HospitalInspections.org

Based on observation, record review and interview, the hospital failed to meet the requirements of the Condition of Participation for Patient Rights as evidenced by:

1) The hospital failed to ensure patients received care in a safe setting. This deficient practice is evidenced by failing
to ensure all patients were monitored as ordered by the physician which placed patients at risk for harm to self and others. Staff failed to observe patients as ordered by the physician on 09/26/17 at 1:26 p.m. for 15 patients (#1, #2, R2, R4, R5, R6, R8, R9, R10, R11, R12, R13, R14, R15, R16). The staff failed to maintain Patient #1 on VC as ordered by the physician and to monitor psychiatric patients every 15 minutes as ordered by the psychiatrist for 8 patients (#2, #4, R1, R2, R3, R4, R5, R6) on Q 15 minute observations and 1 patient (#1) with orders for VC as evidenced by observation of a hospital-provided video recording from a sample of 5 patients and 19 random patients. S18MHT failed to document Q 15 minute observations at 7:30 a.m., 7:45 a.m., and 8:00 a.m. on 09/28/17 for 8 patients assigned to him with physician orders for Q 15 minute observations (#1, R1, R2, R7, R8, R17, R18, R19). (see findings in tag A-0144).

2) Failing to ensure the milieu was free from ligature risks as evidenced by having hospital gowns with an approximate 8 inch tie on each side of the neck opening in Rooms "e", "h", and "i" (see findings A-0144).

An Immediate Jeopardy situation was identified on 09/27/17 at 4:30 p.m. and reported to S1CEO, S2HRA, S3DON, and S4LPN. The Immediate Jeopardy situation was a result of the hospital failing to ensure all patients were monitored as ordered by physician, including a patient admitted on suicide precautions and ordered to be on Visual Contact (policy defines line of sight as a staff member maintains the patient in his/her visual eye sight at all times), due to hearing voices commanding her to scratch herself and not being able to resist the commands to further injure herself. In addition, the hospital failed to ensure the environment was free from ligature risks. The failure to monitor patients as ordered and to provide a safe environment placed patients at risk for harm to self and others.

An acceptable plan to remove the Immediate Situation was presented on 09/28/17 at 4:00 p.m., and the Immediate Situation was lifted. The deficient practice remains at a Condition level.

3) Failing to ensure the milieu was free from safety risks as evidenced by having a wall-mounted dispenser of hand sanitizer (contained 70% Ethyl alcohol) in 2 hall locations that were accessible to patients and having a torn wedge cushion that presented a risk for suffocation from the accessible plastic/vinyl covering. (see findings in tag A-0144).

Based on observation, record review, and interview, the hospital failed to ensure each patient had the right to personal privacy as evidenced by S6MHT leaving an open binder that contained the"Observation Log" for each patient assigned to him on a chair in the hall outside the Day Room unattended while he went down the hall and entered the nursing station. The chair and open binder were accessible to any staff and patient who walked in the hall.
Findings:

Observation on 09/26/17 at 1:30 p.m. revealed S6MHT left an open binder that contained the"Observation Log" for each patient assigned to him on a chair in the hall outside the Day Room unattended while he went down the hall and entered the nursing station. Further observation revealed the "Observation Log" contained the patient's name, date of birth, insurance provider, level of observation ordered, and the sex of the patient.

Review of the policy titled "Patient Rights", presented as a current policy by S2HRA, revealed that patients have the right to confidentiality of all records, except those where otherwise provided by law.

In an interview on 09/26/17 at 2:00 p.m., S6MHT indicated the patients were in their rooms when he left the open binder on the chair unattended. When the surveyor asked him about the hospital's policy regarding protected health information, S6MHT again indicated the patients were asleep in their room.

In an interview on 09/26/17 at 2:25 p.m. with S1CEO, S2HRA, and S4LPN, S1CEO and S2HRA had no explanation when informed by the surveyor that S6MHT had been observed to leave an open binder with protected health information unattended on the chair in the hall.

Based on observations, record reviews, and interviews, the hospital failed to ensure each patient received care in a safe setting as evidenced by:
1) Failing to ensure all patients were monitored as ordered by the physician which placed patients at risk for harm to self and others. This was evidenced by failure of staff to observe patients as ordered by the physician on 09/26/17 at 1:26 p.m. for 15 patients (#1, #2, R2, R4, R5, R6, R8, R9, R10, R11, R12, R13, R14, R15, R16). The staff failed to maintain Patient #1 on VC as ordered by the physician and to monitor psychiatric patients every 15 minutes as ordered by the psychiatrist for 8 patients (#2, #4, R1, R2, R3, R4, R5, R6) on Q 15 minute observations and 1 patient (#1) with orders for VC as evidenced by observation of a hospital-provided video recording from a sample of 5 patients and 19 random patients. S18MHT failed to document Q 15 minute observations at 7:30 a.m., 7:45 a.m., and 8:00 a.m. on 09/28/17 for 8 patients assigned to him with physician orders for Q 15 minute observations (#1, R1, R2, R7, R8, R17, R18, R19).
2) Failing to ensure the milieu was free from ligature risks as evidenced by having hospital gowns with an approximate 8 inch tie on each side of the neck opening in Rooms "e", "h", and "i".
3) Failing to ensure the milieu was free from safety risks as evidenced by having a wall-mounted dispenser of hand sanitizer (contained 70% Ethyl alcohol) in 2 hall locations that were accessible to patients and having a torn wedge cushion that presented a risk for suffocation from the accessible plastic/vinyl covering.
Findings:

1) Failing to ensure all patients were monitored as ordered by the physician:
Observation on 09/26/17 at 1:26 p.m. revealed S5MHT was making observation rounds. Review of the observation records for Patients R2, R4, R5,R6, R9, R10, and R11, all ordered to be on Q 15 minute observation, revealed S5MHT had not documented an observation for 1:00 p.m. and 1:15 p.m. Further observation revealed S5MHT had not documented an observation at 1:15 p.m. for Patient #1 (ordered to be on VC) and Patients #2, R8, R12, R13, R14, R15, and R16.

Observation of a hospital-provided video recording of observations on the night shift (7:00 p.m. to 7:00 a.m.) of 09/26/17 from 10:15 p.m. to 11:31 p.m., with S2HRA, S3DON, and S4LPN present during the observation, revealed Patient #1, admitted on suicide precautions and ordered to be on VC due to hearing voices commanding her to scratch herself and not being able to resist commands to further injure herself, was not within a staff member's sight at all times on 09/26/17 for 1 hour from 10:31 p.m. to 11:31 p.m. Further observation revealed Patients #2, #4, R2, R3, R4, R5, and R6, all ordered to be observed Q 15 minutes, were not observed by staff for 43 minutes from 10:48 p.m. to 11:31 p.m. on 09/26/17. Patient R1, who was ordered to be observed Q 15 minutes, was not observed by staff for 1 hour and 13 minutes from 10:15 p.m. to 11:28 p.m. on 09/26/17.

Observation on 09/27/17 at 9:55 a.m. revealed S15MHT was seated in the Day Room observing her 8 assigned patients, one of whom was Patient #1 who was admitted on suicide precautions and ordered to be on VC due to hearing voices commanding her to scratch herself and not being able to resist commands to further injure herself. Further observation revealed Patient #1 told S15MHT that she was going to get water, and S15MHT allowed Patient #1 to leave unattended by staff to get water. Continuous observation revealed Patient #1 walked down the hall and turned the corner to enter the dining area where the water was located. Continuous observation revealed Patient #1 was not in sight of S15MHT or the surveyor when she (Patient #1) turned the corner.

Observation on 09/28/17 at 8:04 a.m. revealed S18MHT was making Q 15 minute rounds. Review of the patients' observation records assigned to him revealed the observation records of Patients #1, R1, R2, R7, R8, R17, R18, and R19 had no documented evidence that an observation was made at 7:30 a.m., 7:45 a.m., and 8:00 a.m.

Review of the "Observation Log" for Patients #2, #4, and R5 revealed S13MHT documented observations on 09/26/17 at 11:00 p.m., 11:15 p.m., and 11:30 p.m. when the hospital-provided video recording revealed no observations were made. Review of Patient #1's "Observation Log" revealed S13MHT documented observations at 10:30 p.m., 10:45 p.m., 11:00 p.m., 11:15 p.m., and 11:30 p.m. on 09/26/17 when the hospital-provided video recording revealed no observations were made. Review of Patient R1's "Observation Log" revealed S21MHT documented observations at 10:15 p.m., 10:30 p.m., 10:45 p.m., 11:00 p.m., and 11:15 p.m. on 09/26/17 when the hospital-provided video recording revealed no observations were made.

Review of the policy titled "Levels of Observation", presented as a current policy by S2HRA, revealed that the physician will give an order for required observation status. The charge nurse is responsible for assigning the staff members to perform designated observation status for each patient. Level 1 - Close Observation requires the patient to be visualized Q 15 minutes by a staff member during waking and sleeping hours and documented on the patient observation sheet. Level 2 - Direct Line of Sight Observation means staff visually observes the assigned patient by scanning the patient care area. A staff member may observe more than one patient at a time, but the patient must remain in the assigned staff member's visual eye sight at all times. When a patient on Line of Sight leaves the community area, the patient must continue to be visualized by a staff member at all times, including during shower and bathroom time. Level 2 patients cannot be in their bedrooms during waking hours and must be monitored have the door ajar when using bathrooms. During hours of sleep, staff members will be strategically placed outside assigned patient rooms to ensure patients are still monitored in direct line of sight. Level 3 - One to One means the assigned staff member must be within arm's length of the patient at all times, including being in the bathroom, showering, and walking out of group.

Review of the policy titled "Patient Rights", presented as a current policy by S2HRA, revealed that patients have the right to an environment that assures the patient's safety, health, and well-being delivered in a service area that adequately supports the program's treatment goals.

In an interview on 09/26/17 at 1:26 p.m., S5MHT indicated he was "keeping an eye on patients when the other MHT went to lunch." He further indicated he's supposed to monitor the patients Q 15 minutes regardless of what's going on. He confirmed Patients R2, R4, R5,R6, R9, R10, and R11 and Patients #2, R8, R12, R13, R14, R15, and R16 were not observed at the times listed above. He further indicated one MHT was at lunch, the other MHT was serving lunch, and he was observing patients in the dining room. He confirmed when patients left the dining room and went to their room, he couldn't leave the dining room to check on the patients in their room.

In an interview on 09/27/17 at 9:55 a.m., S15MHT confirmed she couldn't see Patient #1 when she (Patient #1) went around the corner to get water. When the surveyor asked what VC meant, she indicated it means that when the patient goes to her room, "we have to know where she is, have to follow her." She further indicated she has to do Q 15 minute checks when the patient is in the room. S15MHT confirmed Patient #1 was allowed in her room on the afternoon of 09/26/17 during rest time with the door closed, and no staff present with Patient #1 while she ordered to be on VC. S15MHT confirmed she was assigned to monitor patient #1 during the day shift on 09/26/17.

In an interview on 09/27/17 at 1:40 p.m., S2HRA confirmed S13MHT and S14MHT had worked the night shift on 09/26/17.

In an interview on 09/27/17 at 1:45 p.m., S4LPN confirmed the observations of the hospital-provided video recording of the night shift on 09/26/17 from 10:15 p.m. to 11:31 p.m.

In an interview on 09/28/17 at 8:04 a.m., S18MHT indicated he was told that the hospital was trying something new by having one MHT conduct the patient observations as ordered for all patients. During the interview S18MHT presented his assigned patients' "Observation Log" for review. When the review revealed that S18MHT had no documented evidence of observation of patients for 45 minutes, he indicated he had just gotten out of report and had to do environmental rounds. He further indicated he knew the patients' location, but he hadn't documented yet.

In an interview on 09/28/17 at 9:53 a.m. with S1CEO, S2HRA, and S4LPN, S2HRA indicated S18MHT had not been educated on the new process yet, and he should not have made the environmental rounds.

In a telephone interview on 09/28/17 at 11:00 a.m., S13MHT confirmed he worked the night shift on 09/26/17. He indicated he usually checks the patients in their rooms on the hall without a camera view. He further indicated he goes to the nurse's station and looks at the camera video view of patients whose rooms have a camera. S13MHT confirmed he didn't make observations Q 15 minutes on the night of 09/26/17. He further indicated he didn't know Patient #1 was on VC. He indicated he probably didn't pay close enough attention to her observation sheet. S13MHT confirmed he didn't have patient #1 on VC throughout the shift. S13MHT indicated he has worked at the hospital less than a month. He further indicated his orientation included a walk-through with another MHT showing him where everything was and worked a couple of shifts with other MHTs before he was allowed to work on his own.

2) Failing to ensure the milieu was free from ligature risks:
Observation on 09/26/17 at 12:30 p.m. during a tour of the psychiatric unit with S4LPN present revealed a hospital gown with an approximate 8 inch tie on each side of the neck opening in Rooms "e", "h", and "i" that presented a ligature risk.

In an interview on 09/26/17 at 12:30 p.m., S4LPN confirmed the ties on the hospital gowns were a ligature risk.

Observation on 09/28/17 at 1:10 p.m. revealed Patient R3 was in the seclusion room. Further observation revealed he had a pair of paper scrub pants with a sleep short over it that had ties attached to the short that approximately 6 inches long on each side of the waist that were tied together. This observation was confirmed by the MHT observing Patient R3 while in seclusion.

In an interview on 09/28/17 at 1:55 p.m., S2HRA confirmed the ties on Patient R3's sleep shorts were a ligature risk.

3) Failing to ensure the milieu was free from safety risks:
Observation on 09/26/17 at 12:30 p.m. during a tour of the psychiatric unit with S4LPN present revealed a wedge cushion on the shelf in Room "e" that had the plastic covering torn and separated from the foam. The accessible plastic covering presented a risk for suffocation. Patient #1, one of the patients assigned to this room was on suicide precautions and VC (that was not being implemented as noted above under part 1).

Observation on 09/26/17 at 12:50 p.m. during a tour of the psychiatric unit with S4LPN present revealed a hand sanitizer dispenser mounted on wall outside Room "c" and in the hall near the dining area, both areas accessible to patients. Observation of the label revealed the sanitizer contained 70% Ethyl Alcohol.

In an interview on 09/26/17 at 12:30 during the observation, S4LPN indicated the wedge cushion should not be in the room, and she didn't know if it was for a current patient in the room or for a previously discharged patient.

In an interview on 09/26/17 at 2:25 p.m. with S1CEO, S2HRA, and S4LPN present, when informed about the hand sanitizer containing 70% Ethyl Alcohol, S1CEO asked "what should it be?" When the surveyor informed S1CEO that handsanitizer that contained alcohol was a safety risk for psychiatric patients, S1CEO indicated they would have to remove it. S4LPN confirmed the wedge cushion found in Room "e" was used by a former patient who is no longer here.

Based on observations, record reviews, and interviews, the hospital failed to ensure a RN supervised and evaluated the nursing care for each patient as evidenced by:
1) The RN failed to ensure patients were observed by the MHTs as ordered by the physician as evidenced by failure of MHTs to observe patients as ordered by the physician on 09/26/17 at 1:26 p.m. for 15 patients (#1, #2, R2, R4, R5, R6, R8, R9, R10, R11, R12, R13, R14, R15, R16). The MHTs failed to maintain Patient #1 on VC as ordered by the physician and to monitor psychiatric patients every 15 minutes as ordered by the psychiatrist for 8 patients (#2, #4, R1, R2, R3, R4, R5, R6) on Q 15 minute observations and 1 patient (#1) with orders for VC as evidenced by observation of a hospital-provided video recording from a sample of 5 patients and 19 random patients. S18MHT failed to document Q 15 minute observations at 7:30 a.m., 7:45 a.m., and 8:00 a.m. on 09/28/17 for 8 patients assigned to him with physician orders for Q 15 minute observations (#1, R1, R2, R7, R8, R17, R18, R19).
2) The RN failed to ensure vital signs were assessed as ordered by the physician for patients being detoxed for 2 (#2, #5) of 2 patient records reviewed with detox orders from a total sample of 5 patients.
3) The RN failed to ensure patient wounds were assessed in accordance with hospital policy for 3 (#2, #3, #4) of 3 patient records reviewed with wounds from a total sample of 5 patients.
4) The RN failed to perform wound care as ordered by the physician for 2 (#3, #4) of 3 (#2, #3, #4) patient records reviewed with wound care orders from a total sample of 5 patients.
5) The RN failed to assess and document an assessment of a patient with a capillary blood glucose of 49 and ensure physician orders were implemented for 1 (#1) of 1 patient record reviewed with orders for capillary glucose monitoring from a total sample of 5 patients.
Findings:

1) The RN failed to ensure patients were observed by the MHTs as ordered by the physician:
Observation on 09/26/17 at 1:26 p.m. revealed S5MHT was making observation rounds. Review of the observation records for Patients R2, R4, R5,R6, R9, R10, and R11, all ordered to be on Q 15 minute observation, revealed S5MHT had not documented an observation for 1:00 p.m. and 1:15 p.m. Further observation revealed S5MHT had not documented an observation at 1:15 p.m. for Patient #1 (ordered to be on VC) and Patients #2, R8, R12, R13, R14, R15, and R16.

Observation of a hospital-provided video recording of observations on the night shift (7:00 p.m. to 7:00 a.m.) of 09/26/17 from 10:15 p.m. to 11:31 p.m., with S2HRA, S3DON, and S4LPN present during the observation, revealed Patient #1, admitted on suicide precautions and ordered to be on VC due to hearing voices commanding her to scratch herself and not being able to resist commands to further injure herself, was not within a staff member's sight at all times on 09/26/17 for 1 hour from 10:31 p.m. to 11:31 p.m. Further observation revealed Patients #2, #4, R2, R3, R4, R5, and R6, all ordered to be observed Q 15 minutes, were not observed by staff for 43 minutes from 10:48 p.m. to 11:31 p.m. on 09/26/17. Patient R1, who was ordered to be observed Q 15 minutes, was not observed by staff for 1 hour and 13 minutes from 10:15 p.m. to 11:28 p.m. on 09/26/17.

Observation on 09/27/17 at 9:55 a.m. revealed S15MHT was seated in the Day Room observing her 8 assigned patients, one of whom was Patient #1 who was admitted on suicide precautions and ordered to be on VC due to hearing voices commanding her to scratch herself and not being able to resist commands to further injure herself. Further observation revealed Patient #1 told S15MHT that she was going to get water, and S15MHT allowed Patient #1 to leave unattended by staff to get water. Continuous observation revealed Patient #1 walked down the hall and turned the corner to enter the dining area where the water was located. Continuous observation revealed Patient #1 was not in sight of S15MHT or the surveyor when she (Patient #1) turned the corner.

Observation on 09/28/17 at 8:04 a.m. revealed S18MHT was making Q 15 minute rounds. Review of the patients' observation records assigned to him revealed the observation records of Patients #1, R1, R2, R7, R8, R17, R18, and R19 had no documented evidence that an observation was made at 7:30 a.m., 7:45 a.m., and 8:00 a.m.

Review of the "Observation Log" for Patients #2, #4, and R5 revealed S13MHT documented observations on 09/26/17 at 11:00 p.m., 11:15 p.m., and 11:30 p.m. when the hospital-provided video recording revealed no observations were made. Review of Patient #1's "Observation Log" revealed S13MHT documented observations at 10:30 p.m., 10:45 p.m., 11:00 p.m., 11:15 p.m., and 11:30 p.m. on 09/26/17 when the hospital-provided video recording revealed no observations were made. Review of Patient R1's "Observation Log" revealed S21MHT documented observations at 10:15 p.m., 10:30 p.m., 10:45 p.m., 11:00 p.m., and 11:15 p.m. on 09/26/17 when the hospital-provided video recording revealed no observations were made.

Review of the policy titled "Levels of Observation", presented as a current policy by S2HRA, revealed that the physician will give an order for required observation status. The charge nurse is responsible for assigning the staff members to perform designated observation status for each patient. Level 1 - Close Observation requires the patient to be visualized Q 15 minutes by a staff member during waking and sleeping hours and documented on the patient observation sheet. Level 2 - Direct Line of Sight Observation means staff visually observes the assigned patient by scanning the patient care area. A staff member may observe more than one patient at a time, but the patient must remain in the assigned staff member's visual eye sight at all times. When a patient on Line of Sight leaves the community area, the patient must continue to be visualized by a staff member at all times, including during shower and bathroom time. Level 2 patients cannot be in their bedrooms during waking hours and must be monitored have the door ajar when using bathrooms. During hours of sleep, staff members will be strategically placed outside assigned patient rooms to ensure patients are still monitored in direct line of sight. Level 3 - One to One means the assigned staff member must be within arm's length of the patient at all times, including being in the bathroom, showering, and walking out of group.

Review of the policy titled "Patient Rights", presented as a current policy by S2HRA, revealed that patients have the right to an environment that assures the patient's safety, health, and well-being delivered in a service area that adequately supports the program's treatment goals.

In an interview on 09/26/17 at 1:26 p.m., S5MHT indicated he was "keeping an eye on patients when the other MHT went to lunch." He further indicated he's supposed to monitor the patients Q 15 minutes regardless of what's going on. He confirmed Patients R2, R4, R5,R6, R9, R10, and R11 and Patients #2, R8, R12, R13, R14, R15, and R16 were not observed at the times listed above. He further indicated one MHT was at lunch, the other MHT was serving lunch, and he was observing patients in the dining room. He confirmed when patients left the dining room and went to their room, he couldn't leave the dining room to check on the patients in their room.

In an interview on 09/27/17 at 9:55 a.m., S15MHT confirmed she couldn't see Patient #1 when she (Patient #1) went around the corner to get water. When the surveyor asked what VC meant, she indicated it means that when the patient goes to her room, "we have to know where she is, have to follow her." She further indicated she has to do Q 15 minute checks when the patient is in the room. S15MHT confirmed Patient #1 was allowed in her room on the afternoon of 09/26/17 during rest time with the door closed, and no staff present with Patient #1 while she ordered to be on VC. S15MHT confirmed she was assigned to monitor patient #1 during the day shift on 09/26/17.

In an interview on 09/27/17 at 1:40 p.m., S2HRA confirmed S13MHT and S14MHT had worked the night shift on 09/26/17.

In an interview on 09/27/17 at 1:45 p.m., S4LPN confirmed the observations of the hospital-provided video recording of the night shift on 09/26/17 from 10:15 p.m. to 11:31 p.m.

In an interview on 09/28/17 at 8:04 a.m., S18MHT indicated he was told that the hospital was trying something new by having one MHT conduct the patient observations as ordered for all patients. During the interview S18MHT presented his assigned patients' "Observation Log" for review. When the review revealed that S18MHT had no documented evidence of observation of patients for 45 minutes, he indicated he had just gotten out of report and had to de environmental rounds. He further indicated he knew the patients' location, but he hadn't documented yet.

In an interview o 09/28/17 at 9:53 a.m. with S1CEO, S2HRA, and S4LPN, S2HRA indicated S18MHT had not been educated on the new process yet, and he should not have made the environmental rounds.

In a telephone interview on 09/28/17 at 11:00 a.m., S13MHT confirmed he worked the night shift on 09/26/17. He indicated he usually checks the patients in their rooms on the hall without a camera view. He further indicated he goes to the nurse's station and looks at the camera video view of patients whose rooms have a camera. S13MHT confirmed he didn't make observations Q 15 minutes on the night of 09/26/17. He further indicated he didn't know Patient #1 was on VC. He indicated he probably didn't pay close enough attention to her observation sheet. S13MHT confirmed he didn't have patient #1 on VC throughout the shift. S13MHT indicated he has worked at the hospital less than a month. He further indicated his orientation included a walk-through with another MHT showing him where everything was and worked a couple of shifts with other MHTs before he was allowed to work on his own.

2) The RN failed to ensure vital signs were assessed as ordered by the physician for patients being detoxed:
Patient #2
Review of Patient #2's medical record revealed physician orders on 09/26/17 at 1:00 p.m. to assess vital signs every 4 hours for 3 days. Review of her "Graphic Sheet" revealed her vital signs were assessed at 8:00 a.m. and 8:00 p.m. on 09/26/17 (admitted at 9:25 a.m. on 09/26/17) and 8:00 a.m. and 8:00 p.m. on 09/27/17. There was no documented evidence that Patient #2's vital signs were assessed every 4 hours as ordered.

In an interview on 09/28/17 at 2:35 p.m., S20RN confirmed Patient #2's vital signs were not assessed every 4 hours as ordered.

Patient #5
Review of Patient #5's medical record revealed physician orders on 07/13/17 at 5:30 p.m. to assess vital signs every 4 hours for 3 days. Review of her "Vital Signs Flow sheet Q 4 Hours" revealed no documented evidence that her vital signs were assessed on 07/14/17 at 12:00 a.m. and 4:00 a.m. and on 07/16/17 at 4:00 a.m.

In an interview on 09/28/17 at 3:45 p.m. with S3DON and S4LPN present, S3DON confirmed Patient #5's vital signs were not assessed every 4 hours as ordered by the physician.

3) The RN failed to ensure patient wounds were assessed in accordance with hospital policy:
Review of the policy titled "Wound care", presented as a current policy by S2HRA, revealed that the RN will be responsible to assess the patient skin for alteration in skin integrity upon admission. The RN will describe the wound and document the type. location, size (length, width), amount of drainage if any, odor, and coloration of the wound. The RN will use the "Human" diagram to indicated the location of the wound(s) and document findings on the "Wound Care" nursing progress note along with the care provided. The RN will implement appropriate wound care management and treatment as ordered by the physician.

Patient #2
Review of Patient #2's "Wound Documentation Progress Sheet" documented on 09/26/17 at 9:45 a.m. revealed wounds to right lower abdomen and right upper thigh with measurements. There was no documented evidence of the type of wound, the presence or absence of drainage, and the color of the wound as required by policy.

In an interview on 09/28/17 at 2:35 p.m., S20RN indicated she didn't document the skin condition and surrounding tissue.

Patient #3
Review of Patient #3's "Wound Documentation Progress Sheet" documented on 07/14/17 revealed documentation of multiple abrasions to bilateral upper extremities, bilateral lower extremities, buttock, and back. There was no documented evidence of the measurement of each wound, the presence or absence of drainage, and the color of the wound and surrounding tissue.

In an interview on 09/28/17 at 8:57 a.m., S10RN confirmed she didn't document an assessment of Patient #3's wounds.

Patient #4
Review of Patient #4's medical record revealed pictures of sutures to the left chest wall, a right forearm healing wound, and wounds to the right thumb and right index finger. There was no documented evidence of the measurement of the excoriated skin to bilateral fingers, the presence or absence of drainage, and the color of the wound and surrounding tissue.

In an interview on 09/28/17 at 3:40 p.m., S3DON confirmed there was no assessment of Patient #4's wounds.

4) The RN failed to perform wound care as ordered by the physician:
Review of the policy titled "Wound care", presented as a current policy by S2HRA, revealed that the RN will implement appropriate wound care management and treatment as ordered by the physician.

Patient #3
Review of Patient #3's medical record revealed a physician's order on 07/16/17 (no documented evidence of the time that the telephone order was received) to clean the wounds on the buttock and left side of the body with Hydrogen Peroxide and apply Silvadene 1% cream to the wounds TID, and cover with gauze if needed for weeping wounds.

Review of Patient #3's MARs revealed no documented evidence wound care was performed as ordered on 07/21/17 at 1:00 p.m. and 9:00 p.m. and at 9:00 a.m. on 07/24/17.

In an interview on 09/28/17 at 8:57 a.m., after reviewing Patient #3's medical record, S10RN confirmed wound care was not performed as ordered.

Patient #4
Review of patient #4's medical record revealed he had sutures to the left chest and excoriated skin to the right thumb and right index finger, and a healing wound to the right forearm. Review of physician orders revealed no documented evidence of wound care orders for the skin excoriations and the treatment to be provided to the sutures.

In an interview on 09/28/17 at 3:40 p.m., S3DON confirmed no orders had been written by the physician or requested by the RN for treatment of Patient #4's wounds and sutures.

5) The RN failed to assess and document an assessment of a patient with a capillary blood glucose of 49 and ensure physician orders were implemented:
Review of Patient #1's medical record revealed a physician order on 09/22/17 at 2:56 a.m. for capillary blood glucose (BS) checks before meals and at bedtime. Further review revealed the sliding scale was as follows:
BS 0 - 60 - hypoglycemic treatment for BS less than 60 mg/dl (milligrams per deciliter): if patient can take food by mouth, give 15 grams of fast acting carbohydrate (4 oz. fruit juice/Non-diet soda, or 8 oz. non-fat milk); if patient cannot take food by mouth, give 1 mg Glucagon intramuscularly; call physician; check BS in 15 minutes and repeat above if blood glucose is less then 60 mg/dl.

Review of Patient #1's "Diabetic Record" revealed her BS on 09/23/17 at 6:00 a.m. was 49. Further review revealed a snack and juice were given with no documented evidence of the type of snack and amount of juice given to determine that it was 15 grams of fast acting carbohydrate as ordered by the physician. There was no documented evidence of an assessment of Patient #3 by a RN, a repeat of the BS in 15 minutes, and that the physician was notified.

In an interview on 09/28/17 at 3:20 p.m. with S3DON and S4LPN, S3DON offered no explanation for the LPN not informing the RN of the low BS with a subsequent assessment by the RN and implementation of the physician orders for low BS.

Based on record reviews and interview, the hospital failed to ensure the nursing staff developed and kept current a nursing care plan for each patient as evidenced by failure to include a nursing care plan for the identified needs of 1 (#3) of 5 sampled patients' records reviewed for s current nursing care plan from a total of 5 sampled patients.
Findings:

Review of Patient #3's "Multidisciplinary Integrated Master Treatment Plan" revealed pain and numerous wounds to the bilateral lower extremities and buttocks were identified on 07/16/17. Further review revealed no documented evidence that a nursing care plan was developed for pain and wounds that included short and long-term goals and interventions.

In an interview on 09/28/17 at 8:57 a.m., S10RN confirmed a nursing care plan was not developed for the identified problems of pain and wounds.

Based on record reviews and interview, the hospital failed to ensure the RN assigned the nursing care of each patient to other nursing personnel in accordance with the specialized qualifications and competence of the nursing staff available as evidenced by having no documented evidence of orientation to job duties and an evaluation of competence for 2 MHTs (S13MHT, S14MHT) of 5 MHT (S5MHT, S6MHT, S13MHT, S14MHT, S22MHT) personnel records reviewed for orientation and competency from a total of 6 personnel records reviewed.
Findings:

S13MHT
Review of S13MHT's job description revealed a minimum of 1 year recent experience on a medical surgical, skilled nursing, and/or psychiatric unit was required. Further review revealed S13MHT did not have prior health care experience when he was hired on 09/02/17. There was no documented evidence that he had been oriented to his job duties as a MHT and evaluated for competency prior to providing direct patient care.

S14MHT
Review of S14MHT's personnel file revealed she was hired on 09/22/17. Further review revealed no documented evidence that she was oriented to her specific job duties as a MHT and was evaluated for competency prior to providing direct patient care.

In an interview on 09/27/17 at 1:40 p.m., S2HRA confirmed S13MHT and S14MHT, both on duty on the night shift of 09/26/17, did not have orientation on conducting Q 15 minute observations, and they had not been evaluated for competency prior to providing direct patient care.

Based on records and interviews, the hospital failed to ensure drugs were administered in accordance with physician orders as evidenced by failure to have documented evidence that patients received medications as ordered by the physician for 2 (#1, #3) of 5 patient records reviewed for medication administration from a total sample of 5 patients.
Findings:

Review of the policy titled "Administration of Medication", presented as a current policy by S2HRA, revealed that drugs must be administered in response to an order from a practitioner.

Patient #1
Review of Patient #1's medical record revealed a physician order on 09/22/17 at 2:56 a.m. for the following: Novolog 20 units SubQ TID with meals; Lantus 20 units SubQ Q night at bedtime; check capillary blood glucose (BS) before meals and at bedtime. Further review revealed the sliding scale was as follows:
BS 0 - 60 - hypoglycemic treatment for BS less than 60 mg/dl (milligrams per deciliter): if patient can take food by mouth, give 15 grams of fast acting carbohydrate (4 oz. fruit juice/Non-diet soda, or 8 oz. non-fat milk); if patient cannot take food by mouth, give 1 mg Glucagon intramuscularly; call physician; check BS in 15 minutes and repeat above if blood glucose is less then 60 mg/dl.
BS 61-150 - no treatment
BS 151-200 - give 2 units Regular Insulin SubQ
BS 201-250 - give 4 units Regular Insulin SubQ
BS 251-300 - give 6 units Regular Insulin SubQ
BS 301-350 - give 8 units Regular Insulin SubQ
BS 351-400 - give 10 units Regular Insulin SubQ
BS greater than 400 - give 12 units Regular Insulin SubQ and notify the physician.

Review of Patient #1's "Diabetic Record" revealed she did not receive Regular Insulin SubQ as ordered on the following days and times:
09/23/17 at 6:00 a.m. - BS was 49; a snack and juice given (no documented evidence of type of snack and amount of juice given);
09/23/17 at 11:30 a.m. - BS 244; 9 units Humalog given rather than 4 units of Regular Insulin;
09/23/17 at 4:30 p.m. - BS 204; 9 units Humalog given rather than 4 units Regular Insulin;
09/24/17 at 11:30 a.m. - BS 202; 9 units Humalog given rather than 4 units Regular Insulin;
09/24/17 at 4:30 p.m. - BS 89/212 (repeat); 9 units Humalog given rather than 4 units Regular Insulin;
09/24/17 at 9:00 p.m. - BS 213; no insulin given when 4 units Regular Insulin should have been administered'
09/26/17 at 6:00 a.m. - BS 155; no insulin given while 2 units Regular Insulin should have been administered.

In an interview on 09/28/17 at 3:35 p.m. with S3DON and S4LPN, when informed of the above errors in insulin administration, S3DON offered no explanation.

Patient #3
Review of patient #3's medical record revealed a physician's order on 07/14/17 at 11:34 p.m. to continue Lexapro 40 mg orally daily. Further review revealed an order on 07/16/17 (no time documented by nurse receiving telephone order but signed off by nurse at 10:45 a.m. on 07/16/17) to clean wounds on the buttock and left side of the body with Hydrogen Peroxide TID and apply Silvadene 1% cream to wounds TID.

Review of Patient #3's MAR revealed wound care was not performed on 07/16/17 at 1:00 p.m. with a note of Hydrogen Peroxide and Silvadene not available. Further review revealed Lexapro was not administered on 07/24/17 at 9:00 a.m. with a note of Lexapro not given due to out of Pixis (medication administration device).

In a telephone interview on 09/28/17 at 10:25 a.m., S12RPh indicated Lexapro is a drug that should be in the med-dispense system. He further indicated the hospital/nurse is supposed to let the pharmacist know if a medication is not available. He indicated when the last Lexapro was administered, the nurse should have let the pharmacist know, so arrangements could be made to send more medication on the next delivery. S12RPH indicated of a medication is needed on the weekend, like Silvadene, the process is that the hospital staff faxes the order and calls the pharmacist on-call to notify him/her of the need. If the staff doesn't call and just faxes the order, the fax may not be seen and the drug may not be delivered until the next delivery, which is on Monday.

In an interview on 09/28/17 at 3:35 p.m. with S3DON and S4LPN, S3DON offered no further information related to the reason the Lexapro, Hydrogen Peroxide, and Silvadene were not available.

Based on record reviews and interviews, the hospital failed to ensure medical records contained a discharge summary documented by the physician or qualified practitioner who admitted the patient to the hospital or co-authenticated the discharge summary when documentation of the discharge summary was delegated to other qualified health care personnel, such as nurse practitioners and physician assistants. The documentation of discharge summaries were delegated to a non-qualified person for 2 (#3, #5) of 2 discharged patient records reviewed from a total sample of 5 patients.
Findings:

Review of the "Delineation of Privileges: Allied Health Personnel" revealed S2HRA had been privileged to dictate discharge summaries.

Patient #3
Review of Patient #3's "Discharge Summary" revealed she was discharged on 07/24/17. Further review revealed her discharge summary was dictated on 08/23/17 with a note of "Discharge Summary Written By: S2HRA." There was no documented evidence that S7Psych had signed the discharge summary as of the time that the medical record was reviewed on 09/26/17 at 3:00 p.m.

Patient #5
Review of Patient #5's "Discharge Summary" revealed she was discharged on 07/18/17. Further review revealed her discharge summary was dictated on 08/15/17 with a note of "Discharge Summary Written By: S2HRA." The discharge summary was signed by S7Psych with no documented evidence of the date and time she signed the discharge summary.

In an interview on 09/27/17 at 4:48 p.m., S7Psych confirmed S2HRA does her discharge summaries for her. When the federal regulation regarding documentation of a discharge summary was reviewed with S7Psych, she offered no comment.

In an interview on 09/28/17 at 8:35 a.m. with S1CEO and S2HRA, S1CEO indicated none of the physicians do their own discharge summaries. She further indicated S2HRA had been privileged to document the discharge summaries.

Based on observations, record reviews, and interviews, the hospital failed to meet the requirements of the Condition of Participation of Patient Rights as evidenced by:

1) The hospital failed to ensure patients received care in a safe setting. This deficient practice is evidenced by failing
to ensure all patients were monitored as ordered by the physician which placed patients at risk for harm to self and others. Staff failed to observe patients as ordered by the physician on 09/26/17 at 1:26 p.m. for 15 patients (#1, #2, R2, R4, R5, R6, R8, R9, R10, R11, R12, R13, R14, R15, R16). The staff failed to maintain Patient #1 on VC as ordered by the physician and to monitor psychiatric patients every 15 minutes as ordered by the psychiatrist for 8 patients (#2, #4, R1, R2, R3, R4, R5, R6) on Q 15 minute observations and 1 patient (#1) with orders for VC as evidenced by observation of a hospital-provided video recording from a sample of 5 patients and 19 random patients. S18MHT failed to document Q 15 minute observations at 7:30 a.m., 7:45 a.m., and 8:00 a.m. on 09/28/17 for 8 patients assigned to him with physician orders for Q 15 minute observations (#1, R1, R2, R7, R8, R17, R18, R19). (see findings in tag A-0144).

2) Failing to ensure the milieu was free from ligature risks as evidenced by having hospital gowns with an approximate 8 inch tie on each side of the neck opening in Rooms "e", "h", and "i" (see findings A-0144).

An Immediate Jeopardy situation was identified on 09/27/17 at 4:30 p.m. and reported to S1CEO, S2HRA, S3DON, and S4LPN. The Immediate Jeopardy situation was a result of the hospital failing to ensure all patients were monitored as ordered by physician, including a patient admitted on suicide precautions and ordered to be on Visual Contact (policy defines line of sight as a staff member maintains the patient in his/her visual eye sight at all times), due to hearing voices commanding her to scratch herself and not being able to resist the commands to further injure herself. In addition, the hospital failed to ensure the environment was free from ligature risks. The failure to monitor patients as ordered and to provide a safe environment placed patients at risk for harm to self and others.

An acceptable plan to remove the Immediate Situation was presented on 09/28/17 at 4:00 p.m., and the Immediate Situation was lifted. The deficient practice remains at a Condition level.

3) Failing to ensure the milieu was free from safety risks as evidenced by having a wall-mounted dispenser of hand sanitizer (contained 70% Ethyl alcohol) in 2 hall locations that were accessible to patients and having a torn wedge cushion that presented a risk for suffocation from the accessible plastic/vinyl covering. (see findings in tag A-0144).

Based on record reviews and interview, the hospital failed to ensure the psychiatric evaluation was countersigned by the physician when reviewed when the psychiatric evaluation was performed by a non-physician as evidenced by failure to have documented evidence that a physician reviewed and countersigned psychiatric evaluations performed by S8PhD for 3 (#3, #4, #5) of 5 patient psychiatric evaluations reviewed from a total sample of 5 patients.
Findings:

Patient #3
Review of Patient #3's psychiatric evaluation revealed it was performed on 07/15/17 at 10:15 a.m. by S8PhD. There was no documented evidence that S7Psych had reviewed the evaluation and countersigned it after review.

Patient #4
Review of Patient #4's psychiatric evaluation revealed it was performed on 09/23/17 by S8PhD. There was no documented evidence that S7Psych had reviewed the evaluation and countersigned it after review.

Patient #5
Review of Patient #5's psychiatric evaluation revealed it was performed on 07/13/17 at 12:00 p.m. by S8PhD. There was no documented evidence that S7Psych had reviewed the evaluation and countersigned it after review.

In an interview on 09/27/17 at 4:48 p.m., S7Psych confirmed that S8PhD did the psychiatric evaluation for the patients listed above. She indicated she usually signed the evaluations done by S8PhD, but she was behind on signing required documentation.

Based on record reviews and interview, the hospital failed to ensure psychosocial assessments were conducted within 72 hours of admission as required by hospital policy as evidenced by having a patient's psychosocial assessment conducted more than 82 hours after admit for 1 (#3) of 5 patient records reviewed for psychosocial assessments from a total sample of 5 patients.
Findings:

Review of the policy titled "Intake Assessment And treatment", presented as a current policy by S2HRA, revealed that psychosocial assessments were to be obtained within 72 hours of admission.

Review of patient #3's medical record revealed she was admitted on 07/14/17 at 10:14 p.m. Her psychosocial assessment was performed on 07/18/17 at 9:00 a.m. by S9LPC, more than 82 hours after admit.

In an interview on 09/28/17 at 12:20 p.m., S9LPC indicated she probably did the assessment late, because the weekend staff didn't do it. She indicated when a patient is admitted on a Friday, she leaves a list of patients who need a psychosocial assessment to be done over the weekend. She further indicated she probably didn't notice on Monday when she returned that it had not been done.