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Based on observations, medical record reviews, staff interviews, and facility policy review it was determined the Psychiatric Acute Care Hospital failed to ensure patient rights by not properly executing consent forms with signatures, witnesses, dates and times (A-0117), by not including the patient and/or the patient's representative to participate in treatment team meetings (A-0130), and by not providing patient care in a safe setting (A-0144).

Based on medical record review, policy review, and staff interview the facility failed to ensure consent forms were properly signed, witnesses and dated. This affected five of ten medical records reviewed including Patient's #1, #6, #7, #8, and #10. The facility census was 82 patients.

Findings include:

On 06/19/15 the hospital policy #CS-100.3, Admissions Assessment, revised on 10/2012, was reviewed for consent information. The policy documented the admission department or designee will have the patient or legal representative sign consents. The policy lacked information regarding who could sign, how many witnesses were needed, or to include dates.

On 06/19/15 at 2:05 PM Staff B stated the hospital expectation for consents included obtaining the patients' or guardians' signature with with date and time and a witness signature with date and time. If the patient or guardian is unable to sign, a verbal consent could be obtained and documented, along with two witness signatures with date and time.

1. On 06/19/15 the medical record for Patient #1 was reviewed. The consent forms documented verbal consent was obtained by the patient's Power of Attorney (POA) on 06/05/15, lacked a second witness to the verbal consent, and the first witness signatures were dated on 05/29/15, seven days before the verbal consents were obtained. The consents not properly executed included Treatment Consents and Authorization, Receipt of Patient Rights, Acknowledgement of Privacy Notice, Phone Call/Visitation Consent, Medicare Rights, Advance Directive Acknowledgement, and Voluntary Admission Form.

2. On 06/19/15 the medical record for Patient #8 was reviewed. The consent form, Acknowledgement of Privacy Notice, was documented with a verbal consent by the patient's POA dated 03/13/15 and an illegible witness signature dated 03/13/15. The consent lacked a second witness to the verbal consent and lacked the time of the signature(s). The medical record, while containing other consent forms, lacked all signatures, witnesses, dates, and times.

3. On 06/19/15 the medical record for Patient #10 was reviewed. The consent form, Voluntary Admission form, was documented with a patient signature dated 03/10/15. The consent lacked a witness signature, date, and time. The medical record, while containing other consent forms, lacked all signatures, witnesses, dates, and times.

4. Review of the medical record for Patient #6, admitted on 05/15/15, revealed no patient or patient's representative's signature on the Certification of Receipt of Patient Rights Program Rules/Responsibilities and Grievance Procedure form. A note was written on the form "Pt (patient) unable to sign & has POA (power of attorney)". There was no documentation of an attempt to notify patient's family or representative to inform them of the patient's rights.

5. Review of the medical record for Patient #7, admitted on 03/20/15, revealed no patient or patient representative's signature on the Certification of Receipt of Patient Rights Program Rules/Responsibilities and Grievance Procedure form. A note was written on the form "hard of hearing - confused". There was no documentation of an attempt to notify the patient's family or representative to inform them of the patient's rights.




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Based on medical record review, staff interview, and policy review the facility failed to include or notify patients or the patients' representative to participate in the development and implementation of treatment plans and treatment team meetings. This had the potential to affect all patients. The hospital census was 82 patients.

Findings include:

On 06/19/15 the hospital policy #CS-200.64, Treatment Planning Process, revised 06/2012, was reviewed. The policy documented the patient and significant others would be notified of team meetings and invited to attend and participate in the team to the fullest extent possible and to sign the completed plans.

On 06/18/15 at 11:00 AM, Staff D, the interim medical director during March, April, and May 2015, stated the treatment team meeting includes a discussion regarding multiple patients on a specific unit and that including the patient or the patient's representative would conflict with privacy of patient information. Staff D also stated the hospital does not include the patient or the patient's representative at the treatment team meeting because it would take too much time.

On 06/19/15 the medical records of 10 patient charts were reviewed. All charts failed to include notices to patients and patients' representatives of the treatment team meetings. The medical records included treatment team review forms documented with staff signatures, but lacked signatures of the patient or of the patient's representative.

Based on observations, staff interviews, and policy review the facility failed to provide a safe environment for psychiatric patient care. This had the potential to affect all patients. The facility census was 82 patients.

Findings include:

On 06/19/15 the hospital policy #CS-100.3, Admissions Assessment, revised 10/2012, was reviewed. The policy documented to ensure a safe, therapeutic milieu for all patients and a safe environment for staff, each patient would be searched for contraband upon arrival to the unit. Personal items of all patients must be checked. Those items which may present a danger to patient, staff, or others must be removed.

On 06/17/15 from 10:30 AM through 11:30 AM, a tour was conducted of the hospital including the main lobby, gym, dining room, and five psychiatric patient units.

The Crisis Stabilization Unit (CSU) was found to have an unlocked laundry room and an unlocked shower room. Staff B indicated both areas should have been locked when not in use.

The unlocked laundry room contained an over flowing trash receptor. There was trash and articles of clothing (socks and shoes) on the floor. The floor was visually dirty. Staff closed the door after the surveyors observed the condition of the laundry room.

The unlocked shower room was located down a short separate hallway. The shower room contained three shower stalls with tear away shower curtains. The shower room lacked any seating area to dress or undress. The shower stalls and the dressing area lacked any form of call lights to summon help if needed. Staff B stated staff make rounds every 15 minutes and if a patient fell, was unconscious, or bleeding, they would be found during rounds. Staff B confirmed a patient could enter the unlocked spaces and harm oneself or others depending on the patient's psychiatric situation.

The tour continued with observations of patient rooms on the five units. The hospital was licensed for 90 beds. Two of the units contained a mixture of electric hospital beds and platform beds. Two other units contained electric hospital beds exclusively. One unit contained platform beds exclusively. Staff B indicated the electric hospital beds were used for patients with special needs like having the head of the bed elevated. Staff B confirmed the electric bed cords could have been used to harm oneself or others depending on the patient's psychiatric situation.

The hospital's 90 beds were each paired with a five drawer upright dresser and a night stand. Each room was also equipped with a desk and chair. The furniture was not secured to either the floor or walls. Staff B confirmed an incident were a patient used the desk chairs to shatter a window. Staff B also confirmed the furniture was moveable and a patient could barricade themselves in a room in order to harm oneself or others depending on the patient's psychiatric situation.

The hospital gym was observed with 16 metal folding chairs that were folded and leaning against a wall. Patients were observed in the gym. Staff B confirmed the folding chairs could easily be picked up by a patient and used as a weapon depending on the patients' psychiatric situation.

Based on record review, staff interview and policy review, the facility failed to develop and update the interdisciplinary care plan. This affected three (Patient #6, #7 and #9) of ten patient records reviewed. The facility census was 82 patients.

Findings include:

1. Review of the medical record for Patient #6 revealed the patient was admitted on 05/15/15 for agitation and aggression. Review of the Comprehensive Treatment Plan - Treatment Team Review, dated 05/19/15, revealed Patient #6 had poor by mouth intake. No nursing staff was present during the team review. Further review of the medical record revealed no plan was developed for concerns of poor by mouth intake. The Nursing Integrated Progress Notes, dated 05/25/15 documented Patient #6 was sent to a hospital emergency room for poor food intake.

2. Review of the medical record for Patient #7 revealed the patient was admitted on 03/20/15 for aggression. The Nursing Reassessment Note, dated 04/01/15, documented Patient #7 had wounds to bilateral lower extremities with black scabs noted in the wound bed.

Review of the Patient Care Observation Record for Patient #7, dated 04/09/15, revealed notes under comments which documented the patient "couldn't chew or swallow, needs put on a pureed diet".

Review of the Patient Care Observation Records for Patient #7 from 04/01/15 to 04/10/15 revealed there was no documentation of meal or fluid intake for 30 of 40 meals or snacks. The Nursing Integrated Progress Notes, dated 04/10/15, documented the patient was sent to the hospital for acute renal failure

Review of the Comprehensive Treatment Plan revealed no treatment plan was developed for the problem of alteration of skin or for poor intake by mouth. There was no documentation these problems were being discussed in the interdisciplinary team meetings.

3. Review of the medical record for Patient #9 revealed the patient was admitted on 03/30/15 with diagnoses of bipolar affective disorder, hypertension, fibromyalgia, neuropathy and Sjogren's syndrome (disorder of your immune system identified by dry eyes and a dry mouth).

Review of the Nursing Readmission Assessment Note for Patient #9, dated 04/06/15 from 7:00 PM to 7:00 AM, revealed on the Narrative of Findings section documentation the patient's oxygen saturation dropped and Patient #9 was put on oxygen to increase saturation above 92 percent. There was no assessment of breath sounds on this Nursing Reassessment Note.

The note of the Doctor of Nursing Practice (DNP), dated 04/07/15, documented he/she assessed the patient for hypoxia (low oxygen level in the body) for a oxygen saturation of 88 percent.

Review of the Patient Observation Record for Patient #9 revealed no oral intake for dinner on 04/06/15. The Patient Observation Record for Patient #9 indicated the patient ate 25 percent of breakfast on 04/07/15, 0 percent of lunch and consumed eight ounces of liquid from 7:00 AM to 3:00 PM. Review of the laboratory results on 04/07/15 revealed Patient #9's blood urea nitrogen level was elevated at 29 (normal range 7-25 mg/dl) and blood urea nitrogen /creatinine was elevated at 41 (normal range 6-25). The Patient Observation Record for Patient #9 revealed the patient had no oral intake from 04/10/15 to 04/13/15.

Review of the Comprehensive Treatment Plan for Patient #9, dated 03/30/15, revealed the problems identified from the nursing assessment were altered mental status and hypertension. The problem of hypertension had a plan initiated for potential for hypertensive crisis with a goal the patient will maintain blood pressure within normal limits. There was no documentation that objectives or interventions were identified, nor was there documentation that the plan was reviewed and the treatment plan updated with concerns of hypoxia, decreased intake of food and fluids and increased lethargy. There were no treatment plan meetings in the record.

Interview with Staff B, on 06/18/15 at 4:40 PM, confirmed the Comprehensive Treatment Plan was to be completed within 72 hours. The treatment plan was to be updated to address new problems.

The policy on the Treatment Planning Process, reviewed on 01/2014, indicated patient treatment was to be delivered according to a written plan for the patient. The policy also indicated team meetings shall be held at least weekly and patients are to participate in the treatment planning process.

Based on observation, staff interview, review of infection control policies and review of manufacturer's instructions, the facility failed to ensure disinfection followed manufacturer instructions for glucose testing for one (Staff C) of two nurses observed performing blood glucose testing. The active census was 82 patients.

Findings include:

On 06/18/15 at 11:50 AM, Staff C was observed performing a blood glucose test using a blood glucose monitor on Patient #3. After the blood glucose test was completed, Staff C was not observed cleaning the blood glucose monitor. Staff C indicated he/she would only clean the monitor if the monitor was soiled. Staff A, Director of Nursing, was present during the observation and interview. On 06/18/15 at 12:15 PM, Staff A confirmed the blood glucose monitor was to be cleaned between patients.

Review of the facility policy on Glucometer Use, reviewed 01/2014, revealed the glucometer was to be cleaned after use with a Sani-Wipe.

Review of the blood glucose monitor manufacturer's instructions indicated the monitor was to be cleaned and disinfected with Super Sani-Cloth Germicidal Disposable Wipe between patients when the monitor was used for multiple patients.