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Based on interview and document review it was determined the facility staff failed to ensure physicians who were contracted to provide services, provided the services they were credentialed/privileged to provide. The facility has 8 physicians who are contracted. The credentials of 4 physicians were reviewed and 2 did not have credentials/privileges to care for the patients that were admitted to their service.

The findings include:

On 9/30 and 10/1/15 the credential of 4 physicians (Physicians 1-4) were reviewed. Physician #1 was last reappointed on 7/14/14 but were only credentialed to care for patients with psychiatric diagnoses and the use of restraints and seclusion. There was no reappointment by the governing body for the care of patients with chemical dependency diagnoses.
Physician #3 was last credentialed on 1/28/15 to care for patients with with psychiatric diagnoses and the use of restraints and seclusion. There was no reappointment by the governing body for the care of patients with chemical dependency diagnoses or geriatric patients.

The medical records of 32 patients who had been admitted from June 2015 to October 2015 of the thirty-two (32) six (6) had a chemical dependency diagnosis. Four (4) of the patients attending physician was Physician #3 and two (2) were the patients of Physician #1.

On 10/1/15 at approximately 12:12 P.M. the above information was reviewed with the CEO (Chief Executive Officer) who stated, "Both (Name of both Physicians) should have been approved to care for psych, CD (chemical dependency), restraint/seclusion and geriatric patients. I contacted the former CEO and he/she said it was an oversight. We will have an emergency governing board meeting tonight to rectify this."

Based on documents review and interview it was determined the facility staff failed to ensure information regarding the sensitivity and or possible sensitivity to medications was provided to the physician, nursing staff and pharmacy staff. In conducting a review of the care provided to Patient #1 and how could the incident be avoided to protect the safety of other patients. The review failed to reveal the physician and the social worker had been informed that Patient #1 had a sensitivty to certain medications. This resulted in an Immediate Jeopardy (IJ). The onsite Medical Facilities Inspectors investigated and communicated the finding to the State Agency at 4:15 P.M. on September 29, 2015. The facility CEO, RM/PI, CFO and Divisional Clinical Director were informed of the IJ at 3:20 P.M. on September 29, 2015. The IJ was lifted after a Plan of Corrections was accepted at 7:27 P.M. on September 29, 2015 and the SA was notifed at 7:37 P.M. on September 29, 2015.

Based on documents review and interviews it was determined the facility staff failed to ensure less restrictive means were attempted prior to placing 2 of 32 patients, Patient #1 and Patient #28 in restraints.

The findings include:

On September 29, 2015 the medical record (MR) of Patient #1 was reviewed.
On August 3, 2015 0015 (1:15 A.M.) Night Shift Progress Note reads in part "During beginning of shift pt anxious and verbalizes having auditory hallucinations. Pt received Haldol and Ativan PRN".
On August 5, 2015 Evening Shift Progress Note reads in part "screaming "I refuse that in the name of Jesus" pt did take PO PRNs and was counseled to do that in his/her room and when he/she is able to come out then he/she can".
On August 10, 2015 At 11:00 A.M. Social Worker note read in part "SW spoke with Patient, Patient appeared drowsy and with delay in speech reporting anxious but also with difficulty in focus and communicating with pronouncing words correctly. Patient's Mother reported that Patient has not done well with Haldol in the past and if continued will need something for side effects. Dr. discontinued Haldol and adjusted Seroquel to night."
On August 10, 2015 at 11:15 A.M. Physician orders show order to discontinued Haldol written by Attending Physician and noted by nurse.
On August 11, 2015 at 12:30 P.M. Physician orders show telephone order to give Haldol 5 mg (milligrams) IM written by nurse and signed by Attending Physician on 08/12/2015 at 09:00 A.M.
On August 12, 2015 at 1350 (1:50 P.M.) Physician orders show telephone order to give Haldol 5 mg IM written by nurse and signed by a different Physician on 08/13/2015 at 09:00 A.M.
On August 13, 2015 at 10:40 A.M. Physician orders show order for Haldol 10 mg PO (by mouth) BID (twice a day) and Cogentin 1 mg PO BID written by Attending Physician and noted by nurse.
On August 14 05:10 A.M. Note reads in part "pt went back to his/her room and the same thing happened, this time he/she ripped down the shower curtain as well. the pt was offered PRN meds but refused."
On August 17, 2015 at 01:15 A.M. TO (telephone order) for Haldol 5 mg, Ativan 2 mg, Benadryl 50 mg IM and at 01:30 A.M. another TO for Haldol 5 mg, Ativan 2 mg, Benadryl 50 mg IM was documented as given in Documentation Addendum.
Patient's daily medications on August 17, 2015 documented as given include Cogentin PO 1 mg twice a day, Haldol PO 10 mg twice a day, Seroquel PO 800 mg at bedtime, and Risperdal PO 3 mg twice a day. Invega Sustea 234 mg IM documented as given on 08/12/2015 with a second dose of 156 mg IM scheduled for 08/19/2015.

On September 1, 2015 Discharge Summary by Attending Physician reads in part "At on point, patients mother indicated that he did not do well on Haldol without a side effect medication and that if he was given Haldol that he should be given a side effect medication along with it. For this reason, on a conservative basis, we decided to discontinue the Haldol altogether and that was discontinued on the 10th. On August 13, 2015 Haldol resumed at 10 mg bid with Cogentin 1 mg PO bid. At no time during this time did the patient appear oversedated or overmedicated. There was no evidence of tardive dyskinesia, extrapyramidal symptoms or cholinerigic toxicity. Patient did indicate on the Haldol, sometimes gets a thickness on the tongue and a tightness on the jaw, which made it difficult for patient to speak but Cogentin seemed to be helping that. Cogentin was deliberately added at a low dose of 1 mg twice a day to avoid anticholinergic toxicity and side effects. The Haldol was continued at 10 mg twice a day."

Staff failed to communicate sensitives and medications as an interdisciplinary team to include all staff involved in Patient #1's care.
An interview with Staff Member Chief Executive Officer (CEO) and (ICP) and Educator on October 1, 2015 revealed that staff should use least restrictive interventions first. There is no evidence in the documentation to show that staff tried less restrictive interventions first (active listening, reducing stimuli, 1:1 verbal interaction, calming exercise, music or television, etc)

Patient #1's MR revealed there is no daily PRN Management flowsheet completed for PRN medications given on 8/2/2015 at 00:35 (1:35 A.M.), 8/3/2015 at 11:45 A.M., 8/5/2015 at 1745 (5:45 P.M.), 8/6/2015 at 09:30 A.M., 8/7/2015 at 2145 (9:45 P.M.), and 8/12/2015 at 08:00 A.M., 1400 (2:00 P.M. and 2145 (9:45 P.M.

An interview with Staff Member #16 on September 29, 2015 revealed that no adverse drug reactions have been reported for Patient #1. Staff Member #16 stated that it a normal standard for Haldol 5 mg, Ativan 2 mg, and Benadryl 50 mg IM to be given together at least 30 minutes apart. Staff Member #16 also stated that the policy and procedure states no more than two (2) major antipsychotic medications shall be used at the same time, including PRN antipsychotics if administered. Long Acting Injection Antipsychotic Reference provided by Staff Member #16 includes Haldol, Fluphenazine, Risperal, Invega and Abilify.

An interview with Staff Member #18 revealed that staff member was unaware that Patient #1 had sensitivities to Haldol or that the medication had been discontinued on August 11 and reordered on August 13. Staff Member #18 admits calling on call Physician for PRN order for IM medication but failed to notified Physician of Patient #1's current medication including PRN's. Staff Member #18 admits preparing IM medications for Patient #1 on August 17, 2015 for 01:15 A.M. injection but handed the medications to Staff Member #19 to administered due to Staff Member #19 having a better rapport with Patient.

An interview with Staff Member #19 revealed that Staff Member was aware of patient but had no direct contact with Patient #1 before August 17, 2015. Staff Member #19 stated that he/she was not aware of any sensitivities to medications by Patient #1. Staff Member #19 acknowledged administering injection at 0115 prepared by Staff Member #18. Staff Member #19 acknowledges calling on call Physician for second dose of IM medications and preparing and administering injections at 01:30 A.M. Staff Member #19 admits he/she failed to notified Physician of Patient #1's current medication including PRN's.

Policy and Procedure titled "Medication Administration - General guidelines" reads in part "Only the licensed nurse preparing an IM medication may administer the medication. When calling the M.D. for a change in patient condition or any emergency you need to report the following to the M.D.: Patient name, Age, Diagnosis, Situation for the request of PRN's, Current medications including any preceding PRN's and any long acting injectable the patient may be taking, Most recent Vital Signs, and Allergies.

On October 1, 2015 the medical record (MR) of Patient #28 was reviewed.
On September 14, 2015 20:00( 8:00 P.M.) Evening Shift Progress Note reads in part "pt irritable during visit with father. Pt given 2 mg Ativan for anxiety".

An interview with Chief Executive Officer (CEO) on October 1, 2015 revealed that staff should use least restrictive interventions first. Staff failed to document least restrictive interventions used first (active listening, reducing stimuli, 1:1 verbal interaction, calming exercise, music or television, etc).
Staff failed to prevent, reduce and eliminate the use of seclusion/restraint through early identification and detection of high-risk behaviors or events for Patient #1. Documentation show that staff identified Patient #1 responded to stimuli in room, heavily in bathroom and worse in dark. However staff failed to move Patient #1 to a quiet, lighted area without bathroom at night for sleep.

Based on interview and document review, it was determined the facility staff failed to use restraint or seclusion when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member, or others from harm. (Patient #1 and 28)

The findings include:

On September 29, 2015 the medical record (MR) of Patient #1 was reviewed.
On August 3, 2015 0015 Night Shift Progress Note reads in part "During beginning of shift pt anxious and verbalizes having auditory hallucinations. Pt received Haldol and Ativan PRN".
On August 5, 2000 Evening Shift Progress Note reads in part "screaming "I refuse that in the name of Jesus" pt did take po prns and was counseled to do that in room and when able to come out then can".
On August 14 0510 Note reads in part "pt went back to room and the same thing happened, this time ripped down the shower curtain as well. the pt was offered PRN meds but refused."

On October 1, 2015 the medical record (MR) of Patient #28 was reviewed.
On September 14, 2015 2000 Evening Shift Progress Note reads in part "pt irritable during visit with father. Pt given 2 mg ativan for anxiety".

An interview with Chief Executive Officer (CEO) on October 1, 2015 revealed that staff should use least restrictive interventions first. There is no evidence in the documentation to show that staff tried less restrictive interventions used first (active listening, reducing stimuli, 1:1 verbal interaction, calming exercise, music or television, etc).

Based on document review and interview it was determined the facility staff failed to ensure data collected related to Assessment and Referral and Discharge Planning was broken down into subsets tat allowed for comparison of performance and that the governing body approved the frequency of data being collected.

And failed to ensure interventions they instituted for areas they identified as needing improvements (physicians electronically signing documentation) were documented.

And failed to ensure all parts of the facility were included in the QAPI (Quality Assessment Performance Improvement) Plan. The Partial Hospitalization Program was removed for approximately 8 months.

Based on document review and interview it was determined the facility staff failed to ensure data collected related to Assessment and Referral and Discharge Planning was broken down into subsets tat allowed for comparison of performance and that the governing body approved the frequency of data being collected.

The findings include:

On 10/1 and 2/15 the Director of Risk Management and Performance Improvement (RM/PI) was interviewed regarding the QAPI (Quality Assessment and Performance Improvement). The Director RM/PI stated, "I have been collecting data related to Assessment and Referral and Discharge Planning for about 18 months. The Admission and Screening Assessment completed by the Intake clinicians (nurse or MSW/MC) were not being completed and there were blanks and documentation was missing. The same was true for the Discharge Planning form completed by the social workers. Sometimes the information about the support system involvement, safety at home (access to weapons) and the after care plans were incomplete."

The Director RM/PI was asked if the data collected compared variables such as the time of day or who completed the intake or discharge information and the Director RM/PI stated, "No, not formally."

The Director RM/PI was also interviewed regarding the governing body's approval of the QAPI Program and of the program indicators and the frequency of data collection. The Director RM/PI stated, "No not the frequency of data collection but they did approved the indicators."

Based on document review and interview it was determined the facility staff failed to ensure interventions they instituted for areas they identified as needing improvements (physicians electronically signing documentation) were documented.

The findings include:

On 10/1 and 2/15 the Director of RM/PI (Risk Management/Performance Improvement) was interviewed regarding an area the facility had identified as being problematic. The Director of RM/PI stated, "Getting the physician's to review and sign electronically their H&P (history and physical), discharge summaries and psychiatric evaluations. We have brought it (the problem with not signing electronically) to Medical Staff meetings. The Medical Director has discussed the issues with the individual physicians who continue to not sign their documentation but we have not documented the Medical Directors interventions."

Based on interview and documents reviewed the facility staff failed to ensure all parts of the facility were included in the QAPI (Quality Assessment Performance Improvement) Plan. The Partial Hospitalization Program was removed for approximately 8 months.

The findings include:

On 10/2/15 the Director RM/PI (Risk Management/Performance Improvement) was interviewed regarding all areas of the hospital being involved in QAPI. The Director RM/PI stated, "The Partial Program was included but at the end of 2014 it was removed as something we looked at. There had been a change in leadership and I realized we were not getting any formal reports from the Partial Program. When this was brought to the current CEO's attention in August 2015 it was immediately corrected."

The Director RM/PI was interviewed regarding physicians. The Director RM/PI stated, "All the physicians (total of 8) are contracted." During the review of the physician's credentials the following was noted:

On 9/30 and 10/1/15 the credential of 4 physicians (Physicians 1-4) were reviewed. Physician #1 was last reappointed on 7/14/14 but was only credentialed to care for patients with psychiatric diagnoses and the use of restraints and seclusion. There was no reappointment by the governing body for the care of patients with chemical dependency diagnoses.
Physician #3 was last credentialed on 1/28/15 to care for patients with with psychiatric diagnoses and the use of restraints and seclusion. There was no reappointment by the governing body for the care of patients with chemical dependency diagnoses or geriatric patients.

The medical records of 32 patients who had been admitted from June 2015 to October 2015 of the thirty-two (32) six (6) had a chemical dependency diagnosis. Four (4) of the patients attending physician was Physician #3 and two (2) were the patients of Physician #1.

The Director RM/PI stated, "I was not aware of that."

Based on interview and document review it was determined the facility staff failed to ensure 2 of 4 physicians were credential to care for the patients that were admitted to their service.

The findings include:

On 9/30 and 10/1/15 the credential of 4 physicians (Physicians 1-4) were reviewed. Physician #1 was last reappointed on 7/14/14 but were only credentialed to care for patients with psychiatric diagnoses and the use of restraints and seclusion. There was no reappointment by the governing body for the care of patients with chemical dependency diagnoses.
Physician #3 was last credentialed on 1/28/15 to care for patients with with psychiatric diagnoses and the use of restraints and seclusion. There was no reappointment by the governing body for the care of patients with chemical dependency diagnoses or geriatric patients.

The medical records of 32 patients who had been admitted from June 2015 to October 2015 of the thirty-two (32) six (6) had a chemical dependency diagnosis. Four (4) of the patients attending physician was Physician #3 and two (2) were the patients of Physician #1.

On 10/1/15 at approximately 12:12 P.M. the above information was reviewed with the CEO (Chief Executive Officer) who stated, "Both (Name of both Physicians) should have been approved to care for psych, CD (chemical dependency), restraint/seclusion and geriatric patients. I contacted the former CEO and he/she said it was an oversight. We will have an emergency governing board meeting tonight to rectify this."

Based on Medical Record (MR) review and interviews the facility failed to ensure drugs and biologicals are prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient's care as specified under §482.12(c), and accepted standards of practice.

The Findings include:

On September 29, 2015 the MR of Patient #1 was reviewed. On August 10, 2015 At 1100 Social Worker note read in part "SW spoke with Patient, Patient appeared drowsy and with delay in speech reporting anxious but also with difficulty in focus and communicating with pronouncing words correctly. Patient's Mother reported that Patient has not done well with Haldol in the past and if continued will need something for side effects. Dr. discontinued Haldol and adjusted Seroquel to night."
On August 10, 2015 at 1115 Physician orders show order to discontinued Haldol written by Attending Physician and noted by nurse.
On August 11, 2015 at 1230 Physician orders show telephone order to give Haldol 5mg IM written by nurse and signed by Attending Physician on 08/12/2015 at 0900.
On August 12, 2015 at 1350 Physician orders show telephone order to give Haldol 5mg IM written by nurse and signed by a different Physician on 08/13/2015 at 0900.
On August 13, 2015 at 1040 Physician orders show order for Haldol 10mg PO BID and Cogentin 1mg PO BID written by Attending Physician and noted by nurse.
On September 1, 2015 Discharge Summary by Attending Physician reads in part "At on point, patients mother indicated that patient did not do well on Haldol without a side effect medication and that if patient was given Haldol that patient should be given a side effect medication along with it. For this reason, on a conservative basis, we decided to discontinue the Haldol altogether and that was discontinued on the 10th. On August 13, 2015 Haldol resumed at 10mg bid with Cogentin 1mg po bid. At no time during this time did the patient appear oversedated or overmedicated. There was no evidence of tardive dyskinesia, extrapyramidal symptoms or cholinerigic toxicity. Patient did indicate on the Haldol, sometimes gets a thickness on the tongue and a tightness on the jaw, which made it difficult for patient to speak but Cogentin seemed to be helping that. Cogentin was deliberately added at a low dose of 1mg twice a day to avoid anticholinergic toxicity and side effects. The Haldol was continued at 10mg twice a day."
On August 17, 2015 at 0115 TO for Haldol 5mg, Ativan 2mg, Benadryl 50mg IM and at 0130 TO for Haldol 5mg, Ativan 2mg, Benadryl 50mg IM documented as given in Documentation Addendum.
Patient's daily medications on August 17, 2015 documented as given include Cogentin PO 1mg twice a day, Haldol PO 10mg twice a day, Seroquel PO 800mg at bedtime, and Risperdal PO 3mg twice a day. Invega Sustea 234mg IM documented as given on 08/12/2015 with a second dose of 156mg IM scheduled for 08/19/2015.
Staff failed to communicate sensitives and medications as an interdisciplinary team to include all staff involved in Patient #1's care. Physician continued to order Haldol PRN after discontinued without a medication to avoid side effects.

An interview with Staff Member #16 on September 29, 2015 revealed that no adverse drug reactions have been reported for Patient #1. Staff Member #16 stated that it a normal standard for Haldol 5mg, Ativan 2mg, and Benadryl 50mg IM to be given together at least 30 minutes apart. Staff Member #16 also stated that the policy and procedure states no more than two (2) major antipsychotic medications shall be used at the same time, including PRN antipsychotics if administered. Long Acting Injection Antipsychotic Reference provided by Staff Member #16 includes Haldol, Fluphenazine, Risperal, Invega and Abilify.

An interview with Staff Member #18 revealed that staff member was unaware that Patient #1 had sensitivities to Haldol or that the medication had been discontinued on August 11 and reordered on August 13. Staff Member #18 admits calling on call Physician for PRN order for IM medication but failed to notified Physician of Patient #1's current medication including PRN's. Staff Member #18 admits preparing IM medications for Patient #1 on August 17, 2015 for 0115 injection but handed the medications to Staff Member #19 to administered due to Staff Member #19 having a better rapport with Patient.

An interview with Staff Member #19 revealed that Staff Member was aware of patient but had no direct contact with Patient #1 before August 17, 2015. Staff Member #19 stated that he/she was not aware of any sensitivities to medications by Patient #1. Staff Member #19 acknowledged administering injection at 0115 prepared by Staff Member #18. Staff Member #19 acknowledges calling on call Physician for second dose of IM medications and preparing and administering injection at 0130. Staff Member #19 admits he/she failed to notified Physician of Patient #1's current medication including PRN's.

Policy and Procedure titled "Medication Administration - General guidelines" reads in part "Only the licensed nurse preparing an IM medication may administer the medication. When calling the M.D. for a change in patient condition or any emergency you need to report the following to the M.D.: Patient name, Age, Diagnosis, Situation for the request of PRN's, Current medications including any preceding PRN's and any long acting injectable the patient may be taking, Most recent Vital Signs, and Allergies)

Based on interview and documentation, it was determined the facility failed to ensure all orders, including verbal orders are dated, timed and authenticated promptly by the ordering practitioner or by another practitioner who is responsible for the care of the patient only if such a practitioner is acting in accordance with State law, including scope of practice laws, hospital policies and medical staff by laws, rules and regulations.

The findings include:

On October 1, 2015 the medical record (MR) of Patient #29 was reviewed.
On September 16, 2015 at 1700 a telephone order reads in part "Transfer to ER r/t tachycardia T.O. Dr. (Physician Name)".
On September 17, 2015 at 0045 a telephone order reads in part "Search pt body and room for contraband for missing staff keys. TORB Dr (Physician Name)".
The orders have no date, time and authenticating signature by physician.

Based on document review and interview it was determined the facility staff failed to ensure all practitioner's notes, orders, nursing notes, reports of treatment, interdisciplinary care plans and other information necessary to monitor the patient's condition was in the patients medical record and was accurate and or verified for 24 of 32 patient's medical records, Patients #1, 2, 3, 4, 5, 6, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 20, 21, 22, 23, 24, 27, and 28.

The findings include:

1. On 9/29/15 the medical record of Patient #2 was reviewed. Patient #1 was a 65 year old admitted to the Partial Program on 9/16/15 with a primary diagnosis of alcohol dependency.

The (Name of Facility) Admission Screening Assessment completed on 9/15/15 indicates on page 3 that Patient #1 has access to a firearm. The form says to Describe there is no description. Page 4 indicates there is a firearm in Patient #1's home. Page 5 indicates Patient #1 had treatment for alcohol in the late 1990's.

A Progress Note written on 9/16/15 and signed by two social workers noted the following, "...met with Patient #1 to complete the social work assessment and safety crisis plan. (Name of Patient #1) denies SI/HI (Suicidal Ideations/Homicidal Ideations). Denies access to firearms, however he reports owning an antique heirloom gun which is locked away for collectible purposes."

Patient #2's Initial Treatment Plan was developed on 9/16/15. The Initial Treatment Plan for the Partial Program is identical to the Inpatient Initial Treatment Plan. On Patient #2's Initial Treatment Plan Anxiety is identified as a problem. The treatment modality is 1:1 with staff and the frequency/duration is Q (every) day and evening with staff as needed. There is no evening portion to the Partial Program.

The physician's admission note completed on 9/17/15 indicated Patient #2 had been in treatment for alcoholism in the late 1990's. The Interdisciplinary Master Treatment Plan which did not show any physician involvement by signature indicated Patient #1 was now in treatment for the first time. The Nurse and 2 Social Workers signed Patient #1's treatment plan on 9/18/15 and Patient #1 did not sign until 9/24/15, six (6) days later.

On 9/22/15 the Nurse and the Social Worker signed the Master Treatment Plan Update/Clinical Staffing Worksheet. The physician and Patient #2 did not sign the Master Treatment Plan Update/Clinical Staffing Worksheet. By signing the Plan Update it would have indicated they were involved in the Plan Update.

Patient #2's Substance Use Individual Treatment Plan had 9 short term goals with a target date of 9/25/15. As of 9/29/15, the date the medical record was reviewed none of the short term goals had been evaluated to determine if the goals had been achieved or discontinued.

On 9/29/15 the medical record of Patient #3 was reviewed. Patient #3 is a 34 year old admitted to the Partial Program on 9/17/15 with a primary diagnosis of Major Depression.

The Interdisciplinary Master Treatment Plan for Patient #3 was signed by the Nurse and Social Worker on 9/21/15. The physician did not signed The Interdisciplinary Master Treatment Plan and Patient #3 did not sign the The Interdisciplinary Master Treatment Plan until 9/25/15. A signature by the physician would have indicated the physician's involvement in Patient #3 treatment plan and a signature on 9/21/15 when the Nurse and Social Worker signed would have indicated Patient #3 was actively involved in the treatment planning.

On 9/29/15 the medical record of Patient #4 was reviewed. Patient #4 is a 21 year old admitted Inpatient on 9/16/15 with a primary diagnosis of Psychosis NOS (Not Otherwise Specified).

Patient #4's UDS (Urine Drug Screen) obtained at an acute medical facility on 9/15/15 was negative for all substances tested. A UDS on 9/16/15 was obtained after Patient #4 was transferred to the psychiatric hospital which was positive for marijuana and benzodiazepines. The medical record of Patient #4 does not address the discrepancies.

Patient #4 signed his Initial Treatment Plan on 9/16/17. Patient #4's Individual Medical Treatment Plan was initiated on 9/16/15 with 2 items as short-term goals. There were no target dates to indicate when the short-term goals would be accomplished and there was no date achieved/discontinued indicated.

The Interdisciplinary Master Treatment Plan was signed by the Nurse on 9/21/15 and by the Social Worker and CTRS (Certified Therapeutic Recreational Specialist) on 9/19/15 there is no signature by the physician indicating the physician was involved in planning and no signature by Patient #4. There is a note that is not dated or signed that states, "Per (Name of Physician) pt (patient) continues to be psychotic and manic. Presenting w/inability to consent to treatment plan". The The Interdisciplinary Master Treatment Plan does not indicate any strengths, limitations, discharge criteria or initial discharge disposition.

There were two (2) Master Treatment Plan Update/Clinical Staffing Worksheets in Patient #4's medical record. One signed on 9/23/15 by Patient #4, the Nurse and the Social Worker; the physician did not sign and there was no Psychiatrist Update completed. The second Master Treatment Plan Update/Clinical Staffing Worksheets was signed by Patient #4 on 9/27/15 and the Social Worker. It was signed by the Nurse on 9/28/15; the physician did not sign and the Psychiatrist Update was initialed by the Nurse not the physician.

Patient #4's medical record contained a from titled "Daily PRN Management Flowsheet". Staff Member #9 stated, "The flowsheets are to be completed each time a PRN (whenever necessary) medication is given." Patient #4 had a Daily PRN Management Flowsheet completed for 9/18 and 24/15 but received PRN medication of Benadryl, Haldol and Ativan on 9/19/15 and 9/20/15, Ativan on 9/21/15 and 9/22/15, Haldol and Ativan on 9/23/15, Benadryl and Ativan on 9/25/15, 9/26/15 and 9/27/15. The Daily PRN Management Flowsheet was not completed for the dates of 9/19, 20, 21, 22, 23, 25, 26 and 27/15.

While the surveyors were in the facility a Code "0" was called on 9/28/15 at approximately 12:00 Noon in the cafeteria for Patient #4. This surveyor was accompanied by the Patient Advocate to the cafeteria. The Patient Advocate stated, "A Code "0" is a medical emergency." The emergency code cart was locked in a room down the hall from the cafeteria. No employee brought the emergency code cart to the dinning room. Patient #4 appeared very pale and was removed from the cafeteria in a wheelchair. When reviewing Patient #4's medical record there was no documentation of Patient #4's vital signs (blood pressure, pulse, respirations or temperature) recorded on the vital signs form or in the nurses notes and there is no indication the physician was notified.

On 9/29 and 30/15 the medical record of Patient #8 was reviewed. Patient #8 is a 21 year old admitted Inpatient voluntarily on 8/29/15 with a primary diagnosis of Bipolar Disorder, Depressed Episode, Severe.

Patient #8's History and Physical dictated on 9/9/15 stated there was no history of alcohol, tobacco or illicit drug use. The UDS collected on 8/29/15 was negative for all substances. Patient #8's Initial Nursing Assessment dated 8/29/15 on Page 6 ask "How often do you have a drink containing alcohol?" Patient #8's response was "Never". The Social Work Assessment dated 8/31/15 states Patient #8 was admitted on a TDO (Temporary Detention Order) (this is not a voluntary means of admission). The Social Work Assessment on page 2 Section VII also states, "(Name of Patient) reported he/she has a hx (history) of abusing ETOH (alcohol) and prescription drugs". There is no notations discussing the discrepancies.

Patient #8's Master Treatment Plan Update/Clinical Staffing Worksheet signed by the Physician, Nurse, Social Worker, CTRS and Patient #8 on 9/3/15 did not have any documentation in any of the following sections: Nursing Update, Social Services Update and the Psychiatrist Update.

Patient #8's medical record contained a from titled "Daily PRN Management Flowsheet". Patient #8 had a Daily PRN Management Flowsheet completed for 9/2 and 3/15 but received PRN medication of Geodon and Ativan on 8/29 and 30/15, Ativan, Vistaril and Motrin on 8/30/15, Vistaril and Motrin are documented on the administration sheet dated 08/31/15 at 0700 thru 09/01/15 at 0659 but is written as given on 8/30/15, Benadryl and Motrin on 9/1/15, Motrin on 9/2/15. The Daily PRN Management Flowsheet was not completed for the dates of 8/29 and 30, 9/1 and 2/15.

On 9/30/15 the medical record of Patient #11 was reviewed. Patient #11 is a 32 year old admitted Inpatient on 9/26/15 with a primary diagnosis of Major Depression, Severe.

The physician ordered a UDS on admission but as of 9/30/15 the UDS was not completed. There was no documentation as to why this was not performed.

The following policies were provided by the Risk Manager/Performance Improvement Director:
The Policy titled PHP Interdisciplinary Treatment Plan for Partial Level of Care with an issue date of 2/14 section #3 states, "No later that the patient's third (3rd) day of attendance in the partial hospitalization program, an individual's Interdisciplinary Treatment Plan (Attachment B), including discharge planning is developed. Utilizing assessments from interdisciplinary team members, data is integrated to identify and prioritize patient needs for care/treatment. The Plan is completed, dated and signed by the attending MD, Case Manager, CD Counselor for CDP, SW, patient/guardian and in the chart with 3rd day of attendance for partial as outlined in #'s 4, 5, 6 below."

The Policy titled: Change in Conditions/Medical Emergencies with a revised date of 8/15 section #1 states, "Any change in the patient's condition should be reported to the physician immediately".





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The finding include:

On September 29 and October 1, 2015 the medical record (MR) for Patients #1, 5, 6, 9, 10, 12, 13, 14, 15, 16, 17, 18, 20, 21, 22, 23, 24, 27, and 28.

Patient #1's MR revealed there is no daily PRN Management flowsheet completed for PRN medications given on 8/2/2015 at 0035, 8/3/2015 at 1145, 8/5/2015 at 1745, 8/6/2015 at 0930, 8/7/2015 at 2145, and 8/12/2015 at 0800, 1400, 2145.

Patient #5's MR review revealed an admitting diagnoses to include Opioid Type Dependence and Tobacco Use Disorder. The Initial Treatment Plan failed to include Substance Abuse and Tobacco Use as a problem. The Admission: Patient/Family Education Record failed to include Chemical Dependent and Smoking Cessation.

Patient #6's MR review revealed Interdisciplinary Master Treatment Plan signed and dated by physician on 8/13/15 at 1300. Pt was admitted to facility on August 22, 2015.
The Master Treatment Plan Update/Clinical Staffing Worksheet revealed Nursing Update and Psychiatrist Update to be blank.
There is no daily PRN Management flowsheet completed for PRN medications given on 8/22/15 at 0945, 1530, and 1900, 8/23/15 at 2145, and 8/24/2015 at 0930.

Patient #9's MR review revealed Psychiatric Evaluation dated 09/23/2015 and Social Worker Assessment dated 09/23/2015 to include patient acknowledgement of alcohol use. Social Worker Assessment dated 09/23/2015 at 1345 reads in part "spoke to pt's roommate who states that pt chooses to drink liquor instead of taking meds, pt drinks every day, can't control drinking." Interdisciplinary Master Treatment Plan does not indicate Substance Abuse as a problem nor do Nursing Notes. There is no indication in MR review that interdisciplinary team discussed pt's alcohol use.
The Master Treatment Plan Update/Clinical Staffing Worksheet revealed Nursing Update and Psychiatrist Update to be blank.
There is no daily PRN Management flowsheet completed for PRN medication given on 9/22/2015 at 1400, 2050, 9/23/2015 at 1940, 2105, 9/24/2015 at 2020, 2300, 9/25/2015 at 2130, 9/26/2015 at 2000, 2255, and 9/28/2015 at 845, 2015, and 2338.

Patient #10's MR review revealed an order written on 9/9/2015 by the physician reading in part "CPAP apply at previous settings per NC attachment QHS (at bedtime) (family to bring in (the machine))". On Medical History Form the question regarding CPAP or BIPAP/sleep apnea Has Machine is marked NO. Pt was admitted on 9/8/2015 and discharged on 9/14/2015 with no documentation on CPAP/sleep apnea. CPAP/sleep apnea is not listed on Interdisciplinary Master Treatment Plan as a problem.
There is no RN signature on the Medical History Form.
Discharge Orders form is incomplete. Questions 1, 2, and 4 are blank.
Informed Consent for Psychoactive Medication Form is incomplete. No date or RN signature.
There is no daily PRN Management flowsheet completed for PRN medications given on 9/9/2015 at 0010.

Patient #12's MR review revealed no Psychiatric Evaluation for this patient however there was a Psychiatric Evaluation for another patient in this patient's MR.
Informed Consent for Psychoactive Medication Form is incomplete. No RN or Patient signatures.
Lisinopril given on 9/7/2015 without documentation of patient's blood pressure as indicated on Medication Administration Record.
There is no daily PRN Management flowsheet completed for PRN medications given on 9/4/2015 at 0405, 1355, 1925.

Patient #13's MR review revealed Discharge Orders form is incomplete. There is no date or MD Signature and Questions 1, 3, and 4 are blank.
Informed Consent for Psychoactive Medication Form is incomplete. There is no date and no RN and Patient signatures.
Discharge Living Arrangements form is incomplete. There is no Discharge Coordinator signature and no Social Worker signature.
Medical History Form reveals no vital signs.
Interdisciplinary Master Treatment Plan has no Physician, Nurse or Patient signature.
Physician Progress Note dated 9/27/2015 has no Patient Name on form and the following note has no date, time or physician signature.

Patient #14's MR review revealed Informed Consent for Psychoactive Medication form has no date and no RN and Patient signatures.
Admission Medication Reconciliation and Nursing Discharge Instruction form has no Physician Signature.
Discharge Living Arrangements Form has no Social Worker signature.
Medical History Form has no RN signature.
Interdisciplinary Master Treatment Plan has no Physician signature.
Master Treatment Plan Update/Clinical Staffing Form revealed Nursing update and Psychiatrist update to be blank and not have Physician Signature.

Patient #15's MR review revealed Admission Medication Reconciliation and Nursing Discharge Instruction form has no Physician Signature.
Progress note written on 9/23/2015 by the Social Worker reads in part "Pt expressed experiencing nightmare related to sexual assault." Interdisciplinary Master Treatment Plan does not indicate Sexual Assault or nightmares related assault as a problem nor do Nursing Notes. There is no indication in MR review that interdisciplinary team discussed patient's sexual assault or nightmare related to assault.
Interdisciplinary Master Treatment Plan is not signed by Physician.

Patient #16's MR review revealed Admission Medication Reconciliation and Nursing Discharge Instruction form has no Physician Signature.
Interdisciplinary Master Treatment Plan is not signed by Physician.
Master Treatment Plan Update/Clinical Staffing Form revealed Nursing update and Psychiatrist update to be blank and not have Physician Signature.

Patient #17's MR review revealed Informed Consent for Psychoactive Medication Form is incomplete; no RN or Patient signature.
Discharge Living Arrangements Form has no Social Worker signature.

Patient #18's MR review revealed Discharge orders incomplete; no date and questions 3 and 4 are blank.
Informed Consent for Psychoactive Medication Form is incomplete; no date and no RN signature.
Interdisciplinary Master Treatment Plan is not signed by the Social Worker.
Master Treatment Plan Update/Clinical Staffing Form revealed Nursing update and Psychiatrist update to be blank.

Patient #20's MR review revealed Informed Consent for Psychoactive Medication Form is incomplete; no RN and patient signature.

Patient #21's MR review revealed Initial Physician contact note incomplete; questions 1, 2, 4, and 5 are blank under TDO recommendation note.
There is no daily PRN Management flowsheet completed for PRN medication given on 9/9/15 at 0900.

Patient #22's MR review revealed Interdisciplinary Master Treatment Plan is not signed by the Physician.

Patient #23's MR review revealed Informed Consent for Psychoactive Medication Form is incomplete; no date and no RN signature.
There is no daily PRN Management flowsheet completed for PRN medications given on 09/28/2015 at 2200 and 2320, 9/29/15 at 0915, 1250, 1630x2, 2220 and 2245 and 9/30/2015 at 0800, 0810, 1530, 1550, and 2100.

Patient #24's MR review revealed there is no daily PRN Management flowsheet completed for PRN medications given on 9/29/2014 at 1825, 1930 and 2220.

Patient #27's MR review revealed a group progress note dated 09/12/2015 for another patient in this patient's MR and the next group progress note dated 09/12/2015 without a patient identification label.

Patient #28's MR review revealed there is no daily PRN Management flowsheet completed for PRN medications given on 9/12/2015 at 2015, 9/13/2015 at 0745, 2210, and 9/14/2015 at 2015.

Based on documents reviewed and interview it was determined the facility staff failed to ensure the discharge planning for 1 of 32 patients, Patient #16 was adequate to assist in preventing readmission to the hospital.

The findings include:

On 10/1 and 2/15 during the review of QAPI (Quality Assessment and Performance Improvement) the medical record of Patient #16 was reviewed.
Patient #16 was admitted on 9/21/15 with the primary diagnosis of schizoaffective disorder, chronic with acute exacerbation. The physician's Psychiatric Evaluation notes that Patient #16 had been hospitalized at this facility in July 2015 and had previously been admitted several times to this facility as well as others in the community.

The Discharge Aftercare Plan was reviewed and the following was noted:
Discharge Living Arrangements: Home (Patient #16 was homeless). The Social Worker note dated 9/28/15 and timed 14:30 (2:30 P.M.) stated, "provided pt. w/ the number to Super 8 motel and to his payee so he can obtain the finances to pay for the hotel."
Aftercare Follow Up Level of Care: Outpatient; Appointment with Psychiatrist: Date of appointment: 10/19/15. There are no other appointments listed.
Safety Plan: Information provided; Suicide Prevention Materials, List of AA/NA/EA meetings, Alternative Housing List, Social Security/Social Services Numbers and Locations and NAMI.
There was no listing of medications or if Patient #16 had medications to take after discharge.

Patient #16's MR review revealed Admission Medication Reconciliation and Nursing Discharge Instruction form has no Physician Signature.
Interdisciplinary Master Treatment Plan is not signed by Physician.
Master Treatment Plan Update/Clinical Staffing Form revealed Nursing update and Psychiatrist update to be blank and not have Physician Signature.

The Director of RM/PI stated, "I think we could have done a better job of accurately completing the Aftercare Follow Up Level of Care."