Plan, and interview, it was determined that the hospital failed to provide training and education for the medical staff. This deficient practice poses a risk to the health and safety of patients, when infection control techniques and prevention are not consistent throughout the hospital.

Findings Include

Policy titled "Infection Control Plan" revealed: " ...POLICY: " ...The Vision of Talas Harbor Behavior Health Hospitals Infection Control Program is to provide infection prevention and control techniques consistent with emerging practices to eliminate preventable disease ...Examples of appropriate prevention and/or control measures include but are not limited to ...Provisions of education to staff, patients, and other persons at the hospital or its facilities ...."

Review of the following credentialing files, Provider #1, #2, #3, and,4 did not contain documentation of Infection Control training.

Employee # 6 confirmed during an interview conducted on 08/31/2023 that the physicians were not provided infection control training.

Provider # 3 confirmed during an interview conducted on 08/31/2023 that [she] was not provided infection control training.

Based on review of facility documents, personnel documents, and interview, it was determined that the hospital failed to ensure a licensed professional provided clinical oversight and supervision to BHTs (behavioral health technician) and BHPPs (behavioral health paraprofessional), This deficient practice poses a potential risk that the hospital has a proper licensed professional to provide supervision and oversight to BHTs, BHPPs while they are providing services to a patient.

Findings Include

Policy titled "Clinical Oversight" requested, none provided.

A review of employee files Employee # 4, 12,13, and 14 did not contain documentation of clinical oversight.

Employee # 5 confirmed during an interview conducted on 08/30/2023 that clinical oversight of the Behavior Health Technicians is not being done.