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Based on the number and nature of deficiencies, the facility failed to be in compliance with the Condition of Participation of Governing Body. Specifically, the Governing Body failed to ensure that the facility was in compliance with the other Conditions of Participation of Medical Staff, Radiologic Services, Laboratory Services and Respiratory Services. In addition the Governing Body failed to ensure that adequate structure/mechanisms were in place to provide medical staff oversight to ensure the quality of care and services in the areas of intake/assessment, laboratory, radiologic services, respiratory services and medical/psychiatric care.

Additionally, the governing body failed to ensure that the chief executive officer maintained and enforced up-to-date and facility specific policies and procedures for all areas of the facility including medical staff, medical records, radiologic services, laboratory services and respiratory services. Finally, the Governing Body failed to ensure that all contracted services, including medical staff, radiologic, laboratory and respiratory services complied with the applicable Conditions of Participation and that a complete/accurate list of contacted services was maintained, as required. The failures created the potential for negative patient outcomes.

The facility failed to meet the following Standards under the Condition of Governing Body:

Tag A 049 Medical Staff Accountability
The Governing Body failed to ensure that the medical staff provided oversight of the clinical services of psychiatric intake services, psychiatric/medical care, radiologic services, laboratory services and respiratory services.

Tag A 057 Chief Executive Officer
The Governing Body failed to ensure that the chief executive officer provided adequate oversight in the areas of medical staff, medical records, intake/assessment, radiology, laboratory and respiratory, to ensure that all areas had adequate oversight mechanisms and current, facility-specific policies and procedures that were enforced.

Tag A 083 Contracted Services
The Governing Body failed to ensure that the contracted services of medical staff, radiologic, laboratory and respiratory complied with applicable Conditions of Participation.

Tag A 085 Contracted Services
The Governing Body failed to ensure that the facility maintained a complete and accurate list of all contracted services, as required.

Based on review of medical records, staff interviews and review of facility documents, the governing body failed to ensure that the medical staff provided oversight of the clinical services of psychiatric intake services, radiologic services, laboratory services and respiratory services. In addition, the medical staff failed to ensure that all medical staff completed discharge summaries on all patients timely, or delegated that responsibility to another MD/DO(medical doctor/doctor of osteopathy) or appropriately qualified clinician (at the nurse practitioner/physician assistant level) knowledgeable about the patient's condition, the patient's care during the hospitalization, and the patient's discharge plans. Finally, the medical staff failed to ensure that the care provided to sample patients #27 and #28 met professional and facility standards of care that addressed the documented clinical needs of the of the patients. The findings created the potential for negative patient outcomes.

The findings were:

1. Failure to provide medical quality oversight of the psychiatric intake and assessment program:

Review on 2/2/11 of the facility document "Departments/Units/Areas/Services and Programs" revealed that the document, which described all programs and services (including contractual services) contained the following description of "Intake and Assessment:"
"Intake and Assessment:
This unit receives referrals for services and processes the request to determine if the patient qualifies for inpatient, partial hospitalization, intensive outpatient or individual/group outpatient care. The screening provides an account of the patient's psychiatric and substance abuse history, current symptoms, acuity and other pertinent personal data."

Review on 2/2/11 of the facility document "Provision of Care Plan" revealed that the document was a comprehensive description of all clinical programs and services (including contractual services) provided by the facility. The document contained the following description of "Screening and Intake" services:

"5.1 Screening and Intake
(The facility) accepts referrals from the professional community (physicians, courts, community agencies, education systems, psychologists and counselors), as well as by self or significant others. Intake screening and evaluations are performed by qualified Intake Counselors or by a member of the clinical supervisory staff, Social Services staff, registered nurse or active members of the Medical Staff, 24-hours per day, seven days per week. The individual is advised of the program structure at the time of the evaluation, together with a recommendation for the appropriate level of treatment according to admission criteria and physician recommendations...If admission criteria is not met, or if (the facility) does not offer a program to meet the patient's needs, recommendations are made for assistance available elsewhere in the community. As needed, provision for a safe transfer to an accepting facility and physician will be arranged. Admission to an inpatient program may be voluntary or involuntary. Patients are admitted to inpatient, partial hospitalization, and programs under the care of a psychiatrist."

On 2/2/11 at approximately 8:30 a.m., the director of intake was interviewed with the chief executive officer and the director of clinical services regarding the operation of the intake and assessment team of the facility. During the interview, the director of intake explained that the staff and activities of the intake/assessment team may consult with individual psychiatrists or the medical director or nursing about the admission of a particular patient, particularly if there are administrative or medical issues that are present that are addressed in the admission exclusion criteria policy. S/he stated that the admitting psychiatrist may be also contacted about accepting a particular patient. S/he stated that the intake assessment team did not have a mechanism or structure in place that allowed for routine case review by a member of the medical staff or the medical director, to ensure that the intake and assessment staff were making the appropriate assessments and clinical plans, utilizing medical and nursing consultation appropriately and adequately coordinating information gathering and other arrangements regarding admissions, referrals, transfers and discharges from the intake area.

Reference Tag A 347 Medical Staff Accountability for findings related to the intake and assessment team failure to available obtain collateral information, including treatment history and medication history and current recommendations, from the referring psychiatrist/psychologist prior to, or at the time of admission, to ensure continuity of care for sample patient #27.

2. Reference Tags A 529 (Radiologic Services), A 582 (Laboratory Services), and A 1152 (Respiratory Services) for findings regarding the medical staff failure to provide oversight of these clinical services.

3. Reference Tag A 468 (Content of Records - Discharge Summary) for findings regarding the medical staff failure to ensure that discharge summaries were completed timely for all patients by the physician or another adequately qualified clinician who had direct knowledge of the patient's condition, care during the hospitalization and discharge plans.

4. Reference Tag A 347 (Medical Staff Accountability) for findings regarding the medical staff failure to ensure that sample patients #27 and #28 were provided quality medical care in accordance with the Medical Staff Rules & Regulation, which addressed the clinical needs/presentation of the patients.

Based on policy review and interview, it was determined that the governing body failed to ensure each element of the hospital was overseen by the chief executive officer. Specifically, the facility failed to maintain Medical Records/Information Service policies that were tailored to the facility and reviewed/approved by the governing body and chief executive officer.

The findings were:

Medical records polices were reviewed on 2/1/11. Twenty-five of the polices, the majority, did not state the facility's name anywhere within. The originator, authorizer, and updaters, as documented on the polices, were not employees of the facility. Each of those 25 polices "Revision Effective" dates were prior to the facility's certification date of March 2007, including six, which were dated 2/01/99. Each of the 25 polices, which were entirely typed text, had a handwritten date of 6/10 and initials next to the "Reviewed Date" section.

An interview with the facility's Chief Executive Officer was conducted on 2/2/11 at approximately 9:30 a.m. When asked about the policies, s/he stated, "Those sound like corporate delivered polices from Philly." When asked about the names of who approved the policies, s/he stated, "They sound like corporate executives." S/he stated, "They could be updated to become our policies."

Based on staff interviews a facility tour, medical record review, staff interviews and review of facility documents, the governing body failed to ensure that all services furnished under contract complied with all applicable conditions of participation and standards for the contracted services of Medical Staff, Radiologic Services, Laboratory Services and Respiratory Services. The failure created the potential for negative patient outcomes.

The findings were:

Reference the findings under Tag A 338 Condition of Participation of Medical Staff Services and Standard Tag A 347 Medical Staff Accountability and Medical Records Condition of Participation Standard Tag A 468 Content of Records - Discharge Summary regarding all medical staff, allied professional staff and medical director services that were provided under contract with a physician medical group to provide care to all patients that had been screened and accepted for admission and treatment.

Reference the findings under Tag A 528 Condition of Participation of Radiologic Services and Standard Tag A 529 Scope of Radiologic Services regarding radiology services and equipment and personnel provided to meet the needs of the all patients that had been screened and accepted for admission and treatment.

Reference the findings under Tag A 568 Condition of Participation of Laboratory Services and Standard Tag A 582 Adequacy of Laboratory Services regarding laboratory services provided to meet the needs of the all patients that had been screened and accepted for admission and treatment.

Reference the findings under Tag A 1151 Condition of Participation of Respiratory Services and Standard Tag A 1152 Organization of Respiratory Services regarding respiratory services and equipment provided to meet the needs of the all patients that had been screened and accepted for admission and treatment.

Based on staff interview and review of facility documents, the governing body of the facility failed to ensure that the facility maintained a complete list of contracts, including the scope and nature of the services provided. Specifically, the facility failed to include a contract with a vendor to provide oxygen for patient respiratory needs on the list master list of contracted services provided.

The findings were:

1. Review on 2/3/11 of the complete list of contracted services, which was requested at the entrance conference on 2/1/11, revealed that the list contained no contracts for respiratory equipment or medical gases, including oxygen.

2. In an interview with the director of clinical services on 2/3/11 at approximately 8:30 a.m., s/he confirmed that the list did not contain a contract/contracts for the respiratory equipment and medical gases (oxygen) that s/he had stated on 2/2/11 at approximately 10:30 a.m., were provided by contracted vendors.

3. In an interview with the director of plant operations on 2/3/11 at approximately 9 a.m., s/he provided a contract for medical gases that provided oxygen tanks to the facility. S/he confirmed that the contract did not include provision of any other respiratory equipment, as previously alleged by the director of clinical services. The director of plant operations stated that s/he was personally unaware of any other contract to provide respiratory equipment.

Based on review of the facility's policies/procedures and staff interview, the facility failed to ensure its formal grievance policy specified time frames for the resolution of grievances. Specifically, the facility's grievance policy did not state when, if the investigation would not be completed within seven days, the patient would be notified and when the hospital would fully resolve the grievance. This failure created the potential for a negative patient outcome.

The findings were:

The facility's policy titled "PATIENT/FAMILY GRIEVANCE PROCESS" was reviewed on 2/1/11. It stated the following, in pertinent part: III. PROCEDURE... 8. The CEO shall have final authority in the resolution of any grievances, or they can be referred to the Patient Grievance Committee for review. Results of the CEO, Patient Grievance Committee or Designee will be provided to the complainant within seven days. If the grievance will not be resolved, or if investigation is not or will not be completed within seven days, the hospital should inform the patient or the patient's representative that the hospital is still working to resolve the grievance and that the hospital will follow-up with a written response within a stated number of days."

An interview with the facility's Patient Advocate was conducted on 2/2/11 at approximately 10:00 a.m. When asked about specific time frames for the complete resolution of grievances, s/he stated the s/he was not aware of that requirement. S/he stated, "I've always followed CMS verbiage in that of timely."

Based on the number and nature of deficiencies, the facility failed to be in compliance with the Condition of Participation of Medical Staff. Specifically, the Medical Staff failed to assume responsibility for monitoring the quality of medical care and other clinical services provide to patients by the hospital.

The facility failed to meet the following Standards under the Condition of Medical Staff:
Tag A 347 Medical Staff Accountability
The Medical Staff failed to provided oversight of the clinical services of psychiatric intake services, psychiatric/medical care, radiologic services, laboratory services and respiratory services.

Reference the Condition of Governing Body Standard Tag A 49 Medical Staff Accountability for addition findings related to medical staff oversight of patient care and clinical services.

Based on medical record review, and staff interview, and Medical Staff Rules & Regulations, the facility failed to ensure that a patient was provided quality medical care in accordance with the Medical Staff Rules & Regulation. Two of 30 medical records reviewed, sample patient #27 and #28, did not receive appropriate care. Sample patient #27 did not receive medications and appropriate medical/psychiatric care to address the reason for admission into the facility and sample patient #28 did not receive the care appropriate to treat his sleep apnea. These failures created the potential for a negative patient outcome.

The findings were:

1. On 1/26/2011, sample patient #27 presented to Highlands Behavioral Health as a walk in patient. S/he was admitted with diagnoses including mood disorder, ADHA (Attention Deficit Hyperactivity Disorder), rapid cycling, a history of violence/aggressive behavior and a danger to him/herself. Documentation on the "Pre Admission Nurse to Nurse Report" listed current home medications as Adderall and Intuniv. There was no documentation as to whom informed the nurse of this information.

A release of information form signed by the parent of the patient on 1/26/11 was a part of the medical record. There was no indication that the request was sent to the patient's treatment therapist or center. Neither the type of information to be disclosed, nor the purpose of the disclosure were checked, indicating that they were applicable. Upon review on 2/2/11, the medical record contained no information that any collateral information was received for this patient. The patient's history and physical performed on 1/27/11 listed no medications, noted problem risk/complexity as moderate and noted that review of records would be performed.

The HBHS (Highlands Behavioral Health System) Inpatient Admission Form completed on 1/27/11 by the Psychiatric Nurse Practitioner documented the following plan:
Admit as an inpatient, stabilize on medications, group, family and individual therapy, Outreach collateral information from family and Outpatient Psychiatrist, provide protective environment with estimated length of stay of 10 days. Current medications listed were Adderall 5 mg and Intuniv 2 mg, both taken on and off. The medication plan documented on this form was to discontinue Adderall and Intuniv, to start Saphris, and to get collateral information.

On 1/28/11, the nurse practitioner checked the box "Patient is a danger to self/others," "Patient's symptoms are not resolving/awaiting adequate response to medication" and "Patient unable to function in less restrictive environment." Medication plan "Considering Saphris after collateral." Collateral information had still not been provided.

On 1/29/11 and 1/30/11, the psychiatrist checked the box, "Patient's symptoms are not resolving/awaiting adequate response to medication." Collateral information still not provided and patient was receiving no medication related to his psychiatric admission diagnoses.

On 1/31/11, the psychiatric Nurse Practitioner documented to begin Saphris 5 mg 1/2 tab by mouth every evening. S/he also documented, "Patient's symptoms are not resolving/awaiting adequate response to medication," in addition to "Patient is a danger to self/others." This medication was not administered to the patient as consent had not been received from the mother of the patient.

On 2/1/11, the psychiatric Nurse Practitioner documented "No meds for now," as well as "Spoke at length c MOC (with mother of child)-We agree to remain off meds until decision made R/T RTC (related to residential treatment center)." This indicated that no medications would be given until a decision was made related to a possible transfer to a Residential Treatment Center. Additional documentation stated, "Patient's symptoms are not resolving/awaiting adequate response to medication" and "Patient is a danger to self/others."

Review of the "Clinical Services/Social Work Progress Note" was completed on 2/2/11. Documentation, dated 1/27/11, stated the following, in pertinent part, "This SW (social worker) spoke c MOC to introduce myself, get collateral and to discuss treatment..." Documentation, dated 1/31/11, stated the following, in pertinent part, "This SW spoke c Dr. (outpatient psychiatrist) to get collateral and to discuss plan and application for Residential..." No additional documentation regarding the patient's past therapy or treatment was documented.

Interview was conducted with the unit nurse manager on 2/2/2011 at approximately 10:30 a.m. S/he stated the patient was admitted to the facility on 1/26/2011 and was brought in by his/her mother. S/he also confirmed that no collateral information from the previous therapist had been received for this patient since his/her admission to the facility on 1/26/2011. The nurse manager confirmed the patient had been receiving no medications as the out of state residential treatment facility would not accept the patient if s/he was on any medications. The patient was receiving Miralax while at this facility due to problems with constipation.

From admission on 1/26/11 through 2/1/11, no treatment or history was received from the previous therapist/psychiatrist to determine the level of treatment and medications needed to assess the level of care required to treat the patient's mental condition. The care provided by the facility was dependent upon the post hospital placement of the patient in a residential care facility, which required the patient could not be on any medications.

The facility Medical Staff Rules and Regulations stated as follows:

"Psychiatric Evaluation Dictation Format Approved by Medical Executive Committee as follows:
"IV. Justification: (The need for facility level of care) Appropriate Admissions (Psychiatric)
5. Failure to outpatient treatment. Previous recent attempts at outpatient therapy must be documented in detail,i.e. intensity and length of therapy, number of times usually seen per week, and the increase in frequency of sessions in order to prevent hospitalizations. Rationale for admission at an acute level versus treatment at a lesser level of care must be documented......"

"Bylaws of the Medical Staff"
"Section IV: Basic responsibilities of Medical Staff Membership"
"Each member of the professional staff shall accept basic responsibilities that shall include:
A. To provide all patients with the same level and quality of patient care, meeting the professional standards of the professional staff of Highlands.

In summary, the team caring for the patient had not yet received collateral information from the patient's previous therapist, approximately seven days after admission. In addition, the patient was not being treated with any medications while at the facility as the potential facility/residential treatment center would not accept patients that were taking medications. Lastly, there was no immediate plans to transfer the patient to the outlying facility and, therefore, the patient's treatment, aside from groups, was essentially on hold.


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2. Sample patient #28 was admitted to the facility on 01/29/2011 via transfer from another facility.

The facility's form titled "Pre-Admission Nurse to Nurse Report" noted the patient's diagnosis, including but not limited to, psychosis and a medical history of sleep apnea.

On 01/28/2011, the transferring facility's psychiatric clinician documented the patient's admission data under "history of present illness" as, "Pt. (patient) reduced his zyprexa to half b/c (because) he says it gives him sleep apnea." Additional documentation on the admission data form stated, current medications Zyprexa (Zydis) 20 mg qd.

On 1/30/11, the registered nurse completed the form "Nursing Assessment" and documented under respiratory assessment, in pertinent part, "(patient has) sleep apnea only when I take zydis."

On 1/30/11, the facility's intake coordinator documented on the "Comprehensive Assessment Tool" indicating that the patient admitted to the following sleep issues "difficulty going to sleep, frequent awakening during night, early morning awakening." The intake coordinator failed to identify sleep apnea in the Axis III (Axis III identifies general medical conditions relevant to the patient) provisional diagnosis.

On 2/03/11, a review of the facility policies was conducted. Policy No. PC-144, titled "Managing the Medically Compromised Patient" stated, in pertinent part, "Patients with complicated medical issues will be followed by an Internal medicine doctor for proper assessment and treatment of medical conditions ... "

The "Medical History and Physical Assessment" failed to address the patient's sleep apnea on three occasions, 1/29/11, 1/30/11, and 2/1/11. The "Medical History and Physical Assessment" contained three dates with three corresponding practitioner signatures and all of which failed to address the patient's documented sleep apnea. On 1/29/11 at 1:15 p.m., the nurse practitioner stated the patient was " ...sleeping and very hard to arouse." On 1/30/11 at 7:10 a.m., nurse practitioner signed the bottom of the form and no sleep apnea was identified, and on 2/1/11, the medical doctor co-signed the nurse practitioners signatures from 1/29/11 and 1/30/11 and no sleep apnea was identified.

The "Psychosocial Assessment" completed on 1/30/11 by a medical assistant failed to address sleep apnea under "Medical Physical Health" section.

On 1/30/11, a Multidisciplinary treatment plan was created and identified Axis III to include "sleep apnea" and a problem descriptor of ineffective airway disease with a severity code of "3" (definition of severity code 3 stated, pertinent in part, "Open. Severe Functional Impairment"). Interventions for this problem included the "physician will order necessary oxygen, oxygen concentrators, or ci/bi pap." Interventions for this problem included for nursing were, pertinent in part, "nursing will assess upon admission: pt hx. (patient history) Reportable s/sx (signs and symptoms) reportable medications, monitor pts (patient's) condition ...evaluate pt re: changes in resp. fxn (respiratory function) to staff immediately ...report immediately dyspnea (shortness of breath), O2 (oxygen) sat less than 92%..."

As of 2/2/11, there was no documentation found in the patient's medical record that additional evaluation of the patient was performed for his sleep apnea or that any physician or nursing documentation related to sleep apnea was evident. The facility also failed to have a contract with a respiratory therapy company to supply equipment for the patient's reported sleep apnea.

On 2/3/11, review of all contracts for the facility revealed that the facility did not have a contract to access/maintain respiratory equipment, such as nebulizers, oxygen concentrators (both identified as part of new employee competencies) or other specialized equipment, such as a C-PAP (continuous positive airway pressure) machine required for maintenance of a patient with sleep apnea. The only respiratory related contract found was for a contract with a medical gas company to provide oxygen tanks to the facility. An interview with the director of plant operations on 2/3/11 at approximately 9 a.m., revealed that no respiratory equipment was available as a part of that contract.

An interview with the Chief Executive Officer (CEO) and the Director of Clinical Services (DCS)/Director of Nursing on 2/2/11 at approximately 10:30 a.m., revealed the following findings: The DCS confirmed that the facility did not have any respiratory policies or a respiratory manual. S/he stated that the facility did have access to oxygen, nebulizers and oxygen concentrators. S/he stated that the facility did not have C-PAP machines, but in the case of sleep apnea patient, the facility could either utilize the patient's C-PAP equipment (that could be brought in from home), or they could get the equipment from a respiratory medical equipment supplier, as needed.

The facility had no contracts in place to access respiratory medical equipment, other than medical gas (oxygen).

The facility failed to ensure the respiratory care services were appropriate to the scope and complexity of the services offered and to meet the need of the patients screened and accepted for admission and treatment. The facility failed to evaluate and accommodate the sleep apnea/upper airway obstruction needs of sample patient #28. The failure created the potential for negative patient outcomes.

Based on staff interview and medical record review, it was determined that the facility failed to ensure nursing staff effectively evaluated the care for each patient. Specifically, one sample patient (#19) record of 30 did not contain evidence that physician orders had been carried out. This failure created the potential for a negative patient outcome.

The findings were:

Sample record #19 was reviewed on 2/3/11. The patient was an adult male admitted for a mental health diagnosis in 12/10. The patient was discharged to an outlying treatment unit after 15 days in the facility. A physician's order, dated 12/19/10 and timed 12:30 p.m., stated, "(check) orthostatics BID x 48 (hours)." A note below the order stated, "(? clozapine-induced orthostasis)." Review of the Vital Signs Flow Sheet from 12/19 to 12/22, the day of discharge, revealed the following:
12/19 at 0945 - one blood pressure documented as 92/54
12/19 at 2000 - one blood pressure documented as 108/67
12/20 at 0835 - two blood pressures documented as 119/85 and 115/90 with a note below which stated "ortho"
12/21 at 0820 - one blood pressure documented as 120/72
12/21 at 1600 - one blood pressure documented as 92/58
12/22 at 0830 - one blood pressure documented as 118/74

An interview with the facility's Director of Clinical Services was conducted on 2/3/11 at approximately 10:50 a.m. It was confirmed that there was not a policy in regards to orthostatic blood pressure checks. When asked what patient positions the facility nursing staff considered as orthostatic, s/he stated, "They (the patient) would be standing and sitting." When asked about sample number 19, s/he stated, "Their documentation is not showing that they did orthos." When asked if nursing staff would document it anywhere other than the Vital Signs Flow Sheet, s/he stated, "That is the only place it would be documented."

In summary, it was evidenced that complete orthostatic blood pressures were only completed once within the 48 hour time frame, instead of four times as ordered. In addition, the patient's blood pressure was only checked at 8:35 a.m. on 12/20, instead twice that day as ordered. The nursing care provided to sample number 19 was not thoroughly supervised and evaluated in order to ensure patient safety.

Based on staff interview and review of medical records, the facility failed to develop and enter timely discharge summaries in 20 (#1, #2, #3, #4, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #22 and #23) of 30 medical records reviewed within the 30 day required time frame. Furthermore, the facility failed to designate the responsibility of dictating the discharge summary to a MD/DO or other qualified practitioner in seven (#1, #7, #10, #11, #12, #13 and #20) of 30 medical records reviewed. This failure created the potential for lack of continuity of care.

The findings were:

The following medical records were reviewed on 2/2/11 and 2/3/11:

1. Sample patient #1 was admitted to the facility on 10/7/10 and discharged on 10/12/10. The discharge summary was dictated on 12/7/10, 25 days late. The summary was dictated by a registered nurse (RN) instead of a qualified practitioner.

2. Sample patient #2 was admitted to the facility on 9/25/10 and discharged on 10/6/10. The discharge summary was dictated on 1/7/11, 60 days late.

3. Sample patient #3 was admitted to the facility on 8/30/10 and discharged on 9/3/10. The discharge summary was dictated on 11/20/10, 47 days late.

4. Sample patient #4 was admitted to the facility on 9/10/10 and discharged on 9/14/10. The discharge summary was dictated on 11/10/10, 27 days late.

5. Sample patient #7 was admitted to the facility on 9/15/10 and discharged on 9/27/10. The discharge summary was dictated on 11/3/10, seven days late. The summary was dictated by a RN instead of a qualified practitioner.

6. Sample patient #8 was admitted to the facility on 8/31/10 and discharged on 9/6/10. The discharge summary was dictated on 11/18/10, 43 days late.

7. Sample patient #9 was admitted to the facility on 12/16/10 and discharged on 12/29/10. The discharge summary was dictated on 2/1/11, three days late.

8. Sample patient #10 was admitted to the facility on 10/15/10 and discharged on 10/19/10. The discharge summary was dictated on 12/9/10, 20 days late. The summary was dictated by a RN instead of a qualified practitioner.

9. Sample patient #11 was admitted to the facility on 11/9/10 and discharged on 11/18/10. The discharge summary was dictated on 1/20/11, 33 days late. The summary was dictated by a RN instead of a qualified practitioner.

10. Sample patient #12 was admitted to the facility on 10/17/10 and discharged on 10/28/10. The discharge summary was dictated on 12/28/10, 30 days late. The summary was dictated by a RN instead of a qualified practitioner.

11. Sample patient #13 was admitted to the facility on 10/27/11 and discharged 11/4/11. The discharge summary was dictated on 12/22/10, 18 days late. The summary was dictated by a Licensed Clinical Social Worker (LCSW) instead of a qualified practitioner.

12. Sample patient #14 was admitted to the facility on 9/9/10 and discharged on 9/13/10. The discharge summary was dictated on 11/8/10, 35 days late.

13. Sample patient #15 was admitted to the facility on 11/28/10 and discharged on 12/2/10. The discharge summary was dictated on 1/21/11, 19 days late.

14. Sample patient #16 was admitted to the facility on 12/5/10 and discharged on 12/7/10. The discharge summary was dictated on 2/1/11, 24 days late.

15. Sample patient #17 was admitted to the facility on 10/15/10 and discharged on 10/24/10. The discharge summary was dictated on 12/10/10, 16 days late.

16. Sample patient #18 was admitted to the facility on 12/10/10 and discharged on 12/14/10. The discharge summary was dictated on 2/1/11, 18 days late.

17. Sample patient #19 was admitted to the facility on 12/7/10 and discharged on 12/22/10. The discharge summary was dictated on 2/1/11, ten days late.

18. Sample patient #20 was admitted to the facility on 11/3/10 and discharged on 11/10/10. The discharge summary was dictated on 12/28/10, 18 days late. The summary was dictated by a RN instead of a qualified practitioner.

19. Sample patient #22 was admitted to the facility on 12/6/10 and discharged on 12/13/10. The discharge summary was dictated on 2/1/11, 19 days later.

20. Sample patient #23 was admitted to the facility on 12/4/10 and discharged on 12/22/10. The discharge summary was dictated on 2/1/11, ten days later.

An interview was conducted with the Director of Health Information Management (HIM) on 2/3/11 at approximately 10:30 a.m. The Director was aware that discharge summary's were frequently being dictated beyond the 30 day requirement. Audits were being performed; however, not at a 100% of the medical records.

During the exit conference on 2/3/11 at approximately 1:30 p.m., the Chief Executive Officer (CEO) stated that RNs and LCSWs were qualified to dictate discharge summary's due to the facility having granted admitting privileges to them.

In summary, according to the regulations discharge summary's must be dictated no later then 30 days and must be dictated by a MD/DO or other qualified practitioner.

Based on interview and policy review, it was determined the facility failed to ensure the provisions of care regarding the wasting and destruction of medications was governed by current standards of practice.

Findings:

Review of the facility policy titled, "Wasting of Medications" stated in pertinent part:
-" The medication nurse will dispose of medications refused or wasted by:
1. poring the liquids and crushed medications down the sink or commode.
2. tablets and pills will be destroyed by flushing down the commode
3. discarding the oral solids in a sharps container if local regulations/law do not allow disposing of medications into the sewage system."

According to, "www.colorado.gov" in pertinent part:
-"Flushing even small quantities of medications down the drain can contaminate valuable water resources, causing potential harm to drinking water supplies.
-Do not flush medications down the toilet or drain."

On 02/02/11 at approximately 2:00 p.m., the Pharmacy Director was interviewed. S/he stated the policy was to discard the medication(s) in the blue sharps containers located in the medication rooms on each unit. S/he further stated the facility does not dispose of any medications into the sewage system. S/he continued and stated the policy should have been revised to reflect their current practice but had been inadvertently overlooked in their process of review.

Based on a tour of a medication room and interview with medication nurse, the facility failed to follow accepted standards of practice, and in accordance with Federal and State laws, of preparation and administration of drugs and biologicals.

Findings:

On 2/02/2011 at approximately 9:45 a.m., a tour of the medication room revealed an opened and punctured multidose insulin vial, which had no written date indicating date opened, no initials indicating who opened the vial, no date indicating an expiration date. During the tour and finding of insulin vial, interview with the medication nurse confirmed that the vial did not contain a date opened, an initial of the person who opened it, or the date it expired.

A position paper from the Association for Professionals in Infection Control and Epidemiology (APIC), dated July 30, 2009, stated in pertinent parts:
"...Vials...
...Dispose of opened multidose medication vials 28 days after opening, unless specified otherwise by the manufacturer, or sooner if sterility is questioned or compromised..."

This failure to properly label and date open vials of injectable medications created the potential for patient harm.

Based on the nature of deficiencies, the facility failed to be in compliance with the Condition of Participation of Radiologic Services. Specifically, the facility failed to ensure that the radiologic services were provided in accordance with acceptable standards of practice and met the needs of the patients screened and accepted into the facility.

The facility failed to meet the following Standard under the Condition of Radiologic Services:

Tag A 529 Scope of Radiologic Services
The Radiologic Services provided by the facility did not meet the needs of all patients screened and accepted into the facility. The facility governing body and medical staff failed to take actions, in the form of contract review (including quality assurance analysis) and policy/procedure and services review to ensure that the Radiology Services were provided in accordance with acceptable standards of practice.

Based on review facility documents and staff interviews, the facility failed to ensure the radiologic services were appropriate to the scope and complexity of the services offered and to meet the need of the patients screened and accepted for admission and treatment. Specifically, the facility failed to have a policy/procedure manual with a description of services provided that was reviewed by the medical staff to ensure that the services met the needs of the patients. In addition, the governing body of the facility failed to ensure that a process was in place to evaluate the quality of the contracted radiologic services. The failure created the potential for negative patient outcomes.

The findings were:

1. Review on 2/2/11 of the facility document "Departments/Units/Areas/Services and Programs" revealed that the document, which described all programs and services (including contractual services) available in the facility, did not identify any available radiologic services.

2. Review on 2/2/11 of the facility document "Provision of Care Plan" revealed that the document was a comprehensive description of all clinical programs and services (including contractual services) provided by the facility. The document did not describe the radiologic services that were available for patient care needs at the facility. Under 4.1 "Adult Psychiatric Program," "Areas of Care," the document stated "Diagnostic Testing: Lab, X-ray, EKG/EEG, MRI, CT, etc," with the "Service Provider" listed as "Physicians."

3. Review on 2/2/11 of a 3-ring binder provided by the contracted radiologic services provider revealed that it contained no evidence of review/oversight by the facility, medical staff or governing body. The binder material was not customized to the facility and contained no policies/procedures related to the tests provided.

4. Review on 2/2/11 of the contractual agreement, dated 10/5/10, revealed that the only place that identified services that could be provided was the attached "Addendum 'A' Multi-Exam Flat Rate Fee Schedule." The addendum revealed the following, in pertinent parts:
"Contract Services...X-ray, Ultrasound Exams, Echocardiography, EKG Service (all exams)."

Based on the nature of deficiencies, the facility failed to be in compliance with the Condition of Participation of Laboratory Services. Specifically, the facility failed to ensure that the laboratory services were provided in accordance with acceptable standards of practice and met the needs of the patients screened and accepted into the facility for treatment. The failure created the potential for negative patient outcomes.

The facility failed to meet the following Standard under the Condition of Laboratory Services:

Tag A 582 Adequacy of Laboratory Services
The facility failed to have a policy/procedure manual with a description of services provided that was reviewed by the medical staff to ensure that the services met the needs of the patients. In addition, the governing body of the facility failed to ensure that a process was in place to comprehensively evaluate the quality of the contracted laboratory services.

Based on review of facility documents and staff interviews, the facility failed to ensure the laboratory services were appropriate to the scope and complexity of the services offered and to meet the need of the patients screened and accepted for admission and treatment. Specifically, the facility failed to have a policy/procedure manual with a description of services provided that was reviewed by the medical staff to ensure that the services met the needs of the patients. In addition, the governing body of the facility failed to ensure that a process was in place to comprehensively evaluate the quality of the contracted laboratory services. The failure created the potential for negative patient outcomes.

The findings were:

1. Review on 2/2/11 of the facility document "Departments/Units/Areas/Services and Programs" revealed that the document, which described all programs and services (including contractual services) available in the facility, did not identify any available laboratory services.

2. Review on 2/2/11 of the facility document "Provision of Care Plan" revealed that the document was a comprehensive description of all clinical programs and services (including contractual services) provided by the facility. The document did not describe the laboratory services that were available for patient care needs at the facility. Under 4.1 "Adult Psychiatric Program," "Areas of Care," the document stated "Diagnostic Testing: Lab, X-ray, EKG/EEG, MRI, CT, etc," with the "Service Provider" listed as "Physicians."

3. Review on 2/2/11 of a paperback bound manual published by the contracted laboratory services vendor revealed that it contained a comprehensive list of all services provided to all facilities. There was no accompanying manual that described the specific services and policies and procedures and scope of services available to the facility. The facility was unable to provide evidence of review/oversight of the contracted laboratory services by the facility, medical staff or governing body.

4. During an interview with the chief executive officer and the director of clinical services on 2/2/11 at approximately 10:30 a.m., they confirmed that the facility did not have a mechanism in place to review the contracted laboratory services to ensure that the services complied with the regulatory requirements for the services or that they met the needs of the patients screened and accepted for admission and treatment. The director of clinical services later provided approximately 2-3 months worth of data related to tracking the reporting of critical or abnormal lab values, which was part of the plan of correction for the last survey of the facility. S/he was unable to provide other evidence of comprehensive evaluation of the quality of the laboratory services.

Based on the food and dietary tour and staff interview, the facility failed to ensure that food and dietetic services organization requirements were met. Specifically, the facility failed to ensure that proper sanitation and monitoring requirements were met.

The findings were:

A tour of the food and dietary area was conducted on 2/1/11 at approximately 10:30 a.m. with the dietary manager. During the tour of the dry storage area, it was observed that scoops were left in the bins of the quinoa, rice and bread crumbs. The scoops were not the usual scoops with handles, but were similar to a lid that was substituted for a handled scoop.

The walk-in freezer was also observed during the tour. It was noted that there was no back-up thermometer inside the freezer. The daily temperatures were being documented using the outside thermometer only.

An interview was conducted with the dietary manager during the tour on 2/1/11. The manager stated that s/he was disappointed that staff had left the scoops in the bins and removed them during the tour. The manager further stated that s/he performed sanitation rounds but that checking for scoops being left in the dry grains and other items was not part of the sanitation rounds. The manager also stated that a back-up thermometer would be placed in the walk-in freezer.

A Life Safety Code survey of the facility was conducted in accordance with C.F.R. 482.41(b) on 10/05/2010 (Survey Event ID WO4G21). Deficiencies were identified during the survey resulting in the Hospital Standard A710 "Life Safety From Fire - 482.41(b) (1)(2)(3)" and the Hospital Condition Of Participation A700 "Physical Environment" being found out of compliance with the Standard and the Condition. Details of the deficiencies can be found in the record for Survey Event ID WO4G21.

A Life Safety Code survey of the facility was conducted in accordance with C.F.R. 482.41(b) on 10/05/2010 (Survey Event ID WO4G21). Deficiencies were identified during the survey resulting in the Hospital Standard A710 "Life Safety From Fire - 482.41(b) (1)(2)(3)" and the Hospital Condition Of Participation A700 "Physical Environment" being found out of compliance with the Standard and the Condition. Details of the deficiencies can be found in the record for Survey Event ID WO4G21.

Based on review of the facility's OPO (organ procurement organization) agreements and staff interview, the facility failed to secure and incorporate an agreement with at least one eye bank to cooperate in the retrieval, processing, preservation, storage and distribution of eyes, to assure that potential tissue and eye donations are obtained from potential donors.

On 02/02/2011, review of the facility's OPO (organ procurement organization) agreements provided by the facility, failed to contain any eye procurement agreement.

Interview with Director of Nursing Administration on 02/03/2011 at approximately 12:00 p.m., verified that the facility does not have a separate eye procurement agreement with any eye bank organization.

Based on the nature of deficiencies, the facility failed to be in compliance with the Condition of Participation of Respiratory Services. Specifically, the facility failed to ensure that the respiratory services were provided in accordance with acceptable standards of practice and met the needs of the patients screened and accepted into the facility.

The facility failed to meet the following Standard under the Condition of Respiratory Services:

Tag A 1152 Organization of Respiratory Care Services
The Respiratory Services provided by the facility did not meet the needs of all patients screened and accepted into the facility. The Respiratory Services were not provided in accordance with acceptable standards of practice.

Based on review of medical records, facility documents and staff interviews, the facility failed to ensure the respiratory care services were appropriate to the scope and complexity of the services offered and to meet the need of the patients screened and accepted for admission and treatment. The facility failed to evaluate and accommodate the sleep apnea/upper airway obstruction needs of sample patient #28. The failure created the potential for negative patient outcomes.

The findings were:

1. Review on 2/2/11 of the facility document "Departments/Units/Areas/Services and Programs" revealed that the document, which described all programs and services (including contractual services) available in the facility, did not identify any available respiratory equipment or services.

2. Review on 2/2/11 of the facility document "Provision of Care Plan" revealed that the document was a comprehensive description of all clinical programs and services (including contractual services) provided by the facility. The document did not identify any available respiratory equipment or services that were available for patient care needs at the facility.

3. Review on 2/2/11 of the facility document "Vital Signs Assessment/Reassessment" revealed that two attached competencies were titled "New Employee Orientation Checklist RN/LPN/BHA - Oxygen Tank/Concentrator Competency Validation Record" and "New Employee Orientation Checklist RN/LPN/BHA - Respiratory Nebulizer Competency Validation Record."

Under the Oxygen Tank/Concentrator Competency Validation Record, the following skills inventory was listed, in pertinent parts:
-"Level read on oxygen regulator"
-"Empty tank process"
-"Restock Tank process"
-"Storing O2 tanks"
-"Turning on Concentrator"
-"How Concentrator works with oxygen in the air"
-"Patient Safety with Oxygen (i.e. tubing, cords, etc)"

Under the Respiratory Nebulizer Competency Validation Record, the following skills inventory was listed, in pertinent parts:
-"Proper Use of Machine"
-"Proper Assembly of Nebulizer Unit"
-"Proper Administration of Medication"
-"Pre Assessment of patient:
-Patient presentation...
-Other devices used..."
-"Maintenance of Equipment"

4. Tour of the adult acute unit was conducted on 2/1/11 at approximately 11:15 a.m. Tour of one of the unit's housekeeping closets/ rooms revealed that it was also used for oxygen storage. The room contained a flushable hopper sink, four oxygen tanks, one oxygen regulator, and two extension cords. Stored above the hopper sink was one ambu-rescue bag (within a plastic storage bag), seven nasal cannulas for oxygen administration (within respective plastic storage bags), two bottles of "Super Sorb" instant absorbable product for cleaning up spills, and two "Crew Neutral NA Non-Acid Bowl & Bathroom Disinfectant Cleaner." When the Facility's Manager was asked about the respiratory items stored within the housekeeping room, s/he stated that the room was primary used for respiratory storage, not housekeeping. However, the hopper sink in the room was still functioning and cleaning products were still stored there, directly adjacent to respiratory delivery items.

5. Review on 2/3/11 of all contracts for the facility revealed that the facility did not have a contract to access/maintain respiratory equipment, such as nebulizers, oxygen concentrators (both identified as part of new employee competencies) or other specialized equipment, such as a C-PAP (continuous positive airway pressure) machine required for maintenance of a patient with sleep apnea. The only respiratory related contract found was for a contract with a medical gas company to provide oxygen tanks to the facility. An interview with the director of plant operations on 2/3/11 at approximately 9 a.m., revealed that no respiratory equipment was available as a part of that contract (medical gas). In addition, the director, who also functioned as the safety officer for the facility, was asked if the facility had a policy/procedure for safe storage of oxygen tanks. S/he stated that s/he was unaware of such a policy.

6. An interview with the Chief Executive Officer (CEO) and the Director of Clinical Services (DCS)/Director of Nursing on 2/2/11 at approximately 10:30 a.m., revealed the following findings: The DCS confirmed that the facility did not have a policy/procedure that addressed safe storage/use of oxygen in the facility. The DCS confirmed that the facility did not have any respiratory policies or a respiratory manual. S/he stated that the facility did have access to oxygen, nebulizers and oxygen concentrators. S/he stated that the facility did not have C-PAP machines, but in the case of sleep apnea patient, the facility could either utilize the patient's C-PAP equipment (that could be brought in from home), or they could get the equipment from a respiratory medical equipment supplier, as needed.
Note: Reference above section #4 with findings that indicated the facility had no contracts in place to access respiratory medical equipment, other than medical gas (oxygen).

7. Review on 2/1/11 of sample patient #28 was an adult patient admitted on 1/29/11 with psychosis, mania and medication non-compliance related to sleep apnea symptoms on his/her anti-psychotic medication (Zyprexa/Zydis). Review of the care plan for problem "Ineffective airway clearance/sleep apnea" dated 1/30/11 revealed that patient's physician would "order necessary oxygen, oxygen concentrators, or C-PAP/BiPAP (bilevel [biphasic] positive airway pressure)." The record revealed no evidence of an evaluation of the sleep apnea by a physician. The history and physical did not mention the sleep apnea condition. The physician orders contained no order for respiratory support equipment or evaluation or follow-up for the sleep apnea condition.

8. Further findings in the 2/2/11 (10:30 a.m.) interview with CEO and DCS revealed that facility had no mechanism in place to review and evaluate contracted services, including respiratory therapy. They further confirmed that the had no evidence, in meeting minutes or other documents, of medical staff activity to evaluate respiratory care and services, to ensure that they were available to meet the needs of the patients.