HospitalInspections.org

Based on review and interview the facility failed

1. to have current and updated governing bylaws, unable to provide a list of all voting and non voting members of the governing board, have policies and procedures that clearly applied to the hospital in 2 of 2 (Seclusion and Restraint, Suspected Child, Adult, Disabled Person or Elderly Abuse/Neglect/Exploitation) policies reviewed.


The facility failed to ;
2. provide Governing Board Meeting Minutes for the appointment of CEO.

Refer to Tag A 0057

3. have contracts for 6 ( radiology group of providers, radiology facility, OPO, Echo Labs, dietician, van rental lease) contracted services provided.

Refer to Tag A0083

A review of the governing bylaws, last approved on 8/23 stated the facility's applicability was with Springstone Corporate. The bylaws stated on page 3 that the "Authority 1. Ownership. The hospital is owned by Springstone, Inc (the "owner")."

An interview was conducted with the CEO on 6/13/24 concerning the facility's ownership. The CEO stated that Lifepoint Health Inc. had bought out the facility back in October of 2023. The CEO reported that the merger was official in March/April of 2024 but was unsure of the exact date. The CEO was asked if the facility had a DBA (doing business as). The CEO provided a form that stated, "Ownership Structure" The form revealed Lifepoint Health Inc. at the top and the facility as an LLC of Lifepoint Health. There was no further evidence that Springstone Corporate was the "owner" of the facility.


The facility was unable to provide a list of all voting and non voting members of the governing board. The CEO and Quality Director was given the request in writing on 6/10/24 and also verbally asked

The facility failed to provide Governing Board Meeting Minutes for the appointment of CEO.

A review of staff #1's chart revealed he had a job description as the facility CEO on 7/19/23.

The facility failed to have a current or updated governing bylaws. A review of the governing bylaws, last approved on 8/23 stated the facility's applicability was with Springstone Corporate. The bylaws stated on page 3 that the "Authority 1. Ownership. The hospital is owned by Springstone, Inc (the "owner")."

An interview was conducted with the CEO on 6/13/24 concerning the facility's ownership. The CEO stated that Lifepoint Health Inc. had bought out the facility back in October of 2023. The CEO reported that the merger was official in March/April of 2024 but was unsure of the exact date. The CEO was asked if the facility had a DBA (doing business as). The CEO provided a form that stated, "Ownership Structure" The form revealed Lifepoint Health Inc. at the top and the facility as an LLC of Lifepoint Health. There was no further evidence that Springstone Corporate was the "owner" of the facility.

A review of the governing bylaws provided to the surveyor stated, "Members. The Governing Board shall be comprised of the following members:
A. Voting Members:
a. Chief Executive Officer (who shall serve as the Chief Executive Officer/ Chairperson of the Governing Board);
b. Director of Nursing;
c. Four executives of Springstone, Inc. who shall be designated at the beginning of each year.
B. Participants:
a. Hospital Medical Director
b. Hospital Chief Financial Officer
c. Hospital Quality Director ..."

M. Appoint the Administrator. The Governing Board shall manage the affairs of the Hospital through the Administrator. The Administrato

Based on review and interview the facility failed to have contracts for 6 of 6 ( radiology group of providers, radiology facility, OPO, Echo Labs, dietician, van rental lease) contracted services provided.

A review of the contract log revealed all contracts were approved on 2/15/24 by the governing board. A review of the following services rendered at the facility from outside contracted services did not have a contract.

There was no contract for the physician radiology group or a radiology facility, no contract for the Organ Procurement, no contract for Echo Labs, No contract for a dietician, and no contract for the vans that are being leased to transport patients.

Staff # 1 and # 3 were unable to provide the requested contracted services.

Based on document review and interview the facility failed to:

A. chemical restraints/emergency behavioral medications (EBM) administered Intramuscular (IM) or Intravenous (IV) for behavioral emergencies were identified and monitored as a chemical restraint in 2 (Patient #2, #4) of 2 medical records reviewed.

B. ensure chemical restraints/EMBs were added to the restraint log 1 (Patient #2) of 1 medical record reviewed.

C. ensure the policy and procedures addressed and gave clear instructions for the assessment and reassessment of a patient after the administration of a chemical restraint in 1 (Patient #2) of 1 medical record reviewed.

D. ensure staff was educated on the administration of chemical restraints and safe monitoring after administration.

E. an order was obtained from the physician, not longer than 30 minutes after the initiation of seclusion in 1 (Patient #2) of 2 (Patient #2 and #4) medical records reviewed.

Refer to Tag A0160


F. orders written for restraints were not written on a PRN (as needed basis) in 1 (Patient #4) of 2 (Patient #2 and #4) medical records reviewed. Also, the facility failed to follow the facility policy titled, "Seclusion and Restraint".

Refer to Tag A0169

G. ensure the 1-hour face-to-face evaluation was completed by a different nurse than the one who initiated the restraint as required by Texas State Regulation in 1 (Patient #2) of 2 (Patient #2 and #4) medical records reviewed.

Refer to Tag A0180



46435

Review of documentation, interview, and observations it was determined that, patient #16's right to reasonable protection of personal property from theft or loss was not provided, as the patient's belongings were not returned to him upon discharge from the facility.

Findings Include:

During Observations conducted of the facility on 06/13/2024 at 3:00PM. Review of the medication room in the Sunrise Unit revealed patient home medication containers are stored in the medication dispensing unit in a sealed plastic bag with patient identifiers on them.

An interview was conducted with Staff #34 and Staff #35 on 06/13/2024 at 3:15PM. Staff #34 and #35 were asked what the intake process for new patients that arrive with home medications. Staff #35 states when the patient to the unit and personal belongings and personal searches are conducted if there are any additional medications are found that the intake nurse in the intake area did not find, the medication would be secured and verified by the unit nurse and they would be added to any medication that had already been received by the intake nurse logged on the personal medication sheet, secured in a bag and placed in the medication dispensing cabinet so it could be returned to patient at the time of discharge. Staff #35 states once the medication is verified by the unit nurse and they counter sign the sheet her responsibility for the medication ends because she does not have access to the medication dispensing unit. Staff #34 states as a nurse she would store the medication at admission and part of their discharge process would check the medication dispensing unit for any home medication that needed to be returned to the patient at discharge. Staff #34 and #35 stated that they have the patients sign their sheet when they come in and when they leave but sometimes things just get left behind. When staff #34 asked to look in the cabinet for patient #16 belongings they state there is none.

Documents reviewed included:

1. Review of patient #16's medical record for April 18, 2024, at 3:45PM, revealed during admission on the "Home Medication Belongings Form" there are several medications listed as being received by the facility, with the Patient signature. At time of discharge, it is noted on this sheet the patient refused to sign due to medication missing.

2. Review of the medical record for patient #16 revealed A supplemental sheet dated 04/25/2024 and signed by the patient and two RN's (names unreadable) that indicates "Discharge Home Medications Missing at D/C on 4/25/24: Naproxen, Melatonin, Zoloft (2 Bottles), Mens daily vitamins, Buspar, and Trazadone." But there are several other medications that were received at the same time during admission listed as returned.

Based on record review and interview the hospital failed to ensure patients had the capacity to consent and understand the risks and benefits of psychotropic medications before signing an informed consent in 1 of 1 (Patient #4) medical record reviewed. Also, the physician must sign the informed consent for treatment with psychoactive medications within 2 working days as required by Texas Administrative Code (TAC) Rule 414.405(d).


Findings:

Patient #4
Patient #4 was a 27-year-old female admitted to the facility on 5/23/2024 with a diagnosis of Bipolar Disorder current episode manic with severe psychosis.

A review of the Psychiatric Evaluation completed by Physician #40 on 5/24/2024 was as follows:

" ...Patient was seen with consent. The patient is a 27-year-old female who presents with mania, delusions, psychosis, and severe agitation. She has received multiple PRN (as needed) meds after admission due to aggression and acting out against staff.

During the psychiatric interview, the patient has disorganized thoughts, thought blocking, and needed much encouragement to get the answers .... Pt is minimizing psychiatric symptoms, but her presentation is consistent with psychosis ... Orientation: Not oriented to person, place, and time ..."

A review of the progress note dated 5/25/2024 revealed that the patient's behavior was bizarre, distracted, and only oriented to person. The provider's signature was illegible.

A review of the progress note dated 5/26/2024 revealed the patient was guarded, loud, irritable, and only oriented to person. The provider's signature was illegible.

A review of the progress note dated 5/27/2024 failed to document if the patient was oriented to person, place, time, or situation. The provider'

Based on document review and interview the facility failed to ensure:

A. chemical restraints/emergency behavioral medications (EBM) administered Intramuscular (IM) or Intravenous (IV) for behavioral emergencies were identified and monitored as a chemical restraint in 2 (Patient #2, #4) of 2 medical records reviewed.

B. chemical restraints/EBMs were added to the restraint log in 1 (Patient #2) of 1 medical record reviewed.

C. the policy and procedure titled, "Seclusion and Restraint" gave clear instructions for the assessment and reassessment of a patient after the administration of a chemical restraint/EBM in 1 (Patient #2) of 1 medical record reviewed.

D. staff was educated on the administration of chemical restraints/EBMs and safe monitoring after administration.

E. an order was obtained from the physician, not longer than 30 minutes after the initiation of seclusion in 1 (Patient #2) of 2 (Patient #2 and #4) medical records reviewed.



Findings:

Medical record reviews were conducted on 6/10/2024-6/12/2024 with RN Staff #31. The medical record review was as follows:


Patient #2

Patient #2 was a 15-year-old female admitted to the facility on 5/28/2024 by Physician #23 with a diagnosis of Psychosis.

A review of the medication orders dated 5/29/2024 at 8:30 am by Physician #23 was as follows:

"Haldol (antipsychotic) 5 milligrams (mg) IM NOW and Lorazepam (sedative medication) 1 mg IM NOW for aggression/psychosis".

A review of the medication administration record (MAR) revealed 5 mg of Haldol was administered IM on 5/29/2024 at 8:38 am and 1 mg of Lorazepam was administered IM on 5/29/2024 at 8:42 am by Registered Nurse (RN) Staff #25.

A review o

Based on document review and interview the facility failed to ensure orders written for restraints were not written on a PRN (as needed basis) in 1 (Patient #4) of 2 (Patient #2 and #4) medical records reviewed. Also, the facility failed to follow the facility policy titled, "Seclusion and Restraint."

Findings:

Patient #4

Patient #4 was a 27-year-old female admitted to the facility on 5/23/2024 with a diagnosis of Bipolar disorder with severe manic psychosis and marijuana abuse.

A review of the medication order by Physician #40 dated 5/23/2024 at 3:30 pm was as follows:

"Olanzapine (Zyprexa-antipsychotic medication) 10 milligrams (mg) intramuscular (IM) Q (every) 4 hours PRN for unspecified psychosis not due to a substance or known physical condition. Notes: Verified with RN Staff #41-Max Daily 30 mg".

A review of the facility policy titled, "Seclusion and Restraint," with an effective date of 1/2024 was as follows:

" ...Purpose
To provide guidelines for the use of seclusion and/or restraints at the Hospital and Clinics ...

Definitions

...Emergency Medications (Texas Facilities Only)

A drug or medication that has been ordered to be given "now" because it is immediately necessary to address the signs and symptoms of a patient's mental illness and to prevent:
A. Imminent probable death or substantial bodily harm to the patient because the patient:
1. is threatening or attempting to commit suicide or serious bodily harm; or
2. is behaving in a manner that indicates that the patient is unable to satisfy the patient's need for nourishment, essential medical care, or self-protection; or

B. Imminent physical harm to others because of threats, attempts, or other acts

Based on document review and interview the facility failed to ensure the 1-hour face to face evaluation was completed by a different nurse than the one who initiated the restraint as required by Texas State Regulation in 1 (Patient #2) of 2 (Patient #2 and #4) medical records reviewed.


Texas State Rule was as follows:

"415.260[c][1] Face-to-face evaluation. A physician, physician assistant as provided in paragraph (3) of this subsection, or a registered nurse who is trained and has demonstrated competence in assessing medical and psychiatric stability, other than the registered nurse who initiated the use of restraint or seclusion, shall conduct a face-to-face evaluation of the individual within one hour following the initiation of restraint or seclusion to personally verify the need for restraint or seclusion".


Findings:


Patient #2

A review of Patient #2's medical record was completed on 6/12/2024 after 10:00 am with RN Staff #31.
Patient #2 was a 15-year-old female admitted to the facility on 5/28/2024 with a diagnosis of Psychosis.
A review of the medical record revealed Patient #2 received multiple restraints/seclusions/emergency behavior medications (EMBs) on 5/30/2024.

The review of the medical record was as follows:

" ...5/30/2024-Patient #2 was placed in a physical restraint at 8:33 am and administered a chemical restraint/EBM at 8:40 am by RN Staff #29. Staff #29 documented on a progress note that Patient #2 refused the 1-hour face-to-face evaluation but failed to document a time. A review of the 1-hour face-to-face was documented by RN Staff #29 at 5:00 PM. RN Staff #29 was the same RN who initiated the restraint. Also, this was greater than 8 hours after the initiation of the restraint/E

Based on review and interview the facility failed to;

A. have any performance improvement concerning the previous citations on 3/5/24, or any evidence of action plans or tracking performance to ensure that improvements are sustained.

Refer to Tag A 0283

B.to have an ongoing reporting system for adverse patient events.

Refer to Tag A0286

C. conduct any performance improvement projects. The facility failed to document what quality improvement projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects.

Refer to Tag A0297

Based on review and interview the facility failed to have any performance improvement concerning the previous citations on 3/5/24, or any evidence of action plans or tracking performance to ensure that improvements are sustained.

A review of the Quality Assessment Performance Improvement (QAPI) Meeting Minutes dated May 22, 2024 revealed there was mention of the citations from the 3/4/24 complaint survey. The minutes stated,

"Regulatory Updates:

On April 9, 2024, the statement of deficiencies associated with the unannounced state survey done on March 4, 2024, was received by the Director of Quality and CEO.

There were (1) finding that was substantial in compliance and no deficiencies were cited but there were 4 findings had related deficiencies cited and they were included appropriate nurse staffing, emergency treatment were the hospital failed to ensure there was a documented written plan for the care of all individuals treated in the Emergency Treatment Room and no expired items were located in there, Nursing Reassessments, Emergency medication monitoring and documentation, and restraint and seclusion documentation.

The plan of correction was completed and returned."

There was no performance improvement concerning the citations or any evidence of action plans or tracking performance to ensure that improvements are sustained and provide patient safety. The QAPI meeting minutes discussed an EMTALA that was cleared on the 3/5/24 visit but no other citations.

An interview was conducted with Staff #3 on 6/11/24. Staff #3 was asked if she had made a plan of correction book or had addressed the citations in QAPI from the previous visit. Staff #3 was unable to answer the question and was not able to supply the surveyor with any further information.

Based on review and interview the facility Quality Assessment Performance Improvement (QAPI) program failed to have an ongoing reporting system for adverse patient events.

A review of the QAPI meeting minutes dated 5/22/24 revealed there was no mention of patient adverse events or tracking of medical errors. There was no clear expectations for safety established.

An interview was conducted with Staff #3 on 6/11/24. Staff #3 stated that she was following adverse reactions but had not reported it in the QAPI meeting minutes. Staff #3 had some data but had not analyzed the data or determined the root cause of the incidents.

Based on review and interview the Quality Assessment Performance Improvement (QAPI) program had failed to conduct any performance improvement projects. The facility failed to document what quality improvement projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects.

An interview was conducted with Staff #3 on 6/11/24. Staff #3 stated that the hospital was not participating with the QIO cooperative project. Staff #3 was unable to provide any information of any specific PI projects. The facility was tracing 6 individual tracers that fell below the 90% benchmark goal:

"Discharge Planning Progress note is filled out completely and addresses all areas of DC planning and safety planning = 40%, which is a 10% decrease from March.
"Initial Master Treatment Plan is completed per state required timeframe = 50%, which is a 14% decrease from March.
"Discharge plan is completed in full with follow-up appointments and includes the next provider of care = 60%, which is a 33% decrease from March.
"Safety plan is completed with no blanks and addresses all high-risk items and access to means identified in psychosocial assessment, treatment plan, and throughout treatment= 70%, which is a 1% decrease from March.
"Weekly progress notes completed that describe the progress related to treatment goal (can be embedded into a therapy note or in a separate progress note)= 80%, which is a 6% decrease from February.
"Treatment plan update completed every 7 days from admission== 80%, which is a 6% decrease from March.

The facility had data but minimal analysis of the issue. There was no documentation on any quality improvement projects being conducted, the reasons for conducting these projects, and the measurable progress.

Based on review and interview the facility failed to;

1. to ensure periodical conduct review appraisals were conducted in 8 of 8 ( staff # 23 and staff #42 -49) provider credential files reviewed.

refer to A340

2. ensure
A. The provider had approved privileges from the Medical Executive Committee (MEC) and approved by the Governing Board (GB). 4 (#42, #45, #47, #48, #24) out of 8 (#23, #24, #42-44 and #47-#48) provider files reviewed.
B. The provider failed to have a background check 2(#42, #47) out of 8(#23, #24, #42-44 and #47-#48) provider files reviewed.
C. The provider had an application 2 (#45, #47) out of 8(#23, #24, #42-44 and #47-#48) provider files reviewed.
D. The provider had peer references 3 (#45, #47, #48) out of (#23, #24, #42-44 and #47-#48
E. The Nurse Practitioner failed to have a supervising physician and/or no patient charts listed as reviewed by the physician. 2 (#24, #44) out of 2(#24, #44) files reviewed.

refer to A341

3. to provide information on the official members of the medical staff voting and non-voting, and failed to ensure the that the Medical Executive Committee (MEC) was making voting decisions on provider credentialing and recredentialing in 2 (2/24 and 5/24) of 2 quarters provided.

refer to A347

Based on review and interview the facility failed to ensure periodical conduct review appraisals were conducted in 8 of 8 ( staff # 23 and staff #42 -49) provider credential files reviewed.

A review of provider credential files revealed there was no periodical conduct review appraisals found. Staff # 49 confirmed on 6/12/24 there were no evaluations in the files for periodical conduct review appraisals for staff #23, 42, 43, 44, 45, 46, 46, 48, or 49).

Based on review and interview the facility failed to ensure
A. The provider had approved privileges from the Medical Executive Committee (MEC) and approved by the Governing Board (GB). 4 (#42, #45, #47, #48, #24) out of 8 (#23, #24, #42-44 and #47-#48) provider files reviewed.
B. The provider failed to have a background check 2(#42, #47) out of 8(#23, #24, #42-44 and #47-#48) provider files reviewed.
C. The provider had an application 2 (#45, #47) out of 8(#23, #24, #42-44 and #47-#48) provider files reviewed.
D. The provider had peer references 3 (#45, #47, #48) out of (#23, #24, #42-44 and #47-#48
E. The Nurse Practitioner failed to have a supervising physician and/or no patient charts listed as reviewed by the physician. 2 (#24, #44) out of 2(#24, #44) files reviewed.

An interview and review of the medical providers' credentialing files was conducted on 6/12/24 with staff #50. The following files revealed missing information from the following.

Physician #42
A request for clinical privileges was in the chart for core medical privileges. The standard form had no physician signature, date, or time when requested. Another standard form stated approved for the core privileges but there was no signature on who approved the privileges, date, or time.

No letter from the MEC or Governing Board approved the recertification of clinical privileges. The facility had a contract to allow the contracted telehealth company to perform credentialing functions however the facility failed to have the credential files on site for review. The contract stated, "Upon request and reasonably advanced notice, Group shall provide the company with access to Group's credential/re-credential materials and files related to the credentialing, quality improvement, and peer review act

Based on review and interview the facility failed to provide information on the official members of the medical staff voting and non-voting, and failed to ensure the that the Medical Executive Committee (MEC) was making voting decisions on provider credentialing and recredentialing in 2 (2/24 and 5/24) of 2 quarters provided.

A review of the Medical Executive Committee (MEC) Minutes dated February 5th 2024 revealed staff #1 CEO and staff #5 CNO attended the MEC. A review of the minutes revealed staff #1 approved the minutes form the last meeting and approved the reappointment of the medical director and the radiology group. There was no provider that voted or approved. The meeting was adjourned by the medical director and second by staff #1. There were 5 physicians listed as attending the meeting. There was no sign in sheet that they were present nor any documentation in how they were present at the meeting.

A review of the MEC minutes on 5/6/24 revealed there were 5 physicians in attendance, four corporate board members the CEO, pharmacist, Quality manager, and the minutes taken by the HR manager. There was no information on how they were present (by zoom, teams, etc.) nor was there any sign in sheet.

The CEO approved staff #3 as the MEC president and staff #5 the CNO second the motion but she was not listed as an attendee of the meeting. There was no documentation that any provider voted on the medical director president.

Credentialing was brought up for 5 approved appointments for medical doctors and one nurse practitioner (NP). 2 NPs were mentioned for reappointment. There was no documented evidence that they were voted on or approved by the medical staff.

The surveyor requested a list of all medical staff that were members of the MEC and if they were voting o

Based on review and interview the facility failed to

A. have an approved Nurse Staffing Plan and matrix to ensure a significant number of nurses and staff were available to provide safe patient care of each nursing unit, failed to provide any data or information from nurse staffing advisory meetings to determine safe staffing, failed to ensure nurse staffng was covered during breaks and meals, and failed to protect the nurses who provided input and discussed staffing issues with regulators from retaliation.

Refer to Tag A0392


B. Nursing failed to ensure a physical assessment was completed on 2 of 2 (Patient #1 and #7) patient medical records reviewed.

Refer to Tag A0395

Based on review and interview the facility failed to have an approved Nurse Staffing Plan and matrix to ensure a significant number of nurses and staff were available to provide safe patient care of each nursing unit, failed to provide any data or information from nurse staffing advisory meetings to determine safe staffing, failed to ensure nurse staffng was covered during breaks and meals, and failed to protect the nurses who provided input and discussed staffing issues with regulators from retaliation.

A review of the Governing Board (GB) meeting minutes for 11/20/23, 2/22/24, and 5/22/24 revealed that the GB had not approved any Nurse Staffing Plan or staffing matrix. The facility was unable to provide any information on how nurse staffing was budgeted for the facility.

The facility was cited in 3/24 for not conducting nurse staffing advisory meetings to determine safe staffing levels. An interview was conducted with staff # 5 Director of Nursing (DON) on 6/11/24. Staff #5 stated that she had not presented any other staffing plan for approval other than what was sent down from corporate. Staff #5 confirmed it was the policy and procedure, "Plan for the Provision of Nursing Care in Psychiatric Specialty Areas" last reviewed on 6/2023." Staff #5 stated that since our last visit in March, she has been trying to find a comparable nursing grid from one of the other facilities in their corporation but could not find one. Staff #5 stated that they are using one that was made for an alcohol and drug rehabilitation unit and not specific for this facility and patient population. Staff #5 confirmed the grid was not developed for the facility and she was unable to provide any data or information on how this matrix had safe patient-nurse ratios to provide safe patient care.

Staff #5 stated she had


28659

On the late morning of 6/11/2024, staff Registered Nurse #12, was interviewed. During the interview, staff #12 described a recent event on the unit where a female patient refused to comply with the nurse's request and attempted to force her way into the medication room. The Staff RN stated, "I have this loud whistle and I blew it for help, but no one came to help me".

On 06/12/2024 during rounding in the adult unit, staff #12 approached this surveyor and stated, "Did you or did you not tell the CNO, staff #5, everything I spoke to you about? I spoke to you in confidence". Staff #12 stated, "The CNO, staff #5, came to me and questioned everything I said to you yesterday". A CMS Surveyor witnessed this line of questioning.

On 06/13/2024 in the early afternoon, the CNO, staff #5, was interviewed. The CNO, staff #5, was asked to explain her scheduling process. The CNO explained the expected nurse-patient ratio for each unit. The CNO was asked, "When you prepare your schedule for staffing the units, do you consider nurse/patient care staff breaks (staff are off the unit)? Or when a patient care staff must leave the patient unit to walk to the admission area to escort a new patient to the unit, that the unit, will be short-staffed until the new patient and patient care staff return? The CNO stated, "No, I never considered that".

On 06/13/2024, during an interview, the CNO was asked, "How was the staffing grid determined? The CNO was asked to explain, what process was used to determine the staffing grid. How did nursing leadership, determine if the numbers were sufficient for a safe effective patient-staff ratio? The CNO, Staff #5, replied, "The grid we are using came from another facility of ours in another state. The facility is a chemical dependence rehabilitation and treatment facility. We kno


40989

Findings:

An observation tour was conducted on 6/12/2024 at 10:30 am on the Cedars Unit.

The Cedars Unit was a 12-bed inpatient unit for adults. At the time of the observation, the unit had 10 patients and one being a new admit. Patient #19 was just admitted to the facility. The nursing admission had not been completed at the time of the observation. Registered Nurse (RN) Staff #31 was the RN assigned to the unit and was training another RN. At 10:40 am, 7 patients were taken to the activity room with the activity therapist for a group Yoga session. The therapist was alone for the group activity. This left 3 patients on the unit with one nurse and one Mental Health Tech (MHT) Staff #38. Two patients were in their assigned rooms and the new patient was pacing the unit at a rapid pace. At 10:45 all patients were returned to the day room from the group activity. At 10:50 am MHT Staff #38 was called to the Sunrise Unit to assist with a behavioral emergency. MHT Staff #38 returned to the Cedars Unit at 11:13 am. While the MHT was off the unit, this left RN to monitor 10 patients alone for 23 minutes.
An interview was conducted with RN Staff #31 on 6/12/2024 at 11:20 am. RN Staff #31 was asked what would happen if she had an emergency in the Dayroom area. RN Staff #31 stated, "I would call for help". RN Staff #31 was asked how she would call for help from the dayroom if she was the only RN on the floor. RN Staff #31 confirmed she was not assigned a "walkie-talkie" to radio for help if she was not near a phone.
At 11:25, six patients were taken to the activity room to continue the group session leaving 4 patients on the unit with one RN and one MHT. At 11:30 am MHT #38 left the unit again to process a urine sample for the new admit and returned to the unit at 11:43 am leaving one RN alone on t

Based on observation, document review, and interview, Nursing failed to ensure a physical assessment was completed on 2 of 2 (Patient #1 and #7) patient medical records reviewed.

Findings:

Patient #1

Patient #1 was a 19-year-old female admitted to the facility on 6/07/2024 with a diagnosis of Major Depressive Disorder with Psychotic Features, ADHD, and Autism Spectrum Disorder.
A review of the Nursing Assessment dated 6/08/2024 at 9:12 am revealed a section of the nursing assessment document was titled, "Physical Assessment". The physical assessment included Pain and interventions attempted, Respiratory assessment, Gastrointestinal (GI) Assessment, and COVID-19 Screening. Registered Nurse (RN) Staff #12 documented that Patient #1 had no complaints of pain, the respiratory assessment was normal, the GI assessment was normal, and no symptoms were noted during the COVID-19 screening assessment.

A physical assessment is described as an inspection, palpation (feeling with the fingers or hands), percussion (tapping body parts with fingers, hands, or a small instrument), and auscultation (listening to sounds from the heart, lungs, or other organs typically with a stethoscope).

An interview was conducted with RN Staff #31 on 6/11/2024 at 2:30 pm. RN Staff #31 was when was the nursing assessment completed. RN Staff #31 stated, "We do the assessments when we give the patients their medications". RN Staff #31 was asked if a physical assessment was completed on each patient every 12 hours. RN Staff #31 stated, "We ask the patients if they have any complaints with their bowels or problems breathing or if they are coughing, and if they say yes then we will listen to their bowel sounds or lung sounds. RN Staff #31 was asked if the patient did not have any complaint

Based on document review and interview, the facility failed to follow the Governing Body Bylaws, Medical Executive Bylaws, and the facility policy titled, "Practitioner Deficiency and Delinquency" to ensure medical records were promptly completed thirty (30) days after a patient's discharge in 43 discharged patients whose records were reviewed.

Refer to A0438.

Based on document review and interview, the facility failed to follow the Governing Body Bylaws, Medical Executive Bylaws, and the facility policy titled, "Practitioner Deficiency and Delinquency" to ensure medical records were promptly completed thirty (30) days after a patient's discharge in 43 discharged patients.

Findings:

A review of document titled "Delinquent Charts as of 06/12/2024" was conducted and this document revealed that 43 patient charts were delinquent. Further review revealed 22 charts were greater than 30 days delinquent. Eight (8) charts were greater than 60 days delinquent. 13 charts were greater than 90 days delinquent.

An interview was conducted with Staff #18 on 6/13/2024 at 9:30 am. Staff #18 was asked how she reported the delinquency of records. Staff #18 stated, "I report this in our daily flash meetings every morning. I report a weekly listing of all medical records that have deficiencies and notify the practitioner by email. I also report the delinquent charts to our Quality Director, Staff #3, in our quality meetings and our CEO, Staff #1. They are fully aware of all the delinquent charts".


A review of the Governing Board Bylaws with an effective date of 8/2023 stated:

" ...5. Performance Improvement Responsibilities.
A ...
B ...
C ...
D. The Governing Board charges the Medical Staff to assume a leadership role in organizational performance improvement activities designed for process measurement assessment and improvements. These monitoring and evaluation activities include, but are not limited to, medical assessment and treatment of deviations from established patterns of clinical practice. The Medical Staff must actively participate in the measurement and assessment of all patient care processes, includin

Based on review the facility failed to have a contract for the radiology physicians group or radiological services.

A review of the contract log revealed all contracts were approved on 2/15/24 by the governing board. Radiology services rendered at the facility from outside contracted services did not have a contract. There was no contract for the physician radiology group or a radiology facility.

Staff # 1 and # 3 were unable to provide the requested contracted services.

Based on observation, document review and interview the facility failed to ensure a clean and sanitary environment in 5 of 5 (Dietary department, Clean Supply Rooms, Washer/Dryer Rooms, Consult Rooms, Linen Storage Rooms) areas observed. Also, the Infection Control Professional (ICP) failed to follow the Infection Prevention and Control Plan/Program.

Refer to Tag A0750

Based on observation, document review and interview the facility failed to ensure a clean and sanitary environment in 5 of 5 (Dietary department, Clean Supply Rooms, Washer/Dryer Rooms, Consult Rooms, Linen Storage Rooms) areas observed. Also, the Infection Control Professional failed to follow the Infection Prevention and Control Plan/Program.



Findings:


A tour of the facility was conducted on 6/10/2024 at 10:15 am with CEO Staff #1. The following was observed.

Dietary Department:

A tour of the dietary department was conducted on 6/10/2024 at 10:15 with Staff #1 and Food Service Manager (FSM) Staff #7.

The deep fryer was observed with oil. The internal perimeter of the fryer was dotted with visible
food residue. The surface of the deep well fryer had a cookie sheet resting over the oil. FSM Staff #7 stated, "The cookie sheet is what we cover the oil with. The surveyor observed the cookie sheet did not fully cover the surface of the oil. Dust particles suspended in the air had the potential to settle on the surface of the deep fryer oil contaminating the oil. The outside of the deep well fryer was coated with dried oil splash residue. Staff #1 confirmed the observations.

26 Cookie sheets were observed with heavily burned grease build-up. 12 of the cookie sheets were black on the underside of the pan making it difficult to clean and sanitize after each use.

One (1) Sauté pan was observed heavily discolored on the outside. The pan's inner surface was black. The inner base surface of the pan had been scratched showing a silver metallic surface. FSM Staff #7 confirmed the pan was not originally black but silver in color. FSM Staff #7 stated, "It can no longer be cleaned to silver".

The convection oven

Based on review and interview the facility failed to:

1. have an agreement with an OPO.

Refer to Tag A 0886

2.have an agreement with an eye or tissue bank.

Refer to Tag A 0887

3.have any staff education for designated OPO, tissue bank, eye bank or educated staff on donation issues.

Refer to Tag A 0891

Based on review and interview the facility failed to have an agreement with an OPO.

Review of the contract list revealed there was no contract for an OPO. Staff # 3 confirmed there was no OPO contact on 6/13/24. A review of the policy and procedure "Organ , Tissue, and Eye Procurement" stated there was attachments for Springstone Organ, Tissue & Eye Procurement Services and phone numbers. The facility was unable to provide this attachment nor a OPO contrast.

Based on review and interview the facility failed to have an agreement with an eye or tissue bank.

Review of the contract list revealed there was no contract for an eye or tissue bank. Staff # 3 confirmed there was no agreement on 6/13/24.

Based on review and interview the facility failed to have any staff education for designated OPO, tissue bank, eye bank or educated staff on donation issues.

Review of employee files #1, #2, #5, #18, 26, #28, #31 revealed there was no staff education for for designated OPO, tissue bank, eye bank or educated staff on donation issues. The facility failed to have policy and procedure or a contract.

Based on document review and interview the hospital failed to ensure the Governing Body appointed a physician as the Medical Director of Respiratory Services.

Findings:

A review of the credential file for the physicians working at the facility revealed that the Governing Body had not appointed one of the physicians as the Medical Director of Respiratory Services.

An interview was conducted on 6/12/2024 after 1:30 PM with Staff #1. Staff #1 confirmed that no physician was appointed as the director of respiratory services.

Based on document review and interview the facility failed to ensure a screening neurological exam was conducted by a physician in 2 (Patient #1and #2) of 2 medical records reviewed.

Findings:

Patient #1
Patient #1 was admitted to the facility on 6/07/2024 by Physician #23 with a diagnosis of Major Depressive Disorder with psychotic features, Attention Deficit Hyperactivity Disorder (ADHD) by history, and Autism Spectrum Disorder by history.

A review of the History and Physical dated 6/7/2024 at 12:00 pm revealed Nurse Practitioner (NP) #24 completed the neurological screening exam. There was no documented neurological examination by a physician in the medical record.


Patient #2
Patient #2 was a 15-year-old female admitted to the facility by Physician #23 on 5/28/2024 with a diagnosis of Psychosis unspecified.

A review of the History and Physical dated 5/29/2024 at 10:00 am revealed NP #24 completed the neurological screening exam. There was no documented neurological examination by a physician in the medical record.


An interview was conducted with RN Staff #5 on 6/12/2024. RN Staff #5 confirmed the neurological exam was performed during the history and physical by NP #24 and not a physician.

Based on document review and interview the facility failed to include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or an emergency.

Refer to E0009.

Based on document review and interview the facility failed to include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or an emergency.


Findings:


A review of the facility Policy titled "Emergency Operation Plan" with an effective of 11/2023 was as follows:

"Policy
The hospital shall test its Emergency Operation Plan during exercises and actual events.
Procedure
1 ...
...
5. The Hospital, with emergency services, will conduct at least one exercise a year that includes participating in at least one community wide exercise ..."



A review of the Policy titled "Needs and Vulnerabilities within the Community" with an effective date of 3/2024 was as follows:

"...Purpose
To communicate to our community partners our needs and vulnerabilities in the event of an emergency.
Scope of policy ...
Definition ...
Policy
The Hospital will communicate with its community partners the needs and vulnerabilities of the Hospital on an annual basis during the Emergency Operations Review and whenever its needs or vulnerabilities change ..."

An interview was conducted with Staff #4 on 6/12/2024 after 2:30 pm. Staff #4 confirmed the facility failed to follow its policies titled "Emergency Operation Plan" and "Needs and Vunerabilities within the Community".


During a review of document titled "Annual Performance Evaluation-Emergency Preparedness" revised on 12/5/2022 stated:

"Has the facility coordinated or joined local or state emergency organizations or validated "receiver status" with local entities: Yes."

An interview was conducted wit