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5501 OLD YORK ROAD

PHILADELPHIA, PA 19141

PATIENT RIGHTS

Tag No.: A0115

Based on a systemic nature of standard-level deficiencies related to Patient Rights, it was determined the facility failed to substantially comply with this condition to ensure effective standards of operation for the provision of safe care for patients receiving patient care services at Albert Einstein Medical Center inpatient behavioral health units.

Findings include:

A review of facility policy "Patient Rights and Responsibilities" dated June 1, 2014, revealed "II. Policy. AEMC (Albert Einstein Medical Center) is committed to delivering quality medical care to our patients... The 'Patient rights and Responsibilities', endorsed by the administration and staff of this hospital, applies to all patients. ... III. Procedure. E. Responsibility. 1. It is the responsibility of every employee of AEMC and every member of the medical staff to uphold and adhere to the patient's rights." Further review revealed "Patient Rights & Responsibilities. ...Your rights ...As our patient, you have the right to safe, respectful, and dignified care at all times. You will receive services and care that are medically suggested and within the hospital's services, its stated mission, and required law and regulation."

The following standards were cited and show a systemic nature of noncompliance:

482.13(b)(1) Tag 0130: Patient Rights: Participation in Care Planning.
The information reviewed during the survey provided evidence that the facility failed to ensure patients were permitted to participate in the development of their treatment plan and failed ensure to ensure the treatment plan included interventions to address patient's history of suicide attempts in three of three medical records reviewed (MR1, MR9 and MR11).

482.13(c)(2) Tag 0144: Patient Rights: Care in a Safe Setting.
The information reviewed during the survey provided evidence that the facility failed to appropriately monitor behavioral health patients with a history of suicidal ideation to prevent self-harm in two of two medical records reviewed (MR1 and MR3); failed to appropriately monitor behavioral health patients with close observation orders in place (MR2); failed to safeguard patients by failing to remove sheets and blankets that pose a ligature risk; and failed to administer the Columbia Suicide Severity Rating Scale assessment tool every twelve hours in accordance with facility policy for six of six medical records reviewed (MR1, MR4, MR5, MR6, MR7 and MR10).

PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING

Tag No.: A0130

Based on review of facility policy, medical records (MR) and interview with staff (EMP), it was determined the facility failed to ensure patients in the behavioral health units participated in the development and implementation of the patient's Interdisciplinary Treatment Plan to address behavioral health problems for three of three medical records reviewed (MR1, MR9 and MR11).

Findings include:

A review on April 4, 2022, of facility policy "Inpatient Interdisciplinary Treatment Plan" last reviewed March 3, 2020, revealed "I. Policy. The care of all inpatients at the Einstein Behavioral Health is guided by the treatment plan, which is developed by the interdisciplinary treatment team. The person receiving care participates in the development of his/her plan. The treatment plan consists of the initial Comprehensive Master Treatment Plan and the Treatment Plan Review. ...The content of the plan is the joint responsibility of all members of the treatment team and the person receiving care. As the leader of the treatment team, the attending physician has ultimate responsibility to assure that a timely plan exists for all people in our care. ...III. Procedure. A. 4. Primary Problems are based on integration of information gathered during the initial assessment. All problems identified will be addressed in the treatment plan. Problems checked will be individualized with behaviors or contributing factors most relevant to the management and/or resolution of the problem. ...6. Interventions are multidisciplinary and describe the specific treatment and the frequency that it will be provided. Clinicians responsible for providing each intervention are identified. ...III. Procedure. A. 7. All members of the treatment team and the person in our care sign the treatment plan when it is completed. The person's signature documents his/her involvement in the development of the treatment plan. A member of the treatment team will serve as liaison for people that cannot participate in a group meeting... and confirm their access to the plan through the person's signature ...B. 5. Newly identified problems, goals and interventions are added as needed."

A review of MR1, admitted to a locked behavioral health unit on February 2, 2022, at 3:28 AM after a suicide attempt on February 1, 2022, revealed an Inpatient Psychiatry Interdisciplinary Treatment Plan dated February 2, 2022. Further review revealed no documentation on the Treatment Plan as to the "Primary Problems, Goals for Primary Problems, Interventions, and Clinician(s) Responsible for Interventions." Further review revealed no evidence of documentation in the section of the treatment plan "Suicidal/Self-injurious behaviors" despite the February 1, 2022, suicide attempt.
A review of MR1, revealed an " Inpatient Psychiatry Interdisciplinary Treatment Plan Review " dated February 9, 2022, revealed there was no documentation entered in the treatment plan sections titled "New Problems, Modified Interventions" related to "Suicidal/Self-injurious behaviors" or "Impulsive behavior without regard to consequence" despite MR1 having made a suicide attempt on February 3, 2022, and an attempted to elope from the hospital ED on February 3, 2022. Further review revealed no evidence of documentation that MR1 participated in the Interdisciplinary Treatment Plan Team Meeting nor had access to review and sign the treatment plan.
A review of MR9, admitted to a locked behavioral health unit January 9, 2022, for suicidal ideation revealed an "Inpatient Psychiatry Interdisciplinary Treatment Plan" dated January 9, 2022. Further review of the Treatment Plan Section "Suicidal/Self-injurious behaviors, revealed MR9 had been experiencing suicidal ideation for weeks and had an overdose several days prior to admission. Further review revealed there was no documentation of Goals, Interventions, or clinician(s) responsible for interventions related to "Suicidal/Self-injurious behaviors" identified on the Treatment Plan. Further review revealed "Refused" was documented on the Patient Signature line. No additional confirmation of MR9's participation in the Treatment Plan Team Meeting nor access to review and sign the treatment plan was documented.
A review of MR11, admitted to a locked behavioral health unit on May 30, 2021, for schizophrenia, revealed an "Inpatient Psychiatry Interdisciplinary Treatment Plan" dated June 2, 2021. Further review revealed there was no documentation on the Treatment Plan regarding the Long-Term Goal, Psychiatric Diagnosis, Substance Use Diagnosis, Other/Medical Diagnosis, Problems, Goals for Primary Problems, Interventions, and Clinician(s) Responsible for Interventions. Further review revealed there was no signatures on the Treatment Plan documenting the Physician, Nurse, Rehab Therapist, or MR11 had participated in the Treatment Plan Team meeting. Further review of the Inpatient Psychiatry Interdisciplinary Treatment Plan Review dated June 9, 2021, revealed the Patient Signature line was blank. No additional confirmation of MR11's participation in the Treatment Plan Team Meeting or assent to the treatment plan was documented. Further review of the Inpatient Psychiatry Interdisciplinary Treatment Plan Review dated June 16, 2021, revealed there was no signature on the Treatment Plan Review documenting the Case Manager or Rehab Therapist had participated in the Treatment Plan Team Meeting. Further review revealed "Refused to sign" was documented on the Patient Signature line. No additional confirmation of MR11's participation in the Treatment Plan Team Meeting nor access to review and sign the treatment plan was documented.
An interview conducted on April 4, 2022, at 2:58 PM with EMP5 confirmed the Interdisciplanry Treatment Plans for MR1 dated February 2, 2022, February 9, 2022, and February 15, 2022, was not completed according to the hospital's policy and did not include documentation of the Suicidal/Self-injurious behaviors, the suicide attempt on February 3, 2022, and the elopement attempt in the hospital ' s emergency department.
An interview conducted on April 5, 2022, at 10:09 AM with EMP22, a registered nurse, confirmed the Inpatient Psychiatry Interdisciplinary Treatment Plans should include information related to the patient's history including suicidal and self-injurious behaviors. EMP22 further stated the Inpatient Psychiatry Interdisciplinary Treatment Plan should include interventions for each problem identified and identify the responsible clinician.
A telephone interview conducted on April 5, 2022, at 10:40 AM with EMP27, a resident physician confirmed the psychiatry team does not hold specific "Treatment Team" meetings weekly to complete the Inpatient Psychiatry Interdisciplinary Treatment Plan. EMP27 stated "The process does not differ on the day of the treatment plan meeting."

A telephone interview conducted on April 5, 2022, at 11:42 AM with EMP4, an attending psychiatrist confirmed the psychiatry team does not routinely include patients in weekly Interdisciplinary Treatment Team meetings. EMP4 stated "The Treatment Plans should be updated weekly, but we do it with nursing report in the morning. Someone would take the plan/form separately to the patient. A physician might go to the patient with the plan/form if there needed to be an update. I'm not sure how nursing would include the patient. I document everything in my notes, I do not document on the weekly treatment form."

PATIENT RIGHTS: CARE IN SAFE SETTING

Tag No.: A0144

Based on observation, review of facility document, medical record (MR) and interview with staff (EMP), it was determined that the facility failed to ensure high professional standards were reviewed and maintained to ensure a safe patient care environment for patients on the Behavioral Health Units (Tower7 and Levy 9).

Findings include:

A review of the facility ' s " CORPORATE BYLAWS " dated July 25, 2019, revealed " ARTICLE III BOARD OF TRUSTEES Section 3: Responsibilities and Powers of the Board of Trustees. Subject to the ultimate control and standards provided for by the Member, and in compliance with all applicable laws and regulations, the responsibilities and powers of the Board of Trustees shall include:
1). A review by the survey team on April 4, 2022, of facility document "Reports of In-Patient Self-Harm Events" occurring between April 1, 2021- April 1, 2022, revealed three events of self-harm for MR1, MR2, MR3 and MR4 utilizing facility patient care items.

Review on April 4, 2022, of facility document "Incident Investigation/Timeline" for MR1 revealed February 3, 2022, at 3:45 PM attending physician addendum note: "Patient continues to endorse mood liability, impulsivity, emotional dysregulation, distress intolerance, and dysphoria ... Denies present SI (suicidal ideation) ... statement to fiancé. I will hurt myself if I stay in the hospital. February 3, 2022, at 4:04 PM, " Reports of In-Patient Self -Harm Events: Event Report, " Patient was found on the bathroom floor with a blanket tied around the neck. Patient had strong pulse, was breathing, but unresponsive. RRT (Rapid Response) called. Reddened area around neck. Taken to the ED for evaluation."

A review of MR3, admitted on July 8, 2021, for depression was admitted to a locked behavioral health unit. A review of facility document " Reports of In-Patient Self-Harm Events " incident dated July 9, 2021, revealed " BHA (Behavioral Health Associate) found patient (MR3) with gowns tied to patient neck and gowns tied to the shower, patient sitting on the toilet tilting forward, patient ringing the call bell from the toilet. Patient had gowns removed from neck, MD (medical doctor) made aware and assessed by MD and RN (registered nurse). "

A review of MR4, admitted on September 14, 2020, through May 5, 2021, for schizophrenia was admitted to a locked behavioral health unit. A review of facility document " Reports of In-Patient Self-Harm Events " revealed an incident dated March 2, 2021, " Staff member reported PRS (patient) had reddened mark around the neck and stated, " I put a gown around my neck " .

An interview conducted on April 5, 2022, at 1:00 PM confirmed the incidents for MR1, MR3 and MR4 detailed in the facility document " Reports of In-Patient Self-Harm Events " .

2) An observation tour conducted on April 4, 2022, at 1:38 PM with EMP3 on Tower 7 in room 7006 revealed one fitted sheet and one flat sheet on each bed. An additional set of sheets was noted in the cubby storage shelf by the door of room 7006.

An observation tour conducted on April 4, 2022, at 1:27 PM with EMP3 and EMP5 on Tower 7 in room 7003 revealed two beds made up with one fitted sheet, one flat sheet, one blanket. Further observation revealed a blanket on the floor outside the shower.

An observation tour conducted on April 4, 2022, at 1:55 PM with EMP3 and EMP5 on Tower 7 in room 7009 revealed there was three blankets on each bed. Further observation revealed sheets and blankets was draped over the heating/air conditioning unit under the window.

An observation tour conducted on April 4, 2022, at 2:00 PM with EMP3 and EMP5 on Tower 7 in room 7008 revealed extra linen piled on the floor.

An observation tour conducted on April 4, 2022, at 2:21 PM with EMP3 and EMP5 on Levy 9 in room 9201 revealed an extra blanket on a shelf in the room.

An interview conducted on April 4, 2022, at 2:12 PM with EMP3 and EMP5 confirmed that the patient rooms on Levy 9 and Tower 7 had extra sheets and blankets stored in the patient rooms. EMP3 further confirmed there was no system in place to determine how much linen was allowed in each room.
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Based on a review of facility policy, medical record review (MR), observation and interview with staff (EMP), it was determined the facility failed to provide " Close Observation " to behavioral health patients as ordered by the physician (MR2).

Findings include:

A review of facility policy "6.31 Observation," undated, revealed "Policy. Close observation will be implemented and maintained when it is determined that a person requires this level of observation to maintain a safe therapeutic environment. Definitions: ...B. 1:1 Eyesight: The patient will be observed continuously by nursing staff. A ratio of one staff per patient must be maintained. A. The person must always be in direct view of the assigned staff member. No barriers to vision can be between the person and assigned staff member at any time, including sleeping, or using the bathroom."

A review on April 4, 2022, of MR2, admitted on March 31, 2022, for schizophrenia to Tower 7, a locked behavioral health unit room 7021 revealed a physician ' s order dated April 1, 2022, for "Close Observation/Eyesight." Further review of the physician ' s order revealed no documentation of modification of the physician's order to allow MR2 to use the bathroom without continuous visual observation.
An observation on April 4, 2022, at 1:39 PM with EMP5 on Tower 7 outside room 7020 revealed four Behavioral Health Associates (BHA) gathered in the hallway. Further observation revealed EMP19, a BHA assigned to maintain Close Observation/Eyesight for MR2 in room 7020, was seated outside MR2's room facing the hallway engaged in conversation with peers and was not actively observing MR2.

An observation on April 4, 2022, at 1:46 PM with EMP3 on Tower 7 outside room 7020 revealed EMP19 was seated in a chair at the doorway entrance to the room of MR2 with the door open, providing Close Observation/Eyesight Observation of MR2. Further observation revealed the open door blocked visualization into the bathroom where MR2 was located. EMP19 did not readjust the seated position to ensure 1:1 Eyesight of MR2 in the bathroom.

An observation on April 4, 2022, at 2:01 PM with EMP3 and EMP5 on Tower 7 outside room 7020 revealed EMP20 was seated in a chair at the doorway entrance to the room of MR2 with the door open, providing Close Observation/Eyesight Observation of MR2. Further observation revealed the open door blocked visualization into the bathroom where MR2 was located.

An interview conducted on April 4, 2022, at 2:05 PM with EMP5 confirmed EMP19 was assigned to provide Close Observation/Eyesight Observation of MR2. EMP5 further confirmed EMP19 was seated outside room 7020 facing the hallway, engaged in conversation with other BHAs and was not actively observing MR2.

An interview conducted on April 4, 2022, at 2:27 PM with EMP3 confirmed EMP19 and EMP20 was seated at the doorway to room 7020 and could not visualize MR2 while in the bathroom. EMP3 stated "The order for the one to one will say 'eyesight' for aggression. If you take it literally from the policy, then yes, we should have eyesight on the patient (MR2), but we have to take a more practical approach with this patient."
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2) Based on a review of facility policy, medical record review (MR) and interview with staff (EMP), it was determined the facility failed to administer the Columbia Suicide Severity Risk Assessment tool every twelve hours in accordance with facility policy in six of six medical records (MR1, MR4, MR5, MR6, MR7 and MR10).

Findings include:

A review of facility policy "CSSR-S (Columbia Suicide Severity Rating Scale) Policy for Inpatient Behavioral Health Units" last reviewed March 3, 2020, revealed "I. Purpose: To provide a mechanism to screen and care for the Persons Receiving Services (PRS) who is experiencing suicidal (harm to self) thoughts and/or actions in behavioral health units... III. Policy Statement. Suicidal ideation and/or actions require specialized assessment and treatment interventions. All PRSs admitted to an inpatient behavioral health unit will be screened for risk of suicide so that appropriate safety measures can be implemented. V. Procedure. ...C. Documentation: 1. Screening of the PRSs suicide risk level through the C-SSRS shall be documented by the nurse in the assessment completed by the nurse on admission, q (every) 12 hours, and Depart (discharge)."

A review of MR1, admitted to a locked behavioral health unit on February 2, 2022, through February 17, 2022, after a suicide attempt on February 1, 2022, revealed the Columbia Suicide Severity Risk Score (C-SSRS) assessments was performed once on February 2, 2022, February 5, 2022, February 6, 2022, February 7, 2022, February 8, 2022, February 10, 2022, February 11, 2022, February 13, 2022, and February 14, 2022, and was not performed every 12 hours in accordance with facility ' s policy.
A review of MR4, admitted for schizophrenia September 14, 2020, through May 5, 2021, revealed the Columbia Suicide Severity Risk Score (C-SSRS) assessments was performed once on February 25, 2021, February 26, 2021, February 27, 2021, February 28, 2021, March 1, 2021, and March 2, 2021, and was not performed every 12 hours in accordance with facility ' s policy.

A review of MR5, admitted on March 1, 2021, through April 22, 2021, for chronic schizophrenia and auditory hallucinations of self-harm revealed the Columbia Suicide Severity Risk Score (C-SSRS) assessments was performed once on March 2, 2021, March 4, 2021, March 5, 2021, March 6, 2021, March 7, 2021, March 8, 2021, March 9, 2021, March 10, 2021, March 11, 2021, March 12, 2021, March 27, 2021, March 30, 2021, and April 4, 2021, and was not performed every 12 hours in accordance with facility policy.

A review of MR6, admitted on November 10, 2021, through November 17, 2021, for bipolar disorder with history of suicidal ideation revealed the Columbia Suicide Severity Risk Score (C-SSRS) assessments was performed once on November 11, 2021, November 12, 2021, November 16, 2021, and November 17, 2021, and was not performed every 12 hours in accordance with facility policy.

A review of MR7, admitted on December 5, 2021, through December 10, 2021, for anxiety, depression, bipolar disorder with history of suicidal ideation revealed the Columbia Suicide Severity Risk Score (C-SSRS) assessments was performed once on December 7, 2021, and December 8, 2021, and was not performed every 12 hours in accordance with facility policy.

A review of MR10, admitted on January 21, 2022, through January 25, 2022, for suicidal ideation, revealed the Columbia Suicide Severity Risk Score (C-SSRS) assessments was performed once on January 22, 2022, January 23, 2022, and January 24, 2022, and was not performed every 12 hours in accordance with facility policy.

An interview conducted on April 4, 2022, at 2:58 PM with EMP5 confirmed the Columbia Suicide Severity Risk Score (C-SSRS) assessments to ensure appropriate safety measures was implemented was not documented every 12 hours in accordance with the policy in MR1, MR4, MR5, MR6, MR7 and MR10.

COVID-19 Vaccination of Facility Staff

Tag No.: A0792

Based on review of facility policy, documents and interview with staff (EMP), it was determined that the facility failed to ensure all employees and non-employee workers were fully vaccinated for COVID-19 as evident by the facility's failure to confirm the vaccine manufacturer and dates of vaccine administration for 36 self-reported attestations of staff members for COVID-19 vaccination compliance and failure to ensure the vaccine administration status for an employee (EMP15) was completed according to the manufacturer's vaccine administration requirement.

Findings include:

Review of faciliy policy" "Mandatory Vaccination/Testing" dated August 15, 2021, revealed "Einstein Healthcare Network ("Einstein") is committed to providing a safe environment for patients, families, employees, non-employed workers...and visitors. Einstein believes requiring vaccinations/testing for certain diseases is consistent with our Mission and Code of Conduct. To that end, Einstein requires all employees and non-employed [sic] workers to be vaccinated/tested per medical guidelines and recommendations."

1). A review of facility documentation received on May 13, 2022, from EMP1 revealed thirty-six staff members self-reported receiving the COVID-19 vaccine and were listed as compliant with the vaccine requirement. Further review revealed the facility failed to obtain the name of the vaccine manufacture and the dates of vaccination(s) for the self-reported attestations.

A telephone conversation with EMP1 on May 13, 2022, at 8:17 AM confirmed the facility had not confirmed the vaccine manufacturer and dates of vaccination for the thirty-six staff members that self-reported vaccine status and were listed as "compliant, self-reported".

2). A review of facility documentation received on May 13, 2022, from EMP1 revealed EMP15, a registered nurse, Main Hospital Campus received the first dose of the Moderna vaccine on January 7, 2022, and as of May 13, 2022, EMP15 had not received the second dose of the Moderna vaccine.

A telephone conversation conducted with EMP1 on May 13, 2022, at 8:17 AM confirmed that EMP15 had not completed the 2nd dose of the Moderna vaccination series and continued to be actively employed at the hospital. EMP1 confirmed the facility was not compliant with the facility's policy.