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Based on observation, interview, record review, and policy review, the facility failed to ensure:
-Staff completed patient safety rounds every 15 minutes for 20 (#10, #11, #12, #15, #16, #18, #19, #21, #23, #40, #41, #42, #43, #44, #45, #46,
#47, #48, #49 and #50) of 24 patients on the Senior Mental Health Unit (SMHU);
-Patient safety rounds were accurately documented for four (Patients #9,
#37, #38 and #39) of 24 patients;
-Ligature/looping hazards were unavailable to suicidal patients;
-Suffocation hazards were unavailable to suicidal patients; and
-Staff assessed and investigated bruising on two (#18 and #23) of two patients.

The severity and cumulative effect of these systemic practices resulted in the overall non-compliance with 42 CFR 482.13, Condition of Participation: Patient's Rights.

Please refer to A0144 and A0145.

Based on observation, interview, record review and policy review, the facility failed to provide a safe environment for patients on the Senior Mental Health Unit (SMHU). The facility failed to ensure:
-Staff completed patient safety rounds every 15 minutes for 20 patients (#10, #11, #12, #15, #16, #18, #19, #21, #23, #40, #41,
#42, #43, #44, #45, #46, #47, #48, #49 and #50) of 24 patients;
-Patient safety rounds were accurately documented for four (Patients #9, #37, #38 and #39) of 24 patients;
-Ligature/looping hazards were unavailable to one (Patient #11) of one suicidal patient; and
-Suffocation hazards were unavailable to one (Patient #11) of one suicidal patient. The facility census was 50.

Findings included:

1. Record review of the facility's policy titled, "Senior Mental Health - Nursing Rounds" revised on 06/08/12, showed that the Charge Nurse was responsible for assigning nursing staff to make unit rounds in order to account for all patients' whereabouts and ensure a safe environment as well as direction for:
-Rounds to be made every 15 minutes on all patients during their entire stay;
-Rounds to be completed by assigned staff;
-The Charge Nurse to designate the staff member(s) responsible for each set of rounds;
-The assigned staff member(s) to personally locate each patient listed and document the patient's location on the Round Sheet (forms where staff document patient location and patient activity) under the appropriate time column.

Record review of the facility's policy titled, "Senior Mental Health - Unit Assault and Suicide Precautions" revised on 06/26/12, showed direction for every patient admitted to the Unit to be visually observed at 15 minute intervals, and that patient monitoring is to be documented on the patient 15 minute checks form (patient safety rounds).

2. Record review of the facility's SMHU "Daily Assignment Sheet" (used to document staff shift assignments) dated 08/20/12, showed that "all staff" were assigned to "sign off on 15 minute checks" for the 7:00 AM to 7:00 PM shift.

"All staff assigned" showed that no designated staff member was given the accountability for each 15 minute patient safety check.

3. Record review on 08/20/12 at 2:50 PM, of the SMHU "Activity Record" (15 minute patient safety rounds form) dated 08/20/12, showed no 15 minute rounding documentation for patient safety for the following:
-2:00 PM through 2:50 PM (50 minutes) for Patient #41;
-2:15 PM through 2:50 PM (35 minutes) for Patients #18, #42,
#16, #12 and #11 (Patient #11 on suicide precautions);
-2:30 PM through 2:50 PM (20 minutes) for Patients #23, #19 and #43;
-7:45 PM through 9:00 PM (75 minutes) for Patients #11(on suicide precautions), #12, #16, #19, #23, #43 and #50;
-8:00 PM through 9:00 PM (60 minutes) for Patients #10, #21,
#44, #45, #46, #47, #48, and #49; and
-8:15 PM through 9:00 PM (45 minutes) for Patients #15, #18,
#40, #41and #42.

4. During an interview on 08/20/12 at 3:10 PM, Staff R, Interim Director of the SMHU, stated that she was aware that patient safety rounds were delinquent at times and added that patient safety rounds were not part of Performance Improvement for the SMHU.

5. During an interview on 08/20/12 at 8:50 PM, Staff W, Certified Nursing Assistant (CNA), stated that both he and Staff T, CNA, were responsible for rounding and documenting on the 15 minute rounding sheets. Staff W added that the CNAs usually handed off the rounding sheets to one another throughout the shift as needed to complete the rounding.

During an interview on 08/20/12, at 9:52 PM, Staff W, CNA, stated that he documented observation of the patients on the patient safety rounds on the quarter-hour rather than documenting the actual time. Staff W stated that he completed the rounds in a consistent pattern and did not stagger the rounding times. Staff W stated that the rounds were not necessarily assigned by the charge nurse, but the CNAs handed off the rounding responsibility when they took a break or left the unit.

This routine practice of not staggering the rounding times could lead to patients anticipating staff rounding and could result in increased potential for patient self injury.

During an interview on 08/20/12 at 10:35 PM, Staff W stated that:
-He received education and training during new employee orientation.
-His duties included checking on patients to ensure they were safe (patient safety rounds), as well as documenting the patient's location, action and behavior every 15 minutes on the activity record.
-During patient safety rounds he must visualize the patient.
-Risks associated with failing to complete the 15 minute patient safety rounds included possible injury to the patient, elopement (when a patient flees the unit or hospital), and/or death.
-He was not aware that Patient #11 was on suicide precautions.
-A CNA "usually" attends shift change nursing report, which includes information about patient behaviors, admissions and discharges. The CNA then communicates the patient information to the other CNA's on duty.
-No CNA received or passed on report to the 7:00 PM shift on 08/20/12.

6. During an interview on 08/20/12, at 11:05 PM, Staff T, CNA, confirmed that patient safety rounds were completed in a consistent pattern and not staggered.

7. During an interview on 08/21/12 at 1:10 PM, Staff CC, RN, stated that shift report "sometimes" includes one or two CNAs "if they are available" who take the patient information received during shift report and pass it along to the other CNAs. Staff CC added that if a CNA does not receive shift report, the charge nurse should ensure the CNAs receive patient information such as fall precautions, suicide precautions, etc.

8. During an interview on 08/22/12, at 8:30 AM, Staff T stated that he thought about 10% of the patient population could predict rounding times, and that staggering rounds could be helpful to reduce patient risks. Staff T stated that the reason rounds are done is to keep the patients safe.

9. During an interview on 08/22/12 at 12:00 PM, Staff Y, Medical Director of the SMHU, stated that when patient safety rounds are not completed every 15 minutes, there is definitely a concern for the patients' safety. Staff Y stated concerns would include patient falls and possibly suicide.

10. During an interview on 08/22/12 at 2:17 PM, Staff R, Interim Director of the SMHU, stated that Charge Nurses were responsible for assigning patient safety rounds to staff and ensuring that the safety rounds were completed.

During an interview on 08/22/12, at 3:14 PM, Staff R stated that patient rounds had historically been documented on quarter hour intervals.

11. During a telephone interview on 08/28/12 at 8:23 PM, Staff N, Charge Nurse, stated that:
-She was not aware that 15 minute patient safety rounds were delinquent on the 08/20/12 night shift until surveyor inquiry.
-None of the CNAs attended shift report the evening of 08/20/12.
-Shift report includes information on patient code status, fall precautions and suicide precautions.
-She confirmed she did not give CNAs report on patients.
-Staff N added that when staff fail to do patient safety rounds, the risk for injury from falls, suicide, and other safety issues are heightened

12. Record review of the facility's policy titled, "Reporting Patient Abuse and Neglect" dated 07/23/12, showed the definition of neglect included the failure of a caretaker to provide goods or services necessary to avoid physical harm.

13. Record review of patient safety rounds dated 08/20/12, showed Staff W documented the following:
-Patient #9 was in bed, resting and calm at 8:15 PM, 8:30 PM and 8:45 PM;
-Patient #37 was in bed and asleep at 8:15 PM, 8:30 PM and 8:45 PM;
-Patient #38 was in the dining room, sitting and calm at 8:15 PM, 8:30 PM and 8:45 PM;
-Patient #39 was in her room, sitting and calm at 8:15 PM, and was in the dining room, sitting and calm at 8:30 PM and 8:45 PM.

14. Recorded video surveillance viewed with Staff L, Chief Nursing Officer (CNO) showed between 8:09 PM and 8:49 PM Staff W was in the nurses' station, down the north hall, in the main dining room and off the unit. Staff W was not observed completing safety rounds in patient rooms for Patients #9, #37, and #39, as he documented on the patient safety rounds. It is unknown from the video surveillance if Staff W observed Patient #38 in the dining room as he documented on the patient safety rounds.

15. During an interview on 08/20/12 at 10:35 PM, Staff W stated that:
-He falsely documented 15 minute patient safety rounds on the SMHU Activity Record for Patient #9, Patient #37, Patient #38 and Patient #39 during the 8:15 PM and 8:30 PM rounds.
-He falsely documented the rounding because he "wanted to get the job done" and because he didn't think it was something that the hospital should be "dinged" for by the surveyors.

16. Record review of Staff W's personnel file showed on 11/27/12 he completed training and was assessed competent to complete and document 15 minute patient safety rounds.

17. Record review of the facility's policy titled, "Discipline and Termination of Employment" revised on 07/01/11, showed that patient abuse or neglect and falsification of documents, including medical records, may result in immediate termination.

18. During an interview on 08/22/12 at 2:17 PM, Staff R stated that the facility had not initiated an internal investigation related to Staff W's falsification of the patient safety rounds on 08/20/12.

19. During an interview on 08/23/12 at approximately 8:40 AM, Staff R stated that Staff W continued to work on 08/21/12 from 7:00 PM until 7:00 AM on 08/22/12, and that he continued to perform patient safety rounds while on duty.

20. Record review of the facility's "Daily Staffing Record" showed that Staff W worked on 08/21/12 from 7:00 PM until 7:00 AM on 08/22/12.

21. During an interview on 08/23/12 at 12:03 PM, Staff L, CNO, stated that during the night shift of 08/20/12 he:
-Was aware Staff W had not completed his patient safety rounds based on recorded video monitoring;
-Had been approached by Staff W, who said he "wasn't exactly honest with (my) patient safety rounds" (on 08/20/12 night shift);
-Felt Staff W was neglectful to the patients by not providing patient safety rounds at the required frequency;
-Believed Staff W had falsified patient safety round documentation;
-Stated that Staff W admitted to him that he had falsified patient safety round documentation.
-Staff L added that he did not realize that Staff W had worked on the 08/21/12 night shift and that Staff W was responsible for completing safety rounds on patients.

22. Record review of Patient #11's admitting orders showed the patient was admitted on 08/17/12 with a diagnosis of Major Depression with Suicidal Ideation (to have thoughts of suicide). The physician ordered precautions for falls, suicide, and 15 minute checks.

Record review showed a physician's order for Patient #11dated 08/18/12 at 11:20 AM for oxygen two liters per nasal cannula (long, flexible tubing used to supply oxygen through a patient's nose) as needed (PRN) at night.

Record review of Patient #11's admission assessment on 08/17/12 at 4:00 PM showed she was oriented times three (to person, place and time) and ambulates alone with a steady gait.

Record review of Patient #11's Suicide Risk Assessment Guide (clinical assessment of the patient's suicide risk) dated 08/17/12 at 8:50 PM showed staff noted mental status as a medium risk for some sadness and feelings of hopelessness. Staff noted low risk for suicide attempts or suicidal thoughts. This daily assessment was unchanged through 08/22/12.

23. During an interview on 08/20/12 at 9:15 PM Patient #11 (currently on suicide precautions) stated that the staff did not routinely check on her.

24. Observation on 08/20/12 at 9:40 PM showed Patient #11 and her roommate, Patient #12, each had nasal cannula tubing, approximately 18 feet long, which could be looping/hanging hazards.

25. Review of recorded video monitoring showed on 08/20/12 at 7:31 PM, two staff members rolled three bins, that contained plastic liners, into the SMHU's main hallway. The bins were left unattended from:
-7:38 PM until 7:41 PM, when one patient was seen in the main hall;
-7:59 PM until 8:02 PM, when two patients were seen in the main hall;
-8:02 PM until 8:06 PM, when one patient was seen in the main hall;
-8:10 PM until 8:23 PM, when two patients were seen in the main hall.

Self ambulating patients had access to the main hallway and to plastic liners that could be used for suffocation/self injury.

26. Observation on 08/20/12, at 10:25 PM, showed that trash and linen bins with plastic liners were kept in the hallway just outside Patient #11's (who was identified as suicidal) room.

27. During an interview on 08/22/12, at 10:40 AM, Staff FF, CNA, stated that the trash and linen bins were to be locked in the soiled utility room.

28. During an interview on 08/22/12, at 2:30 PM, Staff R, stated that the trash and linen bins should be kept in the soiled utility room. Staff R stated that she was not sure why they were in the hallway on 08/20/12.

29. During an interview on 08/23/12, at 10:32 AM, Staff ZZ, CNA, stated that she observed plastic lined trash and linen bins in the hallway about 50% of the time she worked. Staff ZZ stated that she had witnessed a patient rummaging through the trash and the patient had to be re-directed.

30. During an interview on 08/23/12, at 10:56 AM, Staff R stated that she was concerned about the plastic lined trash and linen bins in the hallway. Staff R stated that this practice increased the risk for negative patient outcome.

This practice gave suicidal patients the potential to use plastic liners as a suffocating tool, especially since staff failed to observe patients and complete the patient rounds per policy, increasing the risk to patient safety.



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29117

Based on observation, interview, and record review the facility failed to assess and investigate bruising on two (#18 and #23) of two patients in the Senior Mental Health Unit. This failure can be a form of neglect. The facility census was 50.

Findings included:

1. Record review of the facility policy titled, "Housewide Patient Assessment" revised 02/11 showed:
-The assessment process is to provide for the best possible care and treatment and the type of care received through the continuum of care.
-Initial Screening/Assessment of the patient includes consideration of potential victim of abuse.
-A physical assessment is completed by the RN (Registered Nurse) within two hours of admission.
-Reassessment is performed every shift or more frequently as indicated by the patient's condition.

Record review of the facility policy titled, "Reporting Patient Abuse and Neglect" revised 07/23/12 showed:
-The hospital creates and maintains a proactive approach to identify events and occurrences that may constitute or contribute to abuse and neglect.
-The hospital ensures, in a timely and thorough manner, objective investigation of allegations of abuse or neglect.
-Medical neglect is the failure to seek, obtain or to follow through with medical care for the person.
-Physical abuse included bruises.
-Physical abuse in persons 65 years of age and older or disabled persons included contusions (bruises) or lacerations (cuts) found where people are not usually injured, such as the inner thighs.

Record review of the facility policy titled, "Adult Abuse and/or Neglect" revised 03/08 showed the following direction: Nursing and/or physicians will notify social work or case management when an elderly/disabled patient is admitted with questionable bruising. Social work or case management will investigate the medical record, meet with the physician, and make appropriate referrals to DHSS (Department of Health and Senior Services) hotline.

2. Observation on 08/20/12 at approximately 9:30 PM showed Patient #18 with a brownish purple bruise measuring 3 centimeters (cm) by 3 cm on the back of her right hand adjacent to the wrist.

3. Record review of Daily Nurses Notes dated 08/19/12 and 08/20/12 for Patient #18 showed no bruising.

4. During an interview on 08/21/12 at 11:10 AM, Staff DD, Certified Nursing Assistant (CNA), who was assisting Patient #18 to stand, stated that she had not noticed the bruise on the patient's right hand and that if she had, she would have brought it to the nurse's attention.

5. During an interview on 08/21/12 at 1:40 PM, Staff R, Interim Director of the SMHU, stated that unit staff did not assess and investigate the bruise on Patient #18's right hand.

6. Observation on 08/20/12 at approximately 10:15 PM showed Patient #23 with two bruises on her right inner upper arm. Bruise #1 was purple with yellow edges and measured 4 cm by 1 cm. Bruise #2 was light purple and measured 1 cm by 0.5 cm.

7. During an interview on 08/20/12 at approximately 10:15 PM, Staff T, CNA, who was ambulating Patient #23, stated that he had not seen the bruise on the patient's right upper arm before but hadn't worked for a couple of days.

8. Record review of Daily Nurses Notes dated 08/19/12 for Patient #23 showed no bruising. Review of Daily Nurses Notes dated 08/20/12 for the 7:00 PM to 7:00 AM shift (on 08/21/12) showed bruising checked in the Skin section but no descriptive assessment (color, location, and measurement) or intervention.

9. During an interview on 08/21/12 at 1:40 PM, Staff R stated that unit staff did not assess and investigate the bruises on Patient #23's right upper arm.

10. During a telephone interview on 08/28/12 at 8:23 PM, Staff N, Charge Nurse for the 7:00 PM to 7:00 AM shift on 08/20/12, stated that Patient #23 was found to have bruising to her arm that had not been documented in her medical record. Staff N stated that she was unaware of the bruising until the survey team brought the bruising to the attention of the staff.

11. During a telephone interview on 08/30/12 at 8:30 PM, Staff U, Registered Nurse (RN), stated that she was the nurse assigned to Patient #23 for the 7:00 PM to 7:00 AM shift on 08/20/12. She stated that she noticed the bruising on Patient #23's right upper arm and had checked bruising on the Skin section of the Daily Nurses Notes but did not describe the bruise in her narrative notes nor did she bring it to anyone's attention. Staff U stated that she asked the patient how she got the bruise and the patient said she got them all the time.

12. Record review of the Senior Mental Health Admission Assessment dated 07/24/12 for Patient #23 showed nursing documentation of bruising on the patient's inner thighs but no descriptive assessment (color and measurement) or intervention.

13. During an interview on 08/23/12 at 10:05 AM, Staff XX, Social Worker, stated that she was the social worker assigned to Patient #23 and was not notified of the bruises on the patient's inner thighs present on admission and, therefore, did not conduct an investigation.

14. During an interview on 08/23/12 at approximately 10:15 AM, Staff R stated that she was not aware of the bruises on Patient #23's inner thighs and the nurse that did the admission assessment was unavailable.

15. The facility failed to investigate bruising for Patient #18 and Patient #23. By not investigating bruising of unknown origin, the facility was unable to rule out if the patients were potential victims of neglect and/or abuse.

Based on interview and policy review the facility failed to ensure confidentiality of patient information for worker's compensation (an employer must pay or provide insurance to pay the lost wages and medical expenses of an employee who is injured on the job) in one of two out-patient areas observed. The out-patient area treated approximately 12 workers' compensation patients a quarter. The facility census was 50.

Findings included:

1. Record review of the facility policy titled, "Patient Rights" revised 08/11 directed staff that a patient has the right to have his medical record read only by individuals directly involved in his treatment or the monitoring of its quality. Other individuals may only have access to the patient's medical record on his written authorization or that of his legally authorized representative.

Record review of the facility policy titled, "Confidentiality" revised 05/11 directed staff that Protected Health Information (PHI) included the patient's name and other demographic information. The staff should make reasonable efforts to limit the work force's access to PHI to only that information which is needed to carry out their duties.

2. During an interview on 08/22/12 at 9:05 AM and 9:50 AM Staff MM, Director of Rehabilitation Services stated that a fax machine is in the registration area and the workers' compensation company faxed information about patients during the evening and night hours (leaving PHI available to non-clinical staff), which included the patient's name and date of birth (DOB).

3. During an interview on 08/22/12 at 9:30 AM Staff QQ, Business Manager Midwest Bone and Joint, stated that there are times that the registration area is cleaned by housekeeping after clinical staff have exited the building.

Staff failed to ensure PHI faxed to the out-patient area was not accessible to housekeeping staff not involved in patient care.

Based on interview and record review the facility failed to provide clear explanation in their written visitor policy of the clinical rationale for any visitation restrictions or limitations reflected in that policy. This had the potential to affect all patients. The facility census was 50.

Findings included:

1. Review of a facility policy titled, "Visitation" dated 07/27/11 showed the following:
-Visiting hours are specified by unit as follows:
a. Medical/Surgical (Med/Surg)- 11:00 AM to 8:30 PM, two visitors at any one time;
b. Critical Care Unit (CCU)- Closed 6:30 AM to 8:30 AM & PM, at discretion of Registered Nurse (RN)/immediate family only, two visitors at any one time, six years old and under restricted;
c. Emergency Dept.- 24-hours, two persons at a time;
d. Obstetric Dept.- 11:00 AM to 8:30 PM, general public. Twenty-four hours, fathers and laboring patient's family according to department policy, two visitors at any one time;
e. Senior Mental Health Unit (SMHU)- 1:00 PM to 3:00 PM, Monday, Wednesday, Friday, Saturday, and Sunday, two visitors at any one time, required written approval by the patient/guardian/Durable Power of Attorney.

2. Review of a facility-provided welcome brochure, included in the Patient Information Guide, given to patients on admission, showed general visiting hours were 11:00 AM to 8:30 PM. Due to the nature of the CCU; special visiting hours may need to be arranged through your nurse.

Even though the policy identified several visiting hour restrictions, the facility failed to include the explanation of the clinical rationale for these restrictions in their policy.

3. During an interview on 08/22/12, at 8:30 AM, Staff T, Nurse Assistant (NA), stated that the visiting hours on the SMHU were 2:00 to 4:00 PM, Monday, Wednesday, Friday, Saturday, and Sunday (not what policy reflected). Staff T stated that he did not know why there was no visiting on Tuesday and Thursday, other than possible activities occurring on Tuesday and Thursdays.

4. During an interview on 08/22/12, at 2:15 PM, Staff R, Interim Director of the SMHU, stated that the visiting hours of the SMHU were 2:00 to 4:00 PM Monday, Wednesday, Friday, Saturday, and Sunday (not what policy reflected). Staff R stated that Tuesdays and Thursdays were restricted because of physician visits and social work meetings which can cause agitation in the patient population.

5. During an interview on 08/23/12, at 10:32 AM, Staff ZZ, Certified Nurse Assistant (CNA), stated that the visiting hours on the SMHU were 2:00 to 4:00 PM (not what policy reflected), but did not know of any restrictions otherwise, or why the visiting hours were as described.

6. During an interview on 08/22/12, at 10:45 AM, Staff RR, Manager of the Med/Surg unit stated that the visiting hours were 1:30 PM to 8:30 PM (not what policy reflected), as listed in the patient handbook (but not what was in handbook). Staff RR stated that the reason for these particular visiting hours were related to physicians' rounds, and potential patient testing being completed by that time of day, allowing for a less congested morning. Staff RR also said that patients should be resting after 8:30 PM.

7. During an interview Med/Surg Patient #28 (identified as alert and oriented by Staff RR) on 08/22/12 at 10:50 AM, stated that she was unaware of the facility visitor policy. Patient #28's daughter, also visiting at that time, stated that she was also unaware of the visitor policy.

8. During an interview med/surg Patient #30 (identified as alert and oriented by Staff RR) on 08/22/12 at 10:53 AM, stated that she was unaware of the facility visitor policy.

Even though staff identified several restrictions to the visitor policy, and described some rationale for these restrictions, the facility failed to include them in the written policy.