HospitalInspections.org

IMMEDIATE JEOPARDY

Based on observations, record reviews, and staff interviews, the Hospital Governing Body failed to effectively carry out its responsibilities to provide a safe, hazard-free, environment for Patient #16, and for each Patient in the Hospital. Conditional Level (High Likelihood to Cause Harm/Widespread) deficiencies were identified on 4/5/17 by an accrediting agency in the area of Physical Environment/Environment of Care. However, the Hospital failed to address these deficiencies in a timely manner. Medical Staff contracted by the Hospital failed to carry out their duties of assessing, evaluating, and documenting a Patients' risk for committing suicide in accordance with the Hospital Policy.

Findings included:

1. The Governing Body failed to ensure that the medical staff was accountable for the quality of care provided to patients. The contracted Medical Staff had failed to comply with the requirement to complete a Suicide Risk Assessment, as required for each patient admitted to the IPU, even after the suicide attempt and death of Patient #16 on 4/26/17 and notification from the GB.

Refer to A-049, Condition of Participation:

2. The Governing Body failed to ensure that the services performed under a contract are provided in a safe and effective manner in regards to Physician Services. review of documentation and interviews with the GB indicated that the contracted physician services were not performing "Physician comprehensive assessment, admission psychiatric assessment and treatment plans were not being completed within the required timeframes. Many of them all have areas that are not being completed at all." This included the requirement to do suicide risk assessments. A patient admitted with suicide attempts attempted suicide 2 day after admission and died 2 days later after the physician said he/she denied suicidal thoughts and did not put the patient on suicide precautions.

Refer to A-084 and A-144

3. ,The Governing Body failed to develop, implement and maintain an effective QAPI (Quality Assessment and Performance Improvement) Program that evaluated an acute patient event (hanging) to put an effective action plan in place to prevent such events from occurring again and to mitigate environmental hazards (ligature risk points) that threatened the safety of all patients when identified on a survey on 4/5/17.

Refer to A-0700,


4. The Governing Body failed to maintain a physical environment that promoted the safety of all patients and protected all patients from potential harm. One patient (#16) was able to hang him/herself on one of the identified ligature risk points in the environment that had not been mitigated since 4/5/2017.

Refer to A-0115, A-0144, A-0700.

Based on record review and interview, the Governing Body failed to ensure that the medical staff was accountable for the quality of care provided to patients. Findings included:

An accrediting agency survey was conducted on 4/5/17. The results of that survey identified non-compliance by the medical staff in completing various patient assessments to include: physician comprehensive assessments, admission psychiatric assessments, and patient treatment plans that were not being completed according to the Hospital policy.

A letter from the Chairman of the Hospital GB to the Medical Staff Contractor, dated 5/9/17, indicated that "Physician comprehensive assessment, admission psychiatric assessment and treatment plans were not being completed within the required timeframes. Many of them all have areas that are not being completed at all."

In the letter, the Chairman of the GB indicated to the contracted Medical Staff administration a concern that the accrediting agency would be returning for a follow-up survey, the Hospital had admitted 12 patients since the accrediting agency left on 4/5/17, and "thus far and despite daily reminders about what the physicians needed to complete, all 12 records remain out of compliance."

The letter further indicated, "As mitigation to our inpatient ligature risk identified by (accrediting agency), we have asked our Physicians to complete a Suicide Risk Assessment, particularly for the risk of hanging. Thus far the physicians have refused to complete them."

Interview with the Hospital Director on 5/19/17 at 8:20 A.M., said that on 4/26/17, on the IPU, Patient #16 attempted suicide by hanging, was transported by EMS to a local Hospital and died two days later.

The Hospital Director also said that the contracted Medical Staff had failed to comply with the requirement to complete a Suicide Risk Assessment, as required for each patient admitted to the IPU, even after the suicide attempt and death of Patient #16 on 4/26/17.

Based on document review and staff interview, the Hospital failed to ensure that the services performed under a contract are provided in a safe and effective manner in regards to Physician Services. Findings included:

According to a letter dated 5/9/17, sent by the Chairman of the Governing Body (GB) to the agency that provided contracted Physician Services, concerns were addressed regarding a number of requirements that were found to be out of compliance in a recent survey by another accrediting agency. The letter indicated that "Physician comprehensive assessment, admission psychiatric assessment and treatment plans were not being completed within the required timeframes. Many of them all have areas that are not being completed at all."

The Chairman of the GB indicated a concern that the accrediting agency would be returning for an additional visit, the Hospital had admitted 12 patients since the accrediting agency left, and "thus far and despite daily reminders about what the physicians needed to complete, all 12 records remain out of compliance."

The letter further indicated, "As mitigation to our inpatient ligature risk identified by (accrediting agency), we have asked our Physicians to complete a Suicide Risk Assessment, particularly for the risk of hanging. Thus far the physicians have refused to complete them."

Interview with the Hospital Director on 5/19/17 at 8:20 A.M., said that on 4/26/17, on the IPU, Patient #16 attempted suicide by hanging, was transported by EMS to an area Hospital and died two days later.

The Hospital Director also said that the contracted Physicians had failed to comply with the requirement to complete a Suicide Risk Assessment for each patient admitted to the IPU, necessitating a letter from the Chairman of the GB to the Contracted Service Provider.

Immediate Jeopardy

The Condition of Patient Rights is not met. The Hospital's failed to protect and ensure the each patient's right to receive care in a safe environment, for 2 patients (#5 and #16) of 19 clinical records reviewed.

Findings include:

1. For Patient #16, the Hospital failed to ensure the Patient received appropriate care for preventing suicide and failed to properly conduct 15 minute checks, resulting in 1 patient's (#16) suicide attempt, which resulted in eventual death.

2. For Patient #5, the Hospital failed to ensure that each patient's right to received care in a safe environment following each of these sampled patients expressing and threatening to harm self and/or others.

3. The Hospital failed to ensure that the patient's physical environment was safe from ligature risks (potential hanging sites) for patients that were at risk for suicide, despite the Hospital being informed on 4/5/17, by another surveying agency that the physical environment posed a high risk to patients for ligature/hanging. Hospital staff failed to properly conduct safety checks, which lead to 1 patient (#16) being able to hang him/herself in an area identify as a ligature risk point. The patient died of injuries from the hanging.

See related deficiencies A-0114, and A-0700.

Immediate Jeopardy.

Based on observation, record review, documentation review and staff interviews, the Hospital failed to maintain patient safety and failed to ensure that each patient received care in a safe environment, the Hospital failed to ensure that each patient was provided appropriate monitoring for self harm and/or suicide precautions and failed to properly conduct safety checks resulting in 1 patient's suicide attempt (#16) which resulted in the patient's death and for 1 other patient (#5) of 19 clinical records reviewed.

Findings included:

1. During the initial tour of the Hospital's Inpatient Unit (IPU), on 5/15/17 at 10:30 A.M., the Surveyors observed that the unit had environmental hazards that posed a safety risk for patients. The environmental hazards observed included door knobs, door closures, door hinges, and multiple areas noted that could be used by patients who were at risk of harming self or others. Many of the environmental observations posed a risk for ligature/hanging.

On 5/16/17 at 11:30 A.M., an extensive environmental patient safety tour was completed with the Inpatient Unit's (IPU) Supervisor. (See A 0700.)

During the tour, the environmental hazards were discussed with the Unit's Supervisor. The Supervisor said that the Hospital had recently been surveyed by another accrediting agency on 4/5/17. The Supervisor said the survey agency had informed the Hospital that there were potential ligature risk points throughout the inpatient behavioral health unit. She said that the Hospital had taken action shortly after the survey on 4/5/17. The Supervisor said that many of the ligature risk point areas required construction, so the Hospital's immediate plan to mitigate the risk had been to place all ligature risk points/areas and all patients on 5 minute face to face checks and the hospital had restricted the use of 2 bathrooms and a sensory room.

The Supervisor said that several weeks after the survey, the Administration staff had changed the checks from 5 minute to 15 minutes for Patients and ordered the staff to continue to monitor the ligature risk points every 5 minute checks. She said the day after the change in monitoring of Patients (4/25/17) to 15 minutes, a Patient (#16) hung him/herself in a bathroom stall (and eventually died). The Supervisor said since the event, the Hospital staff had resumed 5 minute checks of all Patients and all ligature risk points. The Supervisor said that the bathroom had been identified as having ligature risk points, but said that the accrediting agency had not identified the bathroom stall knob used by the Patient as a ligature risk point. The Surveyor asked if the Supervisor and her staff had a comprehensive list of the ligature risk points that staff were monitoring every 5 minutes and she said no. The Supervisor said that 2 staff were assigned the monitoring of the Patients and the ligature risk points and the staff carried a clip board to record their rounds/observations.

2. For Patient #16, the Hospital failed to ensure the Patient received a comprehensive assessment for suicide risk and failed to properly conduct 15 minute checks, resulting in an attempted suicide which ended in death.

Patient #16 was admitted on 4/2017, with diagnosis that included schizoaffective disorder, depression and acute suicide attempts.

According to the medical record, Patient #16 was brought to the emergency room on 4/22/17, after being found sitting in a car in a parking lot with a hose attached to the exhaust into the car window as a suicide attempt. Emergency room records indicated the patient was depressed and he/she had a history of other prior significant suicide attempts that included an attempt to cut his/her throat with a razor blade the morning of the asphyxiation attempt. Records indicated that the Patient had a long superficial laceration to the right side of his/her neck.

The emergency room records indicated the Patient was considered a high suicide risk and was placed on observation while the hospital searched for a psychiatric bed. According to the periodic nursing assessment, while under direct observation, the Patient attempted to wrap the string that was attached to his/her glasses around his/her neck. The hospital emergency staff increased the Patient's level of supervision as he/she continued to attempt self harm. The Patient attempted to pull the wires from the television and the nursing staff had to inform the Patient numerous times to remove the linens from around his/her neck. The Patient had remained on a face to face safety watch until his/her transfer for inpatient care on 4/24/17.

Review of the Hospital Risk Assessment Policy for admission, dated 5/29/14, indicated that Patient's who were actively suicidal would not be admitted to the Hospital.

Review of the Admission Nursing Assessment dated 4/24/17 at 5:30 P.M., indicated the Patient had been admitted after being cleared medically and assessed by a crisis team for suicide. The nursing assessment failed to include the information that the Patient had been suicidal while under direct supervision in the emergency room. The assessment indicated the Patient stated he/she no longer felt suicidal, though appeared preoccupied, guarded, had a flat affect, stated he/she felt safe at the time of the assessment, but admitted to feeling paranoid.

According to the Admission Psychiatric Assessment, dated 4/24/17 at 8:00 P.M. and the Comprehensive Psychiatric Evaluation signed on 4/25/17 at 10:00 A.M., the Psychiatrist reiterated the hospital admission record of the events prior to the hospital transfer, which indicated the Patient was trying to asphyxiate him/herself with carbon monoxide using the vehicle exhaust. The assessment indicated the Patient's attempt at suicide was because of depression, but had no clear precipitant to this acute worsening of his/her mood that resulted in the suicide attempt. The Psychiatrist indicated the Patient had a history of past suicide attempts and denied suicidal ideation, homicidal ideation, or violent ideation and the Patient was hopeful that he/she would not have to stay at the Facility very long.

The Psychiatrist's plan of care listed on the Admission Psychiatric Assessment included the following generic interventions:

-Admit to Inpatient Unit
-Continue Current meds
-info (information) from family (pt (patient) will allow staff to speak with his/her children)
-info (information from Outpt (outpatient ) provider
-Monitor
-Med (medication) adjustments as necessary
-Regular diet
-FSBSs (fingerstick blood sugars)

Review of the physician orders indicated that the Patient be monitored on close safety checks.

Per Hospital policy and explained by the Hospital Staff, a comprehensive crisis evaluation is completed on all Patients. The physician orders the frequency of the Safety Checks by the Patient's clinical situation. The nursing staff may increase the frequency of the Safety Checks as the situation warrants and a physician's order is needed to decrease the Patient's level of supervision (Safety Checks). The Hospital policy is for all Patient's to be monitored on 15 minute visual checks unless otherwise assessed. The Staff said that Close Safety Checks were consider the standard and equaled 15 minute face to face checks. For a Patient, who was deemed suicidal and/or requiring 5 minutes checks or constant 1 to 1, the policy stipulates that the Hospital has to assign a staff member to visually observe the Patient at risk.

For Patient #16, the level of supervision, ordered by the physician, on admission was for 15 minute Safety Checks. However, due to the potential risk of harm from the identified ligature risk points in the IPU, identified on 4/5/17, and the Hospital's immediate action plan to mitigate the risk of harm from hanging and or asphyxiation, Patient #16's Safety Checks were being conducted every 5 minutes beginning on 4/24/17, in accordance with the Hospital's action plan to the 4/5/17 survey. The 5 minute checks were conducted by 2 staff members that were assigned each shift to monitor the movement of 16 patients and all ligature risk points within the IPU.

On 4/25/17 at 3:45 P.M., the Social Worker completed a Social Service Assessment and History. The assessment included the Patient's acute suicidal behavior prior to his/her transfer and while awaiting placement in the emergency room. The Patient told the Social Worker that he/she felt something bad was going to happen and said he/she was currently having visual and auditory hallucinations. The Social Worker indicated the Patient was denying suicide but had made attempt today in the hospital (was actively suicidal). Her recommendations included to reassess "upon return."

Review of the clinical record shift notes, dated 4/24/17 and 4/25/17 indicated the Patient was isolative, but had participated in the initial Treatment Team Meeting. The Patient was described as soft spoken, cooperative and hopeful for a short stay. The Patient was observed pacing the unit, was encouraged to inform staff if and when feels unsafe and that 5 minute Safety Checks were being completed.

Although, there was no information in the Patient's clinical record indicating a change, the Supervisor had said on 5/16/17 at 11:30 A.M., that the 5 minute ligature and patient safety checks were changed on 4/25/17. She said that the Staff started conducting Safety checks for ligature risk points every 5 minutes and 15 minutes for all patients which included Patient #16 beginning on 4/25/17. The Supervisor said the decision had been made by the Director of Nursing (DON).

On 4/26/17 at 9:48 A.M., the Nurse's note indicated the Nurse found the Patient in the male bathroom stall, kneeling in the stall with his/her head against the door/wall with a ligature tied around his/her neck and attached to the bathroom stall latch.

Staff performed emergency care and called a code blue which brought emergency equipment and staff to the room. EMS was summoned to the hospital. The Patient was transported to a local hospital at 10:20 A.M. and died in the intensive care unit when taken off life support two days later.

A physician's note dated 4/26/17, indicated that the Patient was discovered in the toilet stall unconscious and with a cord (thought to be from a "hoodie" - sweatshirt) tied to the stall latch and round his/her neck. The note indicated the Patient was on 5 minute Safety Checks (however it was later determined the Patient was not on 5 minute checks) and had been seen in his/her room 5 minutes earlier. The physician indicated that staff had described the Patient as being quiet, pleasant and had denied suicide ideation on evaluation.

During interview on 5/22/17 at 1:40 P.M., the Patient's psychiatrist, he said that he had presumed the Patient was stable on admission to the IPU. He said he knew the Patient was depressed and said he was focused on getting the Patient on antidepressant medication. He said that he had not known the Patient was actively suicidal in the emergency room, but would not explain how he had known the information (as it was in the discharge records from the hospital). The Psychiatrist said that he was surprised that the Patient had committed suicide inpatient. He said most patient say they want to kill themselves to get admitted and to get discharged say they won't. He said he would have expected Patient #16 to have attempted suicide after discharge.

Review of the Hospital's internal incident reports indicated (dated 4/28/17) "the Patient attempted suicide by hanging and that a Nurse walked into the bathroom and saw the Patient attempting to hang self and rescued the Patient." The report indicated that the Patient was on 15 minute Safety Checks and that staff had been in and out of the bathroom within 10 minutes of the incident. The reports indicated that according to the Hospital there may be possible omissions in the monitoring frequency. There was no additional information to review.

During interview with the Risk Manager on 5/17/17 at 10:30 A.M., the Risk Manager was asked for additional information on the patient event. The Risk Manager said that there wasn't any, as the Hospital policy was to forward patient incidents to the Licensure unit's investigation department. He said the Investigators complete the investigation of an incident and provide the Hospital with the findings. The Risk Manager said that the investigation had not been completed and that he and the Hospital were waiting for the report, the root cause analysis and financial support to formulate and/or complete an action plan.

The Risk Manager said that following the 4/5/17 survey, the hospital had implemented 5 minute checks and revised the Hospital's the environmental suicide/ligature point risk assessment on 4/10/17. He said the bathroom door latch had not been identified in the 4/5/17 survey and therefore not monitored for ligature risk. The Risk Manager said the incident was unfortunate, and following the 4/26/17 event, the Hospital removed the latch and placed all patients and ligature risk points back on 5 minute checks. The Risk Manager was asked about the discrepancies in the documents that were available and said he could not provide an explanation as the Hospital had not done an investigation. ( See A-0286)

During interview on 5/17/17 at 10:45 A.M., the DON said as of 4/5/17, she became aware of the ligature risk points and that the Hospital's suicide practice, assessments and screening were not evidence based and failed to incorporate tools to better identify a person's risk level on admission and during their stay. She said that the staff were instructed to complete 5 minute checks for all ligature risk points and patients shortly after 4/5/17. The DON said that she and the medical staff change the checks for patients on 4/25/17, based on discussion and not on identified individual patient risks. She said that the Psychiatrist had told the staff during a meeting that Patient #16 was not a suicide risk, but added that this information had not been documented in the record and she could not provide a date or a time. She said that she had started to formulate a task force for suicide risk, screening, assessment and care on 5/4/17, but had not been able to initiate anymore than the idea because of the survey visits. She also said that she had sent an email to staff on 5/11/17 informing staff of the ligature risks on the IPU. She said the email identified general risk areas, the bedrooms and bathrooms, but was not specific or comprehensive. She said she did not know if all the staff had read the email and understood the Hospital's expectations. She said that other than informal discussions with staff to monitor for ligature points, she had not monitored or completed audits. She said she did not know if the plan was effective and did not know if the Staff were understood or were competent in their knowledge and were ensuring that the physical environment was safe from ligature points for patients at risk for suicide.

During interview on 5/19/17 at 8:40 A.M., the Executive Director of the Hospital acknowledge problems associated with the care of Patient #16. He said the Patient was on 15 minute checks at the time of the event, because the day before, on 4/25/17, the Nursing and Medical Staff had decreased the level of supervision, for all Patients, from 5 minutes to 15 minutes Safety Checks. (Per policy, the physician was required to write an order when the Safety checks were decreased unless it was a nursing intervention to increase the check frequency). He said the Staff were to monitor the physical environment for ligature points every 5 minutes. The Director said his understanding was the Patient had been in the bathroom and that a Staff had checked on the Patient, who was in a locked bathroom stall. The Director said, that during the check the Patient's feet were observed flat on the floor in the bathroom stall. He said it was unclear if the Staff spoke with the Patient or only visualized his/her feet. At some time after the check, the Patient was found hanging on the floor. The Director said that Staff stated that the bathroom had been identified as an area for risk of ligature/hanging and that it had been checked three times during the 15 minutes the Patient was in the bathroom.

During an interview, on 5/19/17 at 10:30 A.M., the DON said the bathroom had been on 5 minute checks and the Patient was on 15 minute checks at the time of the event on 4/26/17. She said she did not know if staff saw the Patient face to face, but said they had seen his/her feet behind the stall. She also said that she did not know if staff had spoken with the Patient, but thought someone had asked how he/she was doing but was unsure. She said that no interviews were obtained after the event from staff.

During observations on 5/19/17 at 11:30 A.M., Nurse #2 was touring the IPU with the Surveyors. The Hospital's Risk Manager joined the tour. Nurse #2 was engaged and asked about the safety plan to prevent patient's at risk from harming themselves and what areas were identified as ligature risk points. Nurse #2 said she did not know, and then later asked if she could open a closed bathroom for Patient use, as there was a Patient who wanted to use the bathroom that had been closed due to ligature risk. The Nurse was unaware of the reason the bathroom had been made inaccessible.

Review of the Staff's monitoring sheets (Inpatient Unit Rounds Sheet), dated 5/19/17, identified the Patient, the room number, observation level (i.e.: 5 minute, 15 minute, etc), privilege. Each square was to document each time the face to face was conducted. The time identified in the grid was for 15 minute face to face safety patient checks and staff would document their location and mental status three times in the box for each 15 minute increment. The staff were to initial and sign the sheet at the end of their shift. The sheet included directions for staff to check windows and at the beginning of each shift sign that they completed laundry pick up, closets were locked, check bathrooms and locks, floor, tub, kitchen and client lounge. The sheet did not include information or identify ligature points.

Review of the round sheets for 4/26/17 indicated the Staff checked the Patient in the bathroom at 9:30 A.M. and then 5 minute door checks were completed three times during the time period the Patient was in the bathroom. The round sheets did not identify the bathroom as part of the ligature/environmental checks, nor did the sheets indicate any location being checked every 5 minutes.

Review of additional IPU round sheets, dated 5/17/17 and 5/18/17 (for a 24 hour time period for each day) indicated that the Hospital staff did not complete the 5 minute environmental safety checks and 15 minute patient safety checks for 48 hours.

During an interview on 5/19/17 at 12:00 P.M. , Nurse #1 was asked what the Staff were monitoring for when they completed their 5 minute checks. Nurse #1 said that staff were checking Patients every 5 minutes. The Surveyor asked about the ligature risk points and Nurse #1 said that staff were not looking at ligature risk points, just Patients.

During observation on 5/22/17 at 9:30 A.M., a Mental Health Worker (#1) was observed with a clip board entering one of the large compartment rooms. The Worker walked the perimeter and then began to exit the area. The Worker looked into several patient rooms, but was not observed checking areas such as bathrooms, behind closed doors or documenting on the clip board. General observations of the area and revealed that there were Patient rooms observed in rooms 319 and 321 and two others moving around the area, that included the bathroom.

The Surveyor approached the Worker and asked if he could explain what he had just observed. The Mental Health Worker said he was checking patients and turned back into the area and began checking behind doors, in bathrooms, in rooms and then documenting his findings.

On 5/22/17 at 1:25 P.M., after observing an unlocked and open bathroom that contained several pipes and a mixing valve which were exposed and could easily be used as a ligature point for any patient with thoughts of hurting themselves, and the bathroom was observed being accessed by patients. The Surveyors observed a Mental Health Worker (#2) leaving the area after just completing the 5 minute patient and ligature risk points rounds in the area of the bathroom, just prior to the Surveyors entering the area. The Surveyors asked the Worker to explain what she is looking at during the 5 minute checks and she said she looks inside this room to be sure that there are not any Patients present when she makes her rounds. Nurse #1 was called over and informed of this observation that the Surveyors had found. He then was observed speaking with the Mental Health Worker briefly and then sat down at the nurses station and continued with his daily duties, without checking the identified area.

On 5/22/17 at 1:30 P.M., the Risk Manager was made aware of the observation and stated that staff should have completed an incident report based on the risk identified.

Following the interview with Nurse #1 on 5/19/17 at 12:00 P.M. the DON and Risk Manager, were informed of the interview. The DON and Risk Manager said that there seemed to be a problem and that the Staff were not understanding what they were suppose to do. Both said that the Staff were to complete 5 minute checks on Patients and ligature risk points, by documentation. However, after having been informed on 4/5/17 and a death on 4/26/17, the Hospital administration could not provide any additional evidence other than an email that the Hospital was actively and effectively educating staff in their responsibilities to mitigate the risk of ligature risk points and/or ensure the environment was safe and being monitored effectively.

During the exchange the DON said that she had not formalized staff education and had not completed a comprehensive list of ligature risk points. She said that the method of emailing staff to educate and informal discussions may not have been sufficient to educate staff.

3. For Patient #5, the Hospital failed to alter the patient's environment to maintain safety when the patient threatened to use electrical outlets and pens or other sharp objects to electrocute him/herself.

Patient #5 was admitted following an exacerbation of his/her mental health. The Patient exhibited suicidal thoughts and had been noncompliant with taking his/her psychotropic medications. The Patient's diagnoses included schizoaffective disorder, borderline personality disorder, hypertension and diabetes.

According to the Admission Nursing Assessment, dated 5/2/17, the Patient was admitted after being medically cleared and assessed by a crisis team for inpatient care. The Patient was exhibiting increased agitation, an increase in his/her anxiety and noncompliance in taking his/her psychotropic medications. The nursing assessment indicated the Patient said he/she was not sure why he/she was admitted and had been comfortable at home. Patient #5 denied any suicidal/homicidal ideation's or auditory/visual hallucinations at the time of the assessment. The Nursing assessment indicated the Patient was placed on 5 minute face to face checks for safety.

The Admission Psychiatric Assessment completed on 5/2/17, reiterated the nursing assessment. The assessment included the Patient's recent inpatient treatment at another psychiatric hospital, in which the Patient had been discharged from that hospital on 4/26/17. That hospitalization was due to increased symptoms that had included paranoia, disorganized thoughts, bizarre behaviors, angry and made suicidal statements. The assessment indicated the Pateint was withdrawn, denied suicidal/homicidal thoughts and/or visual/auditory hallucinations and admitted to not taking his/her medications. The Psychiatrist indicated the Patient agreed and signed a voluntary agreement for admission and agreed to start taking his/her medications.

The Psychiatrist assessed the Patient's suicidal risks and identified the risk factors as age, history of self harm and history of suicide attempts, untreated chronic psychosis, limited support, estrangement from family and chronic pain. The Psychiatrist indicated the Patient had attempted overdosing self with medication in the past, but could not recall the last time he/she had attempted to commit suicide. The Patient told the Psychiatrist he/she had deceived the prior treating Hospital to get out of there when he/she was not ready.

The assessment indicated the Patient factors for not committing suicide, had been that he/she had decided against the act in the past, was future oriented, had no access to weapons, no thoughts to hang self, religious prohibition and some close friends. The Psychiatrist indicated that although the Patient had voiced suicidal ideations prior to his/her (current) admission, the Patient denies the thoughts at the time of the assessment, agreed and signed a voluntary agreement for admission, agreed to start taking his/her medications, said positive things about self and "fully contracted for safety in the unit."

The Psychiatrist's initial treatment plan was to admit for safety and start appropriate treatment, gather additional information, coordinate care with outpatient providers at discharge, monitor status daily including safety risk factors, competency issues and provide appropriate safe and structured therapeutic activities.

Review of the Comprehensive Psychiatric Evaluation with was dated as initiated on 5/3/17 and signed and dated as complete on 5/8/17 (however, according to the Hospital policy was to be completed and signed within 4 days of admission), reiterated most of the information in the admission assessment, and added that the Patient admitted to occasionally hearing his/her name whispered to him/her, and had heard voices telling him/her to harm self (but denied that they were recent). The assessment indicated the Patient had been trialed on many failed medication trials and indicated that two antipsychotic medications had caused side effects that included suicidal ideations and rashes (Rexulti and Latuda - antipsychotics). Although, the Patient's medications are not included in the Comprehensive Assessment Evaluation, the Psychiatrist indicated he altered the Patient's medications.

The shift notes for Nursing, Social Service, Mental Health Workers and progress notes by the Occupational Therapist from 5/2/17 through 5/9/17 were reviewed. According to the Hospital's plan following an accrediting survey completed on 4/5/17 and a suicide on 4/26/17, the Patient was being monitoring every 5 minutes. The progress notes, indicated the Patient was exhibiting high levels of depression, some anxiety, had a flat affect and stated he/she had suicidal ideations, but denied a plan. The documentation also indicated poor sleep habits, had episodes of sobbing, auditory hallucinations and told the staff he/she was going to a stick a fork in his/her neck. The Patient reported he/she saw "bugs crawling on the wall" and felt like a "loser and failure." The treatment was focused on medication changes, in which the Patient said the medications were ineffective.

On 5/9/17, the Patient continued to state he/she was depressed, fearful, hopeless, lonely and rageful. At 1:00 P.M., on 5/9/17, the shift note indicated the Patient was isolating him/herself and seemed paranoid. At 3:45 P.M., the Patient told the Social Worker that he/she is having command hallucinations to do things and points to the electrical outlet and said he/she could hurt self by putting a pen in the outlet and that there were other ways. The Social Worker notified the nurse to notify the Psychiatrist. At 9:00 P.M., the shift note on 5/9/17 acknowledged the Patient's verbalization to electrocute self using the wall socket. The Staff indicated they called maintenance and verified the wall socket was "live." The Staff documented that the would monitor the Patient, but failed to indicate how they were monitoring his/her safety and did not indicate they had assessed the patient's environment or how they would prevent the patient's access to sharp instruments and or how to limit access to the electrical outlets in the patient bedroom that they determined were live.

Review of the subsequent shift notes on 5/10/17 indicated the Patient remained confused and was having difficulty remembering and was sedated. The Psychiatrist assessed the Patient on 5/10/17, as a follow-up to the suicide ideation on 5/9/17, and said the Patient denied suicidal ideations and contracted for safety with him, but did not describe the contract conditions. The subsequent notes indicated the patient had some symptoms associated with psychotropic medications and was sent to the emergency room on 5/15/17 and diagnosed with polypharmacy/benzodiazepine overdose which required three doses of a reversal agent.

However, record review and interviews with Hospital Administration on 5/18/17 indicated that the Hospital had not formulated a plan to ensure the Patient's environment was safe other than checking the electric plug in her room and administering multiple medications to sedate the patient. At the time of the survey all the electrical sockets were live on the unit and there had been no change in mitigating access to the electrical sockets.

The Risk Manager had said on 5/19/17 at 11:30 A.M., the electrical sockets were used by Patient and staff and therefore had not developed a plan to mitigate the risk for harming self by electrocution (as described as the Patient's plan to harm/kill self).

Immediate Jeopardy

Based on observation, record review, and staff interviews during a Validation Survey on 5/15/17, 5/16/17, 5/17/17, 5/18/17, 5/19/17, and 5/22/17, the Hospital failed to develop, implement and maintain an effective QAPI (Quality Assessment and Performance Improvement) Program and failed to implement strategies to mitigate patient ligature risk (items that could be used for hanging) for Patient #16, and all Patients on the IPU, following a regulatory agency survey in which the Hospital was cited for an unsafe patient environment on 4/5/17.

Findings included:

From 4/3/17 to 4/5/17, a Regulatory Survey of the Hospital was conducted by another accrediting agency. During that survey, the Hospital was found out of compliance at a Conditional Level (High Likelihood to Cause Harm/Widespread), in the area of Physical Environment/Environment of Care.

The areas cited during the Regulatory Survey were as follows:

"There were potential ligature points throughout the inpatient behavioral health unit. Each and every door was equipped with handles and/or knobs on both sides of the doors that could easily be utilized as a ligature attach point. There were standard non-beveled tri-plex hinge sets on most of the doors. The cord on the patient courtesy telephone was approximately two feet long, and a patient was observed sitting in a chair by the phone in a position that all he would have to do if accompanied was to hang the phone up and drop off the chair. In the handicap shower room, there was a hand-held shower spray and the hamper were observed to have been removed prior to the end of survey the following day."

Mitigation activities implemented during the survey:

-Patient observation monitoring was increased from 15 minute checks to 5 minute checks for all patients.
-Scheduled staff retraining related to initial and ongoing Suicide Risk.
-Assessment of patients and the environment, to include ligature risk.
-Scheduled staff retraining on hospital observation levels with an emphasis on elevating the observation level immediately when clinically indicated.
-A repeat Comprehensive Environmental Suicide Risk Assessment will be completed and documented by April 12th, and the process of obtaining information to replace hardware posing a risk was initiated during the survey.

In spite of the patient safety hazards and potential ligature attachment points cited by the other accrediting agency on 4/5/17, many of the same ligature point hazards were observed on the IPU during multiple tours during the Validation Survey from 5/15/17 to 5/22/15.

On 5/18/17, between 1:15 P.M. and 1:25 P.M. the following potential ligature risk points were observed on the IPU:

-multiple metal door closers were observed throughout the IPU. The metal door closers that protruded from the upper portion of the door at an approximate 30 degree angle, posed a significant risk for hanging by a Patient by attaching a ligature to the metal closer.

-multiple pairs of sneakers with removable laces were observed on a ledge, high on the inside wall to the left in a patient bedroom.

-two green, metal heaters, were observed mounted in the corner of the ceiling of the recreation room. Each of the heaters could be used as potential attachment point for ligatures by a Patient.

-a red fire extinguisher sign was observed attached high up on the wall of the IPU. The sign was attached on each side with the center portion open at the middle. A ligature could easily be inserted through the opening at the middle of the sign and tied, posing a significant patient safety risk.

-multiple fire alarm boxes and a bluish-gray electrical box were observed attached to, and protruding from the wall, allowing a ligature to be hung around the outer part of the box.

-a basketball hoop mounted on a tall metal frame was observed in the recreation room on the IPU. A ligature could easily be attached to the upper frame of the basketball hop and used as a ligature point.

-five vertical window blinds were observed in the IPU group/activity room. Each of the vertical blinds had long cords attached which could be used as a ligature.

-the unit kitchen was observed to have five vertical window blinds, each with a long cord attached.

-each of the patient room doors could be blocked, or barricaded by a patient, rendering it difficult for staff to enter the room in the event of an emergency.

-a fire extinguisher was observed mounted on the wall in the IPU kitchen, that could be used as an attachment point for a ligature.

-The Medication Room door could not be secured when the nurse was not inside the room. The wooden door swung freely and could be used by a patient as an attachment point for a ligature, on the top, or, to swing the door into another patient or staff member. Interview with the Nursing Supervisor on 5/18/17 at 1:25 P.M., said that the door could be used as a ligature point or as a weapon if swung into someone.

Record review from 5/15/17 to 5/22/17, revealed that on 4/26/17 at 9:48 A.M., two days after admission to the Hospital, Patient #16 was found by RN #1 in the bathroom stall, kneeling in the stall with his/her head against the door/wall with a ligature tied around his/her neck and affixed to the bathroom stall latch. According to the Incident Report, the ligature was immediately removed and the patient was lowered to the floor. An assessment revealed the Patient was unresponsive with a strong "pounding" pulse but not breathing. A Code Blue/911 was called at 9:49 A.M. and emergency equipment, including an AED (Automated External Defibrillator), was immediately brought to the scene. Rescue breathing was initiated at 10L/min with non-rebreather mask however, upon reassessment, pulse was absent and CPR was immediately initiated with oxygen delivered via Ambu bag/mask device. The AED was immediately applied, "no shock advised-continue CPR" for 3 cycles. EMS/paramedics arrived at 9:54 A.M., carotid IV placed and epinephrine 2 mg IV administered by EMS at 10:03. Patient reported to be in sinus rhythm at 10:00 A.M. with rescue breathing in progress. The Patient was transported to a local hospital at 10:20 A.M., placed on life support, and later died when life support was withdrawn per the family wishes.

The Risk Manager/QAPI Director was interviewed on 5/18/17 at 10:35 A.M. regarding Patient #16's suicide attempt and the concern regarding the Hospital's failure to effectively address the other accrediting agency's citations regarding the Physical Environment/Environment of Care deficiencies. The Risk Manager/QAPI Director said that as of that time, many of the potential ligature risk points had not been corrected, nor had the investigation and RCA (Root Cause Analysis) into Patient #1's suicide attempt been completed. Additionally, the Risk Manager/QAPI Director acknowledged that the Risk Management Plan, that included 5 minute patient safety checks and 5 minute ligature point risk checks, were not being done consistently by Hospital staff.

During interview with the Risk Manager/QAPI Director on 5/17/17 at 10:30 A.M., he said that the Hospital policy is to forward Sentinel incidents to the Hospital's investigation department. The Hospital does not investigate the event and therefore does not have interviews, information or analysis of the event. The Hospital was waiting for the investigation to be completed and the root, cause and analysis to be completed in order to formulate an action plan. The Risk Manager/QAPI Director was not able to explain some of the discrepancies in the documents reviewed because of lack of an in-house investigation.

During interview on 5/18/17 at 1:00 P.M., the DON said that the Hospital's suicide policy and procedure was woven within multiple policies. She said that the Hospital did not have a policy and procedure that specifically addressed suicide care and assessment. The Director said that during the 4/5/17 survey, the Hospital had been informed that the admission psychiatric assessments did not determine the degree of the Patients risk for suicide ideation and lacked the components required in a descriptive manner to base a treatment plan. She said she had been trying to put together a task force for education on suicide prevention, but had not done this. She said that the Hospital had conducted audits of the psychiatric admission assessments and it was determined for Patient #16's (after reviewing the audit tool) that his/her assessment was not comprehensive and had not contained the standard elements for treatment (Patient #16 was admitted 18 days after the Hospital had been informed of inadequate assessment for Patient's at risk of suicide and ligature points in the IPU). The DON said she was unaware of any action taken, but that physicians were to be educated.

During interview on 5/19/17 at 8:40 A.M., the ED (Executive Director) of the Hospital acknowledged problems associated with the care of Patient #16. He said the Patient was on 15 minute checks at the time of the event, because the day before, on 4/25/17, the Nursing and Medical Staff had decreased the level of supervision for all Patients from 5 minutes to 15 minutes Safety Checks. (Per policy, the physician was required to write an order when the Safety checks were decreased and according to the record the physician had not.) The ED said the Staff were to monitor the physical environment for ligature points every 5 minutes. The ED said his understanding was the Patient had been in the bathroom and that a Staff member had checked on the Patient, who was in a locked bathroom stall. The Director said, that during the check the Patient's feet were observed flat on the floor in the bathroom stall. He said it was unclear if the Staff spoke with the Patient or only visualized his/her feet. At some time after the check, the Patient was found hanging on the floor. The Director said that Staff stated that the bathroom had been identified as an area for risk of ligature/hanging and that it had been checked three times during the 15 minutes the Patient was in the bathroom.

The Risk Manager/QAPI Director said that the Hospital's plan to address the ongoing risks identified during the other accrediting agency survey of 4/5/17, and Validation Survey of 5/22/17, would not be completed until 6/30/17. The Risk Manager/QAPI Director did not provide any information on what role the Governing Body played, if any, in developing and/or overseeing implementation of Quality Assurance Performance Improvement measures to correct the unsafe patient environment following Patient #16's suicide attempt and eventual death.


See A-0289

Based on record review and interview, the hospital's Quality Assurance Performance Improvement Program failed to analyze an acute adverse patient event (patient hanging) for one patient (#16) and implement preventative actions in a timely manner to prevent such events from reoccurring, that were consistent with its risk management policies and procedures, leaving patients at risk for recurrent harm. Findings include:

1. The Risk Management protocols including reporting, dated as last revised on 5/26/2016, state that a critical incident report is to be completed and submitted within 10 days following notification of a death. Critical incidents involving the date of a client are followed by a death report. Critical incidents include a suicide attempt and a suicide where the client death resulted from a suicide attempt. A description of the incident in the report needs to contain the following:who was involved, what happened when and where it happened and how it happened. A supervisor's assessment of the incident needs to be completed. The supervisor is to give his/her analysis of the incident that includes contributing factors which focus on what led up to or caused the incident; actions taken on how the incident was handled and follow-up planned which focuses on the plan to resolve the risk to the particular client(as involved and when appropriate to all others - when the risk factors can be diminished or eliminated.

2. During the initial tour, the hospital Supervisor said that the Hospital had recently been surveyed by another accrediting agency on 4/5/17 which had identified that there were potential ligature points throughout the inpatient behavioral health unit. She said that the Hospital had taken action shortly after the survey on 4/5/17. The Supervisor said that many of the ligature risk areas required construction, so the Hospital's immediate plan to mitigate the risk had been to place all ligature points/areas and all patients on 5 minute face to face checks and the hospital had restricted the use of 2 bathrooms and a sensory room.

3. Patient #16 was admitted on 4/24/2017 after several suicide attempts and was placed on 15 minute checks after being assessed as no longer actively suicidal. On 4/26/17 at 9:48 A.M., the Nurse's note indicated the Nurse found the Patient in the male bathroom stall, kneeling in the stall with his/her head against the door/wall with a ligature tied around his/her neck and attached to the bathroom stall latch.

Staff performed emergency care and called a code blue which brought emergency equipment and staff to the room. EMS was summoned to the hospital. The Patient was transported to a local hospital at 10:20 A.M. and died in the intensive care unit when taken off life support two days later.

Review of the Hospital's internal incident reports indicated (dated 4/28/17) "the Patient attempted suicide by hanging and that a Nurse walked into the bathroom and saw the Patient attempting to hang self and rescued the Patient." The report indicated that the Patient was on 15 minute Safety Checks and that staff had been in and out of the bathroom within 10 minutes of the incident. The reports indicated that according to the Hospital there may be possible omissions in the monitoring frequency. There was no additional information to review. There was no Supervisor's Assessment of Incident as required.

During interview with the Risk Manager on 5/17/17 at 10:30 A.M., the Risk Manager was asked for additional information on the patient event. The Risk Manager said that there wasn't any, as the Hospital policy was to forward patient incidents to the Licensure unit's investigation department. He said the Investigators complete the investigation of an incident and provide the Hospital with the findings. The Risk Manager said that the investigation had not been completed and that he and the Hospital were waiting for the report, the root cause analysis and financial support to formulate and/or complete an action plan.

The Risk Manager said that following the 4/5/17 survey, the hospital had implemented 5 minute checks and revised the Hospital's the environmental suicide/ligature point risk assessment on 4/10/17. He said the bathroom door latch had not been identified in the 4/5/17 survey and therefore not monitored for ligature risk. The Risk Manager said the incident was unfortunate, and following the 4/26/17 event, the Hospital removed the latch and placed all patients and ligature risk points back on 5 minute checks. The Risk Manager was asked about the discrepancies in the documents that were available and said he could not provide an explanation as the Hospital had not done any investigation, although the risk management protocol required that the hospital conduct its own investigation.

Based on record review and interview, the medical staff was not responsible for the quality of medical care provided to the patients by the hospital for 19 of 19 patients. Findings include;

1. During interview with the Risk Manager on 5/17/17 at 10:30 A.M., he said that the Hospital policy is to forward Sentinel incidents to the Hospital's investigation department. The Hospital does not investigate the event and therefore have no interviews, information or analysis of the event. The Hospital are waiting for the investigation to be completed and the root, cause and analysis to be completed in order to formulate an action plan. The Risk Manager was not able to explain some of the discrepancies in the documents reviewed because of no in house investigation.

During interview on 5/18/17 at 1:00 P.M., the Nurse Executive Director said that the Hospital's suicide policy and procedure was woven within multiple policies. She said that the Hospital did not have a policy and procedure that specifically addressed suicide care and assessment. The Director said that during the 4/5/17 survey the Hospital had been informed that the admission psychiatric assessments did not determine the degree of the Patients risk for suicide ideation and lacked the components required in a descriptive manner to base a treatment plan. She said she had been trying to put together a task force for education on suicide prevention, but had not done this. She said that the Hospital had conducted audits of the psychiatric admission assessments and it was determine for Patient #16's (after reviewing the audit tool) that his/her assessment was not comprehensive and had not contained the standard elements for treatment (Patient #16 was admitted 18 days after the Hospital had been informed of inadequate assessment for Patient's at risk of suicide and ligature points in the IPU). The Executive Director said she was unaware of any action taken, but that physician were to be educated.

In the letter, the Chairman of the GB indicated to the contracted Medical Staff administration a concern that the accrediting agency would be returning for a follow-up survey, the Hospital had admitted 12 patients since the accrediting agency left on 4/5/17, and "thus far and despite daily reminders about what the physicians needed to complete, all 12 records remain out of compliance."

Interview with the Hospital Director on 5/19/17 at 8:20 A.M., said that on 4/26/17, on the IPU, Patient #16 attempted suicide by hanging, was transported by EMS to a local Hospital and died two days later.

The Hospital Director also said that the contracted Medical Staff had failed to comply with the requirement to complete a Suicide Risk Assessment, as required for each patient admitted to the IPU, even after the suicide attempt and death of Patient #16 on 4/26/17.

Review of clinical records indicated that the Hospital failed to provide a nursing evaluation as appropriate to assess the needs of two patients (#12 and #17), in a total sample of 19, who were identified at risk for suicide/self harm and failed to develop and/or implement an effective plan to mitigate the risk of those hazards to ensure patient safety and prevention of suicides and or self harm. Findings include:

Review of the Inpatient Unit treatment Planning Protocol, dated 4/24/2014, indicated that anytime a patient has any change in in the psychiatric status and may require a change in level of care such a an episode of violence, assault, self injurious behavior, suicide attempt or restraint, it requires an immediate review of the treatment plan. In addition, the treatment plan is based on an assessment of the patient presenting problems, physical health, emotional status, strengths and behavioral status, all which can change over short periods of time from the admission assessments.

1. For Patient #12, the nursing staff failed to reassess the patient's risk for self harm and suicide to minimize the environmental risks available to the patient to do self harm when the patient's behavior status changed.

Patient #12 was admitted in 4/2017 with diagnosis that included bipolar disorder, anxiety and diabetes.

Prior to admission to the IPU, Patient #12 had been acutely hospitalized for a suicide attempt and admitted to another psychiatric hospital in 4/2017, According to the medical record, after discharge, the patient stated he/she felt unsafe, and was significantly depressed and was not clear what the precipitant was and thought he/she might harm him/herself.

According to the medical record, the patient had a long history of inpatient treatment and suicide attempts, which included overdosing on medications and/or stabbing/cutting him/herself. The clinical record indicated the patient told staff he/she had thoughts of cutting him/herself on 5/1/17.

On 5/2/17, the patient told the staff he/she want to harm self and on 5/3/2017 informed the staff he/she had been looking for objects in the courtyard with thoughts to use an object to harm self.

During the patient admission all the ligature risk points were being monitored by staff for safety every 5 minutes. Observations, interviews with staff confirmed that monitoring was not being consistently done by the Hospital's plan.

After Patient's #12 expressed suicide/self harm declaration, there was no evidence in the clinical record that nursing staff reassessed the patient's risk level or took any actions to remove or limit potential environmental hazards that the patient could harm him/herself with. The record did reflect that the patient informed staff of his/her intent but no action plan was noted.

On 5/4/17, the patient reported to staff, after returning from the dining room, that he/she cut his/her left wrist with a fork. The wound was assessed as superficial and treated. The patient then agreed to eat with staff supervision. The patient had cut him/herself during a breakfast meal while under 5 minute supervision.

The clinical record only indicated that the patient continued to struggle with self harm and had self induced scratches on his/her left wrist on 5/11/2017.

During an interview on 5/19/2017, the Director of Nurses said the risk assessment and reassessment for both self harm events was not comprehensive. The DON said that staff should have assessed the patient's environment for risk factors and safety and staff should be knowledgeable of the patient's intent, determination and desired methods of self harm in order to prevent injuries.

2. For Patient #17, the Hospital staff failed to assess the patient for environmental risks after several allegations of self harm.

Patient #17,was admitted from the emergency room where he/she had been brought after admitting to substance use disorder, depression and making suicidal ideations.

According to the hospital record, dated 1/18/2017, the patient was depressed and the Family had called for emergency response (EMS) because the patient was making suicidal statements and was intoxicated. EMS had to apply restraints.

According to the admission nursing assessment, dated 1/18/2017, the patient signed a 3 day commitment after texting family of suicidal thoughts. The patient was agitated.

The admission psychiatric assessment, completed on 1/18/2017, noted that the patient was admitted for suicidal statements made to family and the patient said he/she was stressed an unable to cope with person he/she lived with and felt depressed and helpless. The psychiatrist wrote that the patient was making a lot of suicidal statements and minimized both suicidal and substance use and that the patient's judgement and insight was impaired.

The Social Service assessment, dated 1/2017, indicated the patient was texting messages to the family making suicidal statements. A treatment and recovery plan was initiated that included goals the patient would be safe and suicidal ideations which would be mitigated by participation in groups, activities and the patient would find way to meet how/her own needs.

The plan and assessment did not indicate what environment factors posed a risk for this patient who voiced suicidal ideations or assessed if the patient had a plan for suicide.

The patient was discharged at the end of the 3 day commitment and was encourage to seek outpatient treatment.

During an interview on 5/19/2017, the DON said that patients with suicide ideations needed a more in depth suicide risk assessment that should include the patients statement of what he/she intended to do to harm self and if any environment factors could impact the patient's plan and if those factors needed to be mitigated for patient safety.

Review of clinical records indicated that the Hospital failed to provide current nursing care plans based on assessed needs that considers treatment goals and as appropriate psychosocial factors for two patients (#12 and #17) who were identified at risk for suicide/self harm. Both patient lacked an effective plan to mitigate the risk of environmental hazards to ensure patient safety and prevention this risk of suicide and/or self harm. Findings include:

Review of the Inpatient Unit treatment Planning Protocol, dated 4/24/2014, indicated that anytime a patient has any change in the psychiatric status, require a change in level of care such a an episode of violence, assault, self injurious behavior, suicide attempt or restraint, it requires an immediate review of the treatment plan. In addition, the treatment plan is based on an assessment of the patient presenting problems, physical health, emotional status, strengths and behavioral status, all which can change over short periods of time from the admission assessments.

1. For Patient #12, the nursing staff failed to review and update the treatment plan based on the patient's risk for self harm and suicide to minimize the environmental risks available to the patient to do self harm when the patient's behavior status changed.

Patient #12 was admitted in 4/2017 with diagnosis that included bipolar disorder, anxiety and diabetes.

Prior to admission to the IPU, Patient #12 had been acutely hospitalized for a suicide attempt and admitted to another psychiatric hospital in 4/2017, According to the medical record, after discharge, the patient stated he/she felt unsafe, and was significantly depressed and was not clear what the precipitant was and thought he/she might harm him/herself.

According to the medical record, the patient had a long history of inpatient treatment and suicide attempts, which included overdosing on medications and/or stabbing/cutting him/herself. The clinical record indicated the patient told staff he/she had thoughts of cutting him/herself on 5/1/17.

On 5/2/17, the patient told the staff he/she want to harm self and on 5/3/2017 informed the staff he/she had been looking for objects in the courtyard with thoughts to use an object to harm self.

During the patient admission all the ligature risk points were being monitored by staff for safety every 5 minutes. Observations, interviews with staff confirmed that monitoring was not being consistently done by the Hospital's plan.

After Patient's #12 expressed suicide/self harm declaration, there was no evidence in the clinical record that nursing staff took any actions to remove or limit potential environmental hazards that the patient could harm him/herself with.

On 5/4/17, the patient reported to staff , after returning from the dining room, that he/she cut his/her left wrist with a fork.

The clinical record only indicated that the patient continued to struggle with self harm and had self induced scratches on his/her left wrist on 5/11/2017.

During an interview on 5/19/2017, the DON said that staff should have assessed the patient's environment for risk factors and safety and staff should be knowledgeable of the patient's intent, determination and desired methods of self harm in order to prevent injuries.

2. For Patient #17, the Hospital staff failed to assess the patient risks after several allegations of self harm.

Patient #17,was admitted from the emergency room where he/she had been brought after admitting to substance use disorder, depression and making suicidal ideations.

According to the hospital record, dated 1/18/2917, the patient was depressed and the Family had called for emergency response (EMS) because the patient was making suicidal statements and was intoxicated. EMS had to apply restraints.

According to the admission nursing assessment, dated 1/18/2017, the patient signed a 3 day commitment after texting family of suicidal thoughts. The patient was agitated.

The admission psychiatric assessment, completed on 1/18/2017, noted that the patient was admitted for suicidal statements made to family. The psychiatrist wrote that the patient was making a lot of suicidal statements and minimized both suicidal and substance use and that the patient's judgement and insight was impaired.

The Social Service assessment, dated 1/2017, indicated the patient was texting messages to the family making suicidal statements. A treatment and recovery plan was initiated that included goals the patient would be safe and suicidal ideations would be mitigated by participation in groups, activities and the patient would find way to meet how/her own needs.

The plan and assessment did not indicate what environment factors posed a risk for this patient who voiced suicidal ideations or assessed if the patient had a plan for suicide and there was no plan to mitigate environmental factors that may impact the patient's safety.

During an interview on 5/19/2017, the DON said that patients with suicidal ideations needed a more in depth suicide risk assessment that should include the patients statement of what he/she intended to do to harm self and a plan to mitigate environmental risk factors that were specify to the patient's intent.

Based on observation and staff interview, the Hospital failed to ensure that staff assigned to make 5 minute safety checks on the Inpatient Unit had a working knowledge, understanding and competence of the assignment to ensure patient safety.

Findings include:

The Hospital's Inpatient Unit (IPU) had been notified by another accrediting agency on 4/5/17 that areas accessible to patients were determined to have ligature risk (hanging) and other environmental hazards that required removal. The Hospital implemented a plan to mitigate the risk of those hazards that had been identified as ligature points which would lend a patient who was at risk of harming self access to hanging themselves. In an effort to address the problem that could not be remedied without financial support, the Hospital implemented a plan to have the staff to monitor the ligature points every 5 minutes.

On 4/26/17, Patient #16 hung him/herself on a ligature point while staff were providing 5 minute ligature checks. Since the incident, the Hospital has continued with 5 minute ligature checks of the IPU.

During the initial tour of the Hospital's Inpatient Unit (IPU), on 5/15/17 at 10:30 A.M., the Surveyors observed that the unit had environmental hazards that posed a safety risk for patients. The environmental hazards observed included door knobs, door closures, door hinges, ceiling tiles, lighting fixtures, vent fixtures and multiple areas noted that could be used for patient who were at risk of harming self or others. Many of the environmental observations posed a risk for ligature/hanging.

On 5/16/17 at 11:30 A.M., an extensive environmental patient safety tour was completed with the Inpatient Unit's (IPU) Supervisor. (See A 0700.)

During the tour, the Unit's Supervisor said that due to ligature points that posed an safety environmental hazard for Patients, which she said had been identified by another survey agency on 4/5/17 and a subsequent Patient death due to hanging on 4/26/17, the unit staff monitor the unit's ligature risk points every 5 minutes throughout the IPU. The Supervisor said that the Hospital had restricted the use of 2 bathrooms and a sensory room due to the hazardous conditions related to ligature points. The Surveyor asked if there was a comprehensive list of the ligature points identified, for use with the 5 minute monitoring checks and she said there was not. During the tour the Surveyor asked the Supervisor to identify the ligature points that Staff were monitoring every 5 minutes. The Supervisor identified door handles and door hinges and said that some of the bathrooms had ligature points. The Supervisor information was general and she was unable to provide a comprehnsive list or understanding the ligature points identified in the IPU. The Surveyor pointed out the door closures, which were located on the top of the doors to bedrooms and were V shaped and a ligature point. The Supervisor said was not aware of their risk.

During observations on 5/19/17 at 11:30 A.M., Nurse #2 was unaware of the safety plan to prevent patients at risk from harming themselves and what areas were identified as ligature points. Nurse #2 asked another Hospital Staff if she could open a bathroom for Patient use. The Nurse was unaware of the reason the bathroom had been made inaccessible. During an interview on 5/19/17 at 12:00 P.M. with the Director of Nurses and Risk Manager, the Surveyor shared the encounter with Nurse #2. The Director said that the Nurse should have known, but that there had been no formal education to support her knowledge of the ligature risks and reasons for stopping the use of the bathroom she inquired about.

Review of the Staff's monitoring sheets (Inpatient Unit Rounds Sheet), dated 5/19/17, identified the Patient, the room number, observation level (ie: 5 minute, 15 minute, etc), priveldge and each square to document in each time the face to face was conducted. The time identified in the grid was for 15 minute face to face safety patient checks and staff would document their location and mental status three times in the box for each 15 minute increment. The staff were to initial and sign the sheet at the end of their shift. The sheet included directions for staff to check windows and at the beginning of each shift sign that they completed laundry pick up, closets were locked, check bathrooms and locks, floor, tub, kitchen and client lounge. The sheet did not include information or identify ligature points. Additional, review of several days prior to 5/19/17 and a copy of a blank form also indicated that the Hospital could not support that staff were ensuring that ligature points were being monitored after a Sentinel event and acknowledged deficient practice since 4/5/17.

During interview with Nurse #1 on 5/19/17 at 12:00 P.M. and in an additional conversation with the Nursing Director and Risk Manager, on 5/19/17 at 12:00 P.M., they agreed there still was problems. Nurse #1 looked at the sheet and said that staff were only doing 5 minute face to face safety checks with the Patients. He said that Staff were not doing 5 minute ligature checks. The Risk Manager said that the Staff were doing both and the Director of Nursing agreed. The Director and Risk Manager said that there was a disconnect to what the knowledge base of the staff was to what they were suppose to be doing. The Nurse Director said that she had emailed staff and had informal meetings with staff since 4/5/17 and 4/26/17, informing them of thr need for constant monitoring of patients and ligature points to ensure the patient's right to safety. However, she said that she had not implemented the plan formally and had no evidence supporting the Hospital's action to ensure patient safety, as the rounding sheets had no method to ensure staff knew what they were monitoring to ensure patient safety.

During observation on 5/22/17 at 9:30 A.M. a Mental Health Worker (#1) was observed with a clip board entering one of the large compartment rooms. The Worker walked the perimeter and then began to exit the area. The Worker looked into several patient rooms, but was not observed checking areas such as bathrooms, closed doors or documenting on the clip board. The Surveyor approached the Worker and asked if he could explain what he had just observed. The Mental Health Worker said he was checking patients and turned back into the area and began began checking doors, bathrooms, rooms and then documenting his findings.

After observing an unlocked and open bathroom (which according to the Hospital Administration was identified as a 5 minute ligature check area) that contained several pipes and a mixing valve which could easily be used as a ligature point for any patient with thoughts of hurting themselves, and was observed accessed by patients on 5/22/17 at 1:25 P.M., a Mental Health Worker (#2) was observed leaving the area after just completing the 5 minute patient and ligature points rounds in the area the bathroom and was observed walking out of the area just prior to the 2 Surveyors entering. The Surveyors asked the Worker to explain what she is looking at during the 5 minute checks and she said she looks inside this room to be sure that there is not any Patients present when she makes her rounds. The Worker said she was not looking at the area (ligature) but looking for Patients. Nurse #1 was called over and informed of this observation that the Surveyors had found. He then was observed speaking with the Mental Health Worker briefly and then continued with his daily duties.

On 5/22/17 at 2:00 P.M., the Surevyor made the Risk Manager aware of the observation and stated that staff should have completed an incident report based on the incident.

Based on documentation review it was determined the Hospital failed to ensure the nursing staff monitored for adverse effects of psychoactive medication administration for one patient (#5) in a total sample of 19, who required hospitalization for a drug overdose.

Findings include:

Patient #5 was admitted in 5/2017 and had diagnoses that included depression, schizoaffective disorder, had suicidal ideations and had stopped taking his/her psychoactive medication medications.

According to the admission medication orders dated 5/2/17, the Patient's psychoactive medications were Effexor (antidepressant) 37.5 mg (milligrams) daily and 75 mg twice a day and Ziprasidone (antipsychotic) 80 mg, twice a day.

According to the the Admission Psychiatric Assessment dated 5/2/17 and the Comprehensive Psychiatric Assessment dated 5/3/17, Patient #5 was admitted following an exacerbation of his/her mental health. The Patient exhibited suicidal thoughts and had been noncompliant with taking his/her psychotropic medications and felt unsafe at home. At the time of the assessment Patient #5 denied any suicidal/homicidal ideation's or auditory/visual hallucinations.

The psychiatric assessment indicated the Patient had recently been treated and discharged from another inpatient psychiatric hospital. The hospitalization was due to increased symptoms that had included paranoia, disorganized thoughts, bizarre behaviors, angry and made suicidal statements. The assessment indicated the Patient was withdrawn, denied suicidal/homicidal thoughts and/or visual/auditory hallucinations and admitted to not taking his/her medications. The Psychiatrist indicated the Patient agreed and signed a voluntary agreement for admission and agreed to start taking his/her medications.

The Psychiatrist assessed the Patient's suicidal risks and identified the risk factors as age, history of self harm and history of suicide attempts, untreated chronic psychosis, limited support, estrangement from family and chronic pain. The Psychiatrist indicated the Patient had attempted overdosing self with medication in the past, but could not recall the last time he/she had attempted to commit suicide, and added that the Patient admitted to occasional hearing his/her name whispered to him/her, and had heard voices telling him/her to harm self (but denied that they were recent). The assessment indicated the Patient had been trialed on many failed medication trials and indicated that two antipsychotic medications had caused side effects that included suicidal ideations and rashes (Rexulti and Latuda - antipsychotics). The Patient told the Psychiatrist he/she had deceived the prior treating Hospital to get out of there when he/she was not actually ready to be discharged.

Although, the psychiatrist does not indicated his reason, according to the medication record on 5/3/17, the psychiatrist ordered 2 additional antipsychotic medications, Seroquel 100 mg daily and Zyprexa 15 mg, daily, and a benzodiazepine medication, Ativan, 1 mg, every 4 hours as needed.

On 5/4/17, the psychiatrist discontinued the antipsychotic Ziprasidone, the antidepressant Effexor and ordered a second benzodiazepine clonzepam 1 mg, three times per day and increased the Zyprexa from 15 mg daily to 20 mg daily.

The Patient had told the staff on 5/3/17 he/she had suicidal thoughts and although this information does not appear to be communicated to the Psychiatrist when he met with the Patient on 5/4/17, he/she states he/she continues feeling depressed, anxious and had racing thoughts that he/she could not control. The Psychiatrist asked the Patient to tell the night staff if he/she is not sleeping well because the Patient's sleep "must be addressed before mood issues can be resolved." (Review of shift notes prior to evaluation had little information that the Patient was not sleeping, the staff had reported he/she was sleeping.) The Psychiatrist increased the Zyprexa from 15 mg to 20 mg daily and discontinued the antidepressant Effexor and the antipsychotic Ziprasidone, attributing this medication to poor sleep and complaints of racing thoughts.

On 5/4/17, the staff indicate no issues and that the Patient voiced no suicidal ideations, was moderately depressed and without evidence of poor sleep pattern.

On 5/5/17, the Psychiatrist's progress note indicated the Patient had reported seeing "bugs crawling on the wall" and had difficulty sleeping the night before. The Patient told the Psychiatrist that he/she had to ask the Nurse for a sleeping medication, because he (the Psychiatrist) had told him/her (the Patient) to. The Patient said the Nurse told him/her that he/she did not need anything. The Patient reported feeling like a "loser and failure." The Patient "complained" to the Psychiatrist that he/she has been on so many medications and doctors continue to switch them. The Psychiatrist said the changes to his/her medications and agreed, even though he indicated the Patient has limited insight and judgement with medications. The Psychiatrist said he had discontinued the antipsychotic Ziprasidone (indicating it was having no effect) and ordered the antipsychotic medication Trilafon 8 mg every morning and 16 mg every night and Ativan, a benzodiazepine medication, that treats anxiety, 1 mg, three times per day.

On 5/6/17, the nursing staff indicated the Patient behaviors included stripping bed and being confused, telling staff he/she would stick a fork in his/her neck and was sobbing and stating that he/she felt that his/her family did not care. The Patient was administered the PRN clonazepam for anxiety.

On 5/7/17, the medication lithium (used to treat bipolar disorder) was ordered by the psychiatrist, 150 mg, three times per day.

On 5/8/17, the psychiatrist increased the antipsychotic medication Seroquel from 100 mg daily to 150 mg daily, after the patient told him that she was depressed, that the medications were ineffective and was experiencing auditory hallucinations.

The shift notes for 5/7/17 and 5/8/17 indicated the Patient had been weepy, but few other observations. There was no indication that the nursing staff acknowledged the medication changes and were monitoring for adverse effects

On 5/9/17, the shift notes indicated the Patient said he/she was depressed, fearful, hopeless, lonely and paranoid. At 1:00 P.M., on 5/9/17, the shift note indicated the Patient was isolating him/herself and seemed paranoid. At 3:45 P.M., the Patient told the Social Worker that he/she is having command hallucinations to do things and points to the electrical outlet and said he/she could hurt self by putting a pen in the outlet and that there were other ways. The Social Worker notified the nurse to notify the Psychiatrist. At 9:00 P.M., the shift note on 5/9/17 acknowledged the Patient's verbalization to electrocute self using the wall socket. The Staff indicated they called maintenance and verified the wall socket was "live."

On 5/9/17, the Patient told the Psychiatrist that he/she was confused and did not remember going to bed. The Patient requested a list of his/her medications because he/she did not feel they were effective. The Psychiatrist ordered the following medication changes: the antipsychotic medication Trilfon 8 mg and 16 mg daily was changed to 36 mg daily, the benzodiazepine Ativan was discontinued and the benzodiazepine alprazolam 1 mg, three times per day and added a antidepressant Luvox 50 mg daily was added.

On 5/10/17, the shift notes indicated the Patient was having nightmares and had difficulty participating in activities of daily living and required physical assistance from staff for care.

Although, the nurses staff documented behaviors, the nursing staff did not monitor the medication changes and their effects. It was not unit 5/10/17, that the Occupational Therapist (OT) indicated the Patient had medication changes and was sedated. The OT said the Patient was given the list of medications and was unable to remember why he/she was given the list. The OT said the Patient was drooling and sedated and questioned the medications.

Review of the subsequent shift notes on 5/10/17 indicated the Patient remained confused and was having difficulty remembering and was sedated. The Psychiatrist assessed the Patient on 5/10/17, as a follow-up to the suicide ideation on 5/9/17, and said the Patient denied suicidal ideations and contracted for safety with him, but the Psychiatrist did not describe the contract conditions. On 5/10/17, the Psychiatrist decreased the Trilifon from 32 mg daily to 18 mg daily and on 5/11/17 added Cogentin (used to treat tremors and extrapyramidyl symptoms), and increased the Luvox to 100 mg daily.

The subsequent shift notes indicated the patient had some side effects associated with psychotropic medications such as tremors, but the notes did not indicate any positive effects from the medication changes. The Patient was transferred to the emergency room on 5/15/17 and diagnosed with polypharmacy/benzodiazepine overdose.

Review of the hospital discharge summary dated 5/16/17 indicated the Patient was unresponsive and over sedated due to multiple psychoactive medications. The Patient was given one dose of Narcan (a medication used to reveres the effects of opioids) without effect and then was given 2 doses of Romazicon (a GABA receptor antagonist used to treat drowsiness caused by sedatives), with effect, as the Patient became arousable. In addition, the Patient was treated for dehydration requiring intravenous fluids.

The Unit Supervisor was interviewed on 5/17/17 at 10:00 A.M. and said the Patient had been transferred unexpectedly on 5/16/17. The Supervisor said the Patient oxygen saturations had dropped as the reason for the transfer.

On 5/17/17 at 10:30 A.M. the Unit Supervisor was asked about the Patient's medications and monitoring the side effects of multiple psychotropic medications. She said that the nursing staff would monitor in their shift notes any adverse effects. The Surveyor asked the Supervisor if she could obtain the notes for review. The Supervisor provided copies of orders and Medication Administration Records.

Subsequently, the Unit Supervisor and the Director of Nurses was asked about the Patient as he/she had been readmitted and the discharge record dated 5/16/17 indicated the Patient had been overdosed with psychotropic medications. The staff provided no information, but said that the Nursing staff should have documented the effects of medication changes. The Director said the case would be reviewed as an incident, but later said on 5/22/16 she was not sure if it would be.

On 5/22/17 at 1:00 P.M., the Patient was observed sitting in the dayroom. The Patient responded to the Surveyor and told the Surveyor he/she had been hospitalized because the IPU had overdosed him/her with too many medications. The Patient said that he/she took the medications because they were given to him/her by the nurses.

Based on record review, observation and staff interview, the facility failed to ensure that Patients that were identified at nutrition/hydration risk were assessed by the Dietitian to ensure that the Patient's nutritional needs were met for 4 (#2,#11, #12, #14) of 15 sampled Patients.

Findings include:

1. For Patient #2, with the diagnoses of diabetes, receiving an 1800 cal diabetic diet and who had a 20 pound weight loss, the facility failed to conduct a nutritional assessment to determine if the Patient's nutritional needs were being met.

Patient #2 was admitted to the facility in 3/2017 with diagnoses that included Bipolar Disorder, polysubstance abuse, insulin dependent diabetes, Chronic Obstructive Pulmonary Disease (COPD), depression and change in mental status.

The Patient's admission height was documented as 5 feet 8 inches tall and weighed 204.5 pounds (Body Mass index 32-obese).

Review of the initial Nursing Assessment dated 3/4/17 indicated that the Patient had a Nutrition Risk factor of diabetes, but a nutritional assessment plan was not indicated.

Review of the clinical record indicated that on 3/31/17 Patient #2 was accompanied to the hospital due to breathing difficulties with seizure activity. The nurse had documented that prior to the hospitalization, the Patient had been drinking excessive amounts of water but their fasting blood sugar was 157 mg/dl.

The Patient returned to the facility on 4/5/17 with diagnoses including hyponatremia and seizure activity. Further review of the clinical record indicated that the Patient was weighed again on 4/29/17 with a documented weight of 184.5 pounds, representing a 20 pound weight loss in 2 months. There was no nutritional assessment conducted by the Dietitian upon admission or after an identified weight loss.

The Charge Nurse was interviewed on 5/16/17 at 10:00 A.M. and said that all Patients get weighed upon admission then the Nurse conducts an Admission Nursing Assessment which included a Nutrition/Hydration Risk section. Within this section the triggers include eating disorder, underweight, food allergies, Hepatitis, diabetes, dysphasia, obese, vomiting greater that 48 hours, renal problems, pregnancy, GI disorder, constipation, diarrhea greater than 48 hours and other. The next section indicated "Nutritional Risk includes but not limited to the above, other nutritional risk include anorexia, bulimia, dental problems, tube feeding, cardiovascular disease, liver disease, HIV/AIDS, hydration risk due to poor oral intake, constipation prescribed lithium, kidney disease, alcoholism, dry oral mucous, multiple medications and polidipsia" (excessive thrust).

The Charge nurse said that although there were nutrition triggers identified in the nursing assessment for Patient #2, there was no criteria given to the nurses to guide them on what constitutes the rational for a nutrition consult.

The clinical record was reviewed with the charge nurse and although the Patient triggered for diabetes she could not identify why the nurse did not request a nutritional consult either at admission or after the Patient experienced weight loss.

Review of the Food Intake Sheets indicated that when a Patient eats in the cafeteria a meal percentage is recorded. If the Patient eats on the unit, there was no documented evidence how much the Patient consumed after receiving a meal tray. The Food Intake Sheets were reviewed with the charge nurse on 5/16/17 at 10:30 A.M. who said it is an area that they need to work on.

The Infection Control Coordinator (ICC) was interviewed on 5/16/17 at 11:00 A.M. and asked if there was a policy about when a Patient is to have a nutritional assessment conducted by the Dietitian. The ICC returned and said that there was no policy as to when Nutritional Assessments should be conducted. The Dietitian was unavailable for interview.

The Patient was observed on 5/16/17 at noon, up on the unit, during the meal time. The Patient declined to eat that meal. Alternative was offered but he/she declined and stayed in their room.

2. For Patient #12, with a diagnoses of diabetes, elevated cholesterol and obesity, the facility failed to conduct a nutritional assessment to determine if the Patient's nutritional needs were being met.

Patient #12 was admitted to the facility in 4/2017 with diagnoses that included Bipolar Disorder, substance abuse, obesity, diabetes, elevated cholesterol and high blood pressure.

The Patient's admission height was documented as 5 feet 4 inches tall and weighted 223 pounds (Body Mass index 38.3-obese).

Review of the initial Nursing Assessment dated 4/25/17 indicated that the Patient had a Nutrition Risk factor of diabetes but a nutritional assessment plan was not indicated.

Review of the Clinical record indicated that the Patient was on an 1800 calorie diabetic diet, but there was no documented evidence that a nutritional assessment was conducted despite the trigger of diabetes, as well as other nutrition risk factors.

3. For Patient #14, with a diagnoses of elevated cholesterol and obesity, the facility failed to conduct a nutritional assessment to determine if the Patient's nutritional needs were being met.

Patient #14 was admitted to the facility in 5/2017 with diagnoses that included Bipolar Disorder, obesity, elevated cholesterol and high blood pressure.

The Patient's admission height was documented as 5 feet 4 inches tall and weighed 171 pounds (Body Mass index 29.4-obese).

Review of the initial Nursing Assessment dated 5/9/17 indicated that the Patient had no Nutrition Risk factor, however the Patient had diagnoses that included elevated cholesterol, and obesity and should have been triggered for a nutritional consult.

Review of the Food Intake Sheets indicated that the Patient consumed 75-100% from 5/13-5/16/17.

Review of the clinical record indicated that there was no indication that the Patient had a nutritional consult to assess the Patient's nutritional needs.




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4. For Patient #11, with diagnosis of diabetes, receiving an 1800 calorie diabetic diet, the hospital failed to conduct a nutritional assessment to determine if the patients nutritional needs were being met.

Patient #11 was admitted to the hospital in 4/2017 with diagnosis that included schizophrenia disorder with chronic mental illness and PTSD, hypertension, COPD, hypercholesteralemia and non insulin dependent diabetes mellitus.

Record review revealed that no admission weight or height was available.

Review of the initial nursing assessment, dated 4/7/2017, revealed that the Patient had a nutritional risk factor of diabetes, but that a nutritional assessment was not indicated.

The Charge nurse was interviewed on 5/18/17, at 11:00 A.M., she said that although there were nutrition triggers identified in the nursing assessment for Patient #11, there was no criteria given to the nurses to guide them on what constitutes the rational for a nutrition consult. There was no nutritional consult to further assess this patients nutritional needs.

Based record review and staff interview, the facility failed to ensure that the approved therapeutic diet manual was not more that 5 years old. Findings include:

During the initial kitchen tour on 5/15/17 at approximately 9:30 A.M., the Surveyor asked the Food Service Director (FSD) if there was a Diet Manual available to staff. The FSD said that the Diet Manual was on the inpatient unit and he would retrieve it.

On 5/16/17 the Infection Control Coordinator brought the Diet Manuel to the Surveyor. Review of the Diet manual indicated that although the manual had been signed by the Dietitian and the Medical Director in February 2017. The manual was was published in the year 2000.

On 5/16/17 at 2:00 P.M., the FSD was interviewed about the Diet Manual and said that he and the Dietitian had spoken in the past about obtaining the electronic Diet Manual but were waiting for funds to cover the cost.

Immediate Jeopardy.

Based on observation, record review and interview, the hospital failed to maintain the patients' physical environment to ensure the safety of all patients and that environment was free from ligature risk points (potential hanging sites) for patients that were at risk for suicide. The Hospital was informed on 4/5/17, by another surveying agency that the physical environment posed a high risk to patients for ligature/hanging and the Hospital staff failed to properly conduct safety checks to mitigate the risks of Patients hanging themselves. On 4/26/17, 1 patient (#16) hung him/herself in an area that had been identified on 4/5/17 as a ligature risk point. The patient died of injuries from the hanging. Following the patient event, the Hospital continued to fail, after more than a month and a half of having knowledge of ligature risk points and a patient hanging, to ensure the patients were provided a safe environment.

Findings include:

During the initial tour of the Hospital's Inpatient Unit (IPU), on 5/15/17 at 10:30 A.M., the Surveyors observed that the unit had environmental hazards that posed a safety risk for patients. The environmental hazards observed included door knobs, door hinges and multiple areas noted that could be used for patient who were at risk of harming self or others. Many of the environmental observations posed a risk for ligature/hanging.

On 5/16/17 at 11:30 A.M., an extensive environmental patient safety tour was completed with the Inpatient Unit's (IPU) Supervisor.

During the tour, the environmental hazards were discussed with the Unit's Supervisor. The Supervisor said that the Hospital had recently been surveyed by another accrediting agency on 4/5/17. The Supervisor said the survey agency had informed the Hospital that there were potential ligature points throughout the inpatient behavioral health unit. She said that the Hospital had taken action shortly after the survey on 4/5/17. The Supervisor said that many of the ligature risk areas required construction, so the Hospital's immediate plan to mitigate the risk had been to place all ligature points/areas and all patients on 5 minute face to face checks and the hospital had restricted the use of 2 bathrooms and a sensory room.

The Supervisor said that several weeks after the survey, the Administrative staff had changed the checks from 5 minute to 15 minutes for Patients and ordered the staff to continue to monitor the ligature risk points every 5 minutes. She said the day after the change in monitoring of Patients (4/25/17) to 15 minutes, a Patient (#16) hung him/herself in a bathroom stall (and eventually died). The Supervisor said since the event, the Hospital staff had resumed 5 minute checks of all Patients and all ligature risk points. The Supervisor said that the bathroom had been identified as a ligature risk point, but said that the accrediting agency had not identified the bathroom stall knob used by the Patient as a ligature risk point. The Surveyor asked if the Supervisor and her staff had a comprehensive list of the ligature risk points that staff were monitoring every 5 minutes and she said no. The Supervisor said that 2 staff were assigned the monitoring of the Patients and the ligature risk points and the staff carried a clip board to record their rounds/observations.

Observations of the IPU indicated it was broken into three compartments that housed a large center day room and with either bedrooms, dayrooms and bathrooms surrounding the compartment. In addition, there were two additional open spaces that were used for socializing and the other accessed a corridor to the medication room, and other social/activity spaces.

There were 10 patient rooms and 6 bathrooms. Two of the 6 bathrooms had a sign on door indicating they were out of order. There were several activity rooms. One of the activity rooms which was identified as the sensory room also had a sign indicating it was out of order.

The environmental hazards observed included:

The door closures, handles and/or the door hinges of all and/or at least 19 of the doors observed in all areas had a combination of ligature risk. Some doors had round knobs, three hinges, allowing a space between the hinges and many closures that could be used as ligature/asphyxiation points.

The door handles and door hinges posed risk for hanging and the mirrors and light coverings could be removed and broken. One of the bathroom's cabinet that contained the shower's faucets was unlocked and the pipes and faucets were accessible for hanging. The Supervisor said the box should be locked at all times and subsequently locked it.

The two areas identified as patient lounges and recreation areas were observed and the Supervisor said that patients were always supervised in these areas. However, observation indicated that the areas contained multiple ligature risks. There were telephone cords, electrical cords and wires. One of the rooms had 10 windows within the 2 rooms and there were Venetian blinds and each blind had two 8 foot cords attached. The area had a sink with a goose neck faucet and access to pipes. There was access to additional telephone cords, wires, door handles, wall pictures and hinges posed a potential risk of harm for patients at risk.

The medication room had two doors and one of the 2 was always locked and the outside door was locked when administering medications. However, when staff was not administering medication, the outside door was not secured and swung out.

At the time of the tour, the Surveyor asked the Supervisor where the ligature points were for patient who may be at risk of hanging Without directly answering the question asked, the Supervisor responded that the 5 minute ligature safety checks had been implement to mitigate the hazard until the the financial funding allowed for the physical changes.

Several pictures hung in each of the open spaces and activity rooms. The pictures were not firmly secured to the wall and the Surveyor was able to pull the pictures up off the flat surface of the wall and could have removed the pictures from the wall, making them a weapon.

During an interview on on 5/17/17 at 10:30 A.M., following the environmental tour, the Risk Manager said that following the 4/5/17 accrediting survey, the Hospital was informed of ligature risk points and based on these findings the Hospital implemented 5 minute checks and revised the Hospital's the environmental suicide/ligature risk point assessment on 4/10/17. The Risk Manager said that the Hospital was waiting for the financial support to alter the environment and that the 5 minute checks were to mitigate the risk. He said following the patient event on 4/26/16, when Patient hung him/herself in the bathroom, he said that the Hospital was waiting for the Hospital's investigation department report and root cause analysis report to revise the current plan. The Risk Manager said that the Hospital did not do their own investigation and had not debriefed the staff. He was unable to offer additional information showcasing alternate interventions to ensure the environment was safe following the patient event. He said the bathroom door latch had not been identified in the 4/5/17 survey and therefore not monitor as a ligature risk point. The Risk Manager said the incident was unfortunate, and following the 4/26/17 event, the Hospital removed the latch and placed all patients and ligature points back on 5 minute checks.

During interview on 5/17/17 at 10:45 A.M., the Director of Nursing (DON) said as of 4/5/17, she became aware of the ligature risk points and that the Hospital's suicide practice, assessments and screening were not evidence based and failed to incorporate tools to better identify a person's risk level on admission and during their stay. She said that the staff were instructed to complete 5 minute checks for all ligature risk points and patients shortly after 4/5/17. The DON said that she and the medical staff changed the checks for patients on 4/25/17, based on discussion and had not on identified individual patient risks. She said that the Psychiatrist had told the staff during a meeting that Patient #16 was not a suicide risk, but added that this information had not been documented in the record and she could not provide a date or a time. She said that she had started to formulate a task force for suicide risk, screening, assessment and care on 5/4/17, but had not been able to initiate anymore than the idea because of the survey visits. She also said that she had sent an email to staff on 5/11/17 informing staff of the ligature risks on the IPU. She said the email identified general risk areas, the bedrooms and bathrooms, but was not specific or comprehensive. She said she did not know if all the staff had read the email and understood the Hospital's expectations. She said that other than informal discussions with staff to monitor for ligature risk points, she had not monitor or completed audits. She said she did not know if the plan was effective and did not know if the Staff understood or were competent in their knowledge and were ensuring that the physical environment was safe from ligature risk points for patients at risk for suicide/self harm.

During additional interviews and observation of the Staff the following information was obtained:

During interview on 5/19/17 at 8:40 A.M., the Executive Director of the Hospital acknowledge problems associated with the care of Patient #16. He reiterated the incident of the change in monitoring and level of supervision of Patient verses environment. The Director said his understanding was the Patient had been in the bathroom and that a Staff had checked on the Patient, who was in a locked bathroom stall. The Director said, that during the check the Patient's feet were observed flat on the floor in the bathroom stall. He said it was unclear if the Staff spoke with the Patient or only visualized his/her feet. At some time after the check, the Patient was found hanging on the floor. The Director said that Staff stated that the bathroom had been identified as an area for risk of ligature/hanging and that it had been checked three times during the 15 minutes the Patient was in the bathroom.

During an interview with the DON on 5/19/17 at 10:30 A.M., she said the bathroom had been on 5 minute checks and the Patient was on 15 minute checks at the time of the event on 4/26/17. She said she did not know if staff saw the Patient face to face, but that they had seen his/her feet underneath the stall door. She also said that she did not know if staff had spoken with the Patient, but thought someone had asked how he/she was doing but was unsure. She said that no interviews were obtained after the event from staff.

During observations on 5/19/17 at 11:30 A.M., Nurse #2 was touring the IPU with the Surveyors. The Hospital's Risk Manager joined the tour. Nurse #2 was engaged and asked about the safety plan to prevent patient's at risk from harming themselves and what areas were identified as ligature risk points. Nurse #2 said she did not know, and then later asked if she could open a bathroom for Patient use, as there was a Patient who wanted to use the bathroom. This bathroom had been closed due to ligature risk, following the accreditation survey on April 5, 2017. The Nurse was unaware of the reason the bathroom had been made inaccessible. Following the interview the DON said that she had not formalized staff education and had not completed a comprehensive list of ligature risk points, she agreed that the method of emailing staff to educate and informal discussions may have not been sufficient.

Review of the Staff's monitoring sheets (Inpatient Unit Rounds Sheet), dated 5/19/17, identified the Patient, the room number, observation level (i.e.: 5 minute, 15 minute, etc), privilege. Each square was to document each time the face to face was conducted. The time identified in the grid was for 15 minute face to face safety patient checks and staff would document their location and mental status three times in the box for each 15 minute increment. The staff were to initial and sign the sheet at the end of their shift. The sheet included directions for staff to check windows and at the beginning of each shift sign that they completed laundry pick up, closets were locked, check bathrooms and locks, floor, tub, kitchen and client lounge. The sheet did not include information or identify ligature risk points.

Review of additional IPU round sheets, dated 5/ 17/17 and 5/18/17 (for a 24 hour time period for each day) indicated that staff failed to document 5 and 15 minute safety checks for 48 hours.

Review of the round sheets for 4/26/17 indicated the Staff checked the Patient #16 into the bathroom at 9:30 A.M. and that 5 minute door checks were competed three times during the time period the Patient was in the bathroom. The round sheets did not identify the bathroom as part of the ligature/environmental, nor did the sheets indicate any location being checked every 5 minutes.

During observation on 5/22/17 at 9:30 A.M. a Mental Health Worker (#1) was observed with a clip board entering one of the large compartment rooms. The Worker walked the perimeter and then began to exit the area. The Worker looked into several patient rooms, but was not observed checking areas such as bathrooms, closed doors or documenting on the clip board. General observations of the area revealed patients in room 319 and 321 and two others moving around the area, that included the bathroom. The Surveyor approached the Worker and asked if he could explain what he had just observed. The Mental Health Worker said he was checking patients and turned back into the area and began checking doors, bathrooms, rooms and then documenting his findings.


On 5/16/17 at 10:30 A.M., the Surveyor observed the mixing valve in the bathroom to be unlocked . The Unit Supervisor said the policy and procedure was to have the door of the valve locked at all times. The policy was for the staff to unlock the box when a patient showers, relock the door during the shower and unlock the door and turn the water off then relock the door.

On 5/22/17 at 1:25 P.M. the locked door which housed the mixing valve, as well as multiple large diameter water supply pipes was observed left open and ajar. Several of these pipes could easily be used as a ligature point for any patient with thoughts of hurting themselves. All patients on the IPU had access to this bathroom at the time. A Mental Health Worker (MWH) that had just completed rounds in this room and was observed walking out of the area just prior to the 2 surveyors entering the area. The MHW was asked about her observation of this area. She said she looks inside this room to be sure that there is not any Patients present when she makes her rounds. The charge nurse was called over and informed of this observation that the Surveyors had found. He then was observed to speak with the MWH briefly and continued with his daily dutieswithiut checking the area.

On 5/22/17 at 1:30 P.M., the Risk Manager was made aware of the observation and stated that staff should have completed an incident report based on the unlocked mixing valve door that was accessible to patients.

Subsequent, on 5/22/17 at 2:00 P.M., the Hospital Staff including the Risk Manager, Nurse Director and Administrator said that there had been no formal training. The Director of Nurses said that she formulated and provided a hand written copy of ligature risk points, dated 5/19/17. She said she would make sure the Staff were given the list to ensure that the staff can consistently implement safety checks of the hazards posed by the environment.

Based on observation, interview, and record review, the facility failed to:

I. Ensure that the social work assessments for eight (8) of eight (8) active sample patients (1, 5, 7, 8, 10, 11, 13, and 14) were completed before treatment planning occurred so that critical information could be provided for the development of the comprehensive treatment plan; and (2) failed to ensure that the social work assessments for five (5) of eight (8) active sample patients (8, 10, 11, 13, and 14) included recommendations regarding the role of the social worker in treatment and discharge planning. The absence of social work assessments at the time of treatment planning meetings and specific recommendations on the role of the social worker in treatment provision and discharge planning does not allow the treatment team to integrate the social worker into the planning and delivery of care, therefore prevents the treatment team from clarifying treatment interventions and goals related to the patient's psychosocial needs. (Refer to B108)

II. Ensure that the Treatment Plans for five (5) of eight (8) active sample patients (7, 8, 11, 13, and 14) were revised when patients failed to participate in the prescribed treatment. This failure impedes the provision of active treatment to meet the specific treatment needs of patients. (Refer to B118)

III. Develop treatment plans that clearly delineated interventions to address the specific treatment needs of seven (7) of eight (8) active sample patients (1, 5, 8, 10, 11, 13 and 14). Instead, treatment plans included interventions that were routine, generic discipline functions. In addition, there was failure to include interventions to guide personnel in the care of patients presenting safety issues in the clinical areas. This results in treatment plans that failed to reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment. (Refer to B122)

IV. Provide active treatment for five (5) of eight (8) active sample patients (7, 8, 11, 13, and 14) based on their individual needs. These patients were too acutely ill and/or not motivated to attend the treatment groups as prescribed in their treatment plan. Although the treatment plans for these patients included several group therapies/activities, these patients regularly and repeatedly did not attend these groups. This failure negates the clinical effectiveness of the patient's treatment goals and objectives, potentially delaying the patient's improvement. (Refer to B125, Section I)

V. Provide sufficient numbers of structured therapeutic groups to meet the needs of the patient population. This failure hinders patients' participation in active treatment and results in patients roaming the wards, sleeping in their bedrooms, and idly sitting around on the units. (Refer to B125, Section II)

Based on record review and interview, the facility: (1) failed to ensure that the social work assessments for eight (8) of eight (8) active sample patients (1, 5, 7, 8, 10, 11, 13, and 14) were completed before treatment planning occurred so that critical information could be provided for the development of the comprehensive treatment plan; and (2) failed to ensure that the social work assessments for five (5) of eight (8) active sample patients (8, 10, 11, 13, and 14) included recommendations regarding the role of the social worker in treatment and discharge planning.

Completion of social work assessments after the treatment planning meeting has taken place does not allow for essential psychosocial information to be integrated into the care planning process. The absence of specific recommendations on the role of the social worker in treatment provision and discharge planning does not allow the treatment team to integrate the social worker into the delivery of care and prevents the treatment team from clarifying treatment interventions and goals related to the patient's psychosocial needs.

Findings are:

A. Record Review

1. Patient 1: The Social Service Assessment and History was signed and dated on 8/9/16. The Treatment Plan meeting was held on 7/27/16.

2. Patient 5: The Social Service Assessment and History was signed and dated on 5/11/17. The treatment Plan held on 5/9/17.

3. Patient 7: The Social Service Assessment and History was signed and dated on 2/13/17. The Treatment Plan meeting was held on 2/6/17.

4. Patient 8: The Social Service Assessment and History was signed and dated on 3/6/17. The Treatment Plan meeting was held on 3/2/17. In addition, the assessment did not provide specific recommendations on the social worker's role in the patient's treatment and discharge planning. The following non-specific recommendations were included: "Providers ...case manager have been contacted re: this admission ...NP [Nurse Practitioner] has also been notified, as has guardian. Initially the plan is to return to On Grounds when stabilized and no longer a threat."

5. Patient 10: The Social Assessment and History was signed and dated on 4/4/17. The Treatment Plan meeting was held on 3/29/17. In addition, the assessment provided no specific recommendations on the social worker's role in treatment and discharge planning were provided. The following non-specific recommendation was included: "Initial focus will be on ensuring safety and working to start treatment to aid [his/her] to stabilize and set an aftercare plan for discharge, when [sic] [s/he] will be living and to also work out a plan with DCF."

6. Patient 11: The Social Service Assessment and History was signed and dated on 4/15/17. The Treatment Plan meeting was held on 4/10/17. In addition, the assessment provided no specific recommendations on the social worker's role in the patient's treatment and discharge planning for this homeless patient. The following non-specific recommendations were included: "Stabilization through pharmacological and psychosocial (individual and group) interventions. Establish and maintain contact with [patient's] DMH case manager. Coordinate with outpatient providers ... Explore other potential discharge options including. [sic] Spanish speaking providers."

7. Patient 13: The Social Service Assessment and History was not signed as of 5/15/17. The Treatment Plan meeting was held on 3/29/17. In addition, the assessment provided no specific recommendations on the social worker's role in the patient's treatment and discharge planning. The following non-specific recommendations were included: "Focus will center on stabilizing current symptoms though [sic] medication interventions aim [sic] on get [sic] [patient's name] back on long acting IM medications. Once stabilized we will work [sic] [his/her] DMH site and PACT on getting [him/her] returned to the community ... While here we will provide ongoing insight building psycho/educational supports."

8. Patient 14: The Social Assessment and History was not signed as of 5/15/17. The Treatment Plan meeting was held on 5/10/17. In addition, no specific recommendations on the social worker's role in treatment and discharge planning were provided.

B. Policy Review:

The Corrigan Mental Health Center "Admission Workflow" document stated that the Social Services Assessment & History Report will be "signed by day 10." However, the "Fall River Site Protocol" for "Treatment planning - Inpatient Unit" stated on page 3 of 4 that, "The comprehensive treatment plan is completed within 72 hours of admission ...."

B. Staff Interview:

An interview was conducted with W3, the MSW covering for the Director of Social Work, and the Director of Nursing on 5/16/16 at 4:15 p.m. When the late sample social work assessments were reviewed, both parties acknowledged that the assessments were not completed before the treatment planning meetings for these patients were held. When the treatment planning protocol and admission workflow documents were discussed, both parties acknowledged that the required completion date for social work assessments was not consistent with the CMS requirements and that the assessment should not be due after the due date for the completion of the treatment plan. When the lack of specific recommendations for the role of the social worker in treatment and discharge planning was pointed out in the documents, both acknowledged the deficiencies. Both concluded, "We have some work to do."

Based on interview and record review, the facility failed to ensure that the Treatment Plans for five (5) of eight (8) active sample patients (7, 8, 11, 13 and 14) were revised when the patients failed to participate in the prescribed treatment. The Treatment Plans were not revised to provide alternative treatment modalities. This failure impedes the provision of active treatment to meet the specific treatment needs of patients.

Findings include:

A. Patient 7 was admitted on 2/3/17.

1. According to the psychiatric evaluation (2/6/17), the patient, aged 52, was admitted for "psychotic decompensation in the context of medication non-adherence" and with a "primary complaint related to a parasitic infection which occurred when [s/he] was 15," a "chronic delusion of parasitic infection."

2. During an interview on 5/15/17 at 11:00 a.m., the patient perseverated on "crimes" committed against him/her; documentation that s/he was taped on "a reality TV program against my will;" and concerns that his/her parasitic infection was not being addressed. S/he indicated that s/he did not attend many groups.

3. Observation of Patient 7 throughout the day by the surveyor revealed that the patient remained in the common areas talking to himself/herself and carrying many papers and [his/her] cell phone. No staff interactions with the patient were observed.

4. Review of Patient 7's treatment plan (5/10/17) indicated that the patient was only able to engage in non-delusional conversation for up to "5 minutes." The psychiatric intervention included "monitor mental status ... encourage to take Trilafon" - the patient was currently being prescribed fluphenazine, not Trilafon according to the MAR printed on 5/1/5/17. "The occupational therapy intervention was, "To engage in leisure activities for at least 15 minutes to distract from stressors" and "Encourage participation in 1 group/activities [sic] daily for 15 minutes ..."

5. Review of OT, group, and leisure activity attendance notes for Patient 7 from 5/1/17-5/15/17 revealed that 87 out of 109 groups/activities were refused. The patient was excused from another 4 of the 109 groups/activities. 13 of the 109 groups/activities attended were "Snack Social" sessions. Five (5) of the 109 groups/activities attended were "Community meetings." Four (4) of the groups/activities attended were "Leisure/recreational."

6. Even though this patient refused to attend the preponderance of groups offered and remained preoccupied with delusional thoughts, which impaired the patient's ability to tolerate groups, as of 5/15/17 the treatment plan for Patient 7 had not been revised to ensure interventions that were more appropriate for this patient's treatment needs.

B. Patient 8 was admitted on 3/1/17.

1. According to the psychiatric evaluation (3/2/17), the patient was admitted with history of "chronic mental illness ...refused doses of medication ...tried to strike staff ...threatens to harm self and other [sic]."

2. During an interview on 5/15/17 at 10:55 a.m., Patient 8 was very agitated and hostile, refusing to talk. S/he got up and left the room.

3. A review of Patient 8's treatment plan (5/10/17) showed that the staff was to encourage patient's "attendance to [sic] Expressive Therapy, Sensory and Unit activities ..." A social worker intervention was to "provide support to focus on [his/her] own treatment ..."

4. A review of the group attendance notes for Patient 8 from 5/1/17-5/15/17 revealed that s/he failed to attend 18 of 29 groups conducted by the occupational therapist and five (5) of seven (7) groups conducted by social work.

5. Even though this patient was not able to tolerate groups and his/her frequent disruption of group process for other patients, as of 5/15/17 the treatment plan for Patient 8 had not been revised to ensure interventions that were more appropriate for this patient's treatment needs.

C. Patient 11 was admitted on 4/7/17.

1. According to the psychiatric evaluation (4/12/17), the patient required translator services due to limited English proficiency. The patient was described as "hearing voices" and repeating over and over "My mind is gone." The patient was further described by the translator as "difficult to understand and thinking seemed disjointed [sic]. Was not able to provide information in a linear fashion." The mental status section of the evaluation described the patient as, "Very limited with low IQ."

2. The surveyor attempted to interview the patient on two occasions on 5/15/17, at 11:20 a.m. and again at 3:00 p.m. Patient 11 was always in the bed with covers pulled up and refused to participate even for a brief hello.

3. A review of Patient 11's treatment plan (5/3/17) indicated that Nursing, "will encourage [the patient] to participate in unit activities; that Occupational Therapy, "will meet with [the patient] to engage in focusing activities to distract form [sic] AH (dominos, artwork) ...will provide a daily visual schedule to provide organization/orientation to the unit; that Social Work will, "continue working on discharge disposition and assist with paperwork as needed for DDS."

4. A review of OT, group, and leisure activities notes from 5/1/17-5/15/17 for Patient 11 revealed that Patient 11 refused 79 out of 124 offered opportunities. The patient was excused from nine (9) of the 124 offerings. Four (4) of the groups attended were community meetings; 11 of the groups attended were for Snack/Social sessions.

5. Even though this patient refused the majority of groups and unit activities offered, spent substantial time in bed, and was not able to tolerate group situations due to persisting thought disorder, as of 5/15/17 the treatment plan for Patient 11 had not been revised to ensure interventions that were more appropriate for this patient's treatment needs.
D. Patient 13 was admitted on 5/5/17.

1. According to the psychiatric evaluation (5/8/17), the patient was transferred from another facility "because of a conflict there with another [male/female] patient ...with a perceived risk of escalation of the conflict between these two and hence for safety [Patient] has been transferred here." "Violence Risk Assessment: recent violent behaviors with [male/female] patient at Pocasset-hence [his/her] transfer here."

2. During observation of a group conducted by OT on 5/15/17 at 1:30 p.m., Patient 13 entered the group late and left after about five (5) minutes.

3. During an interview on 5/15/17 at 2:10 p.m., Patient 13 stated that [s/he] "usually does not go to any groups."

4. Rounds of the unit on 5/16/17 at 11:10 a.m. revealed Patient 13 was covered up asleep in his/her bed. The surveyor was not able to get the patient to respond to verbal approach.

5. Patient 13's treatment plan (5/8/17) included a nursing intervention that stated, "Encourage participation in groups/unit activities" An OT intervention stated, "Encourage participation on [sic] ADLs [Activities of Daily Living] and unit activities."

6. Review of the group attendance notes for Patient 13 from 5/7/17-5/15/17 revealed that s/he failed to attend eight (8) of 16 groups conducted by the occupational therapist and three (3) of three (3) groups conducted by social work.

7. Even though this patient was not able to tolerate groups, as of 5/15/17 the treatment plan for Patient 13 had not been revised to ensure interventions that were more appropriate for this patient's treatment needs.

E. Patient 14 was admitted on 5/9/17.

1. According to the psychiatric evaluation ((5/10/17), Patient 14 had, "Become increasingly disinterested in things ... brain is not working properly ... It has been difficult for [the patient] to get out of bed in the morning ... spends day sitting ... no longer watches TV ... today could not get out of bed ... Male companion ... is recovering [sic] from some unknown condition in NH [Hospital] so [the patient] has virtually no human contact other than [the patient's] sister's visits." The plan section of the evaluation raises questions of "early dementia ... needs imaging to R/O [rule out] subcortical, vascular dementia from [the patient's] HTN [hypertension]."

2. During observation of the Motivation Group on 5/15/17 at 1:30 p.m., Patient 14 was observed joining the group late, interrupting to state "this place is making me worse ...it's making me sick ... it's a sin." Patient 14 then exited the group abruptly.

3. Patient 14's treatment plan ((5/10/17) did not contain any problem related to the concern regarding dementia or its further evaluation. The Occupational Therapy intervention stated, "Encourage participation in task groups (Expressive Therapy, Sensory Exercise) to promote improved mood and provide distraction from upsetting thoughts."

4. A review of OT, group, and leisure activity notes from 5/10/17-5/15/17 revealed that Patient 14 refused 33 out of 43 offerings. Patient 14 was excused from two (2) of the offerings. Of the offerings attended, three (3) groups were a "Snack/Social" opportunity, two (2) were recreational activities, and two (2) groups were "Community meetings."

5. Even though this patient refused the preponderance of offered groups and activities and was, at times, disruptive when group activities were attended, as of 5/15/17 the treatment plan for Patient 14 had not been revised to ensure interventions that were more appropriate for this patient's treatment needs.

Based on record review and interview, treatment plans included deficient outcome patient goals for eight (8) of eight (8) active sample patients (1, 5, 7, 8, 10, 11, 13 and 14). Goals were stated in non-measurable terms and failed to delineate specific outcome behaviors for patients. Some patient goals did not correlate with the identified problems or were treatment compliance rather than outcome goals. These deficiencies in goal statements hinder the ability of the team to individualize treatment and to measure change in the patient consequent to treatment interventions.

Findings include:

A. Record Review

1. Patient 1-treatment plan dated 5/2/17

For the problem of, "Discharge planning as evidenced by upset about discharge from Taunton and unwilling to upset [sic] recommended services in the community ...," the long-term goal was stated as, "Will have clear thinking and return to the community." This was a non-measurable goal.

A short-term goal was stated as, "Will attend and participate in two structured groups a day to increase social participation with peers." The correlation of this goal to the problem statement was not clear.

2. Patient 5-treatment plan dated 5/10/17

For the problem of, "Suicidal thoughts as evidenced by looks depressed. States [s/he] does not want to look at self at [sic] the mirror ...stated I wish someone will shoot me," the long-term goal was stated as, "Will feel safe and free of suicidal thought and return to the community." This was a non-measurable goal.

A short-term goal was stated as "Will continue to attend at least 2 groups to develop relaxation techniques to help [him/her] deal with frustrations." This was a statement of treatment compliance, rather than an outcome goal to measure whether the problem has been decreased/resolved.

3. Patient 7-treatment plan dated 5/10/17

For the problem of, "Problems with living situation as evidenced by believes that [s/he] has been infected by a parasite for the last 39 years ... Believes that [s/he] has snakes that pop out of [him/her]," a non-measurable long-term goal was stated as, "Will demonstrate clear thing and return to the community."

4. Patient 8-treatment plan dated 5/10/17

For the problem of, "Threatening behavior in group home as evidenced by staff report increased paranoia and agitation, attempted to punch the staff, refused some of [his/her] medication," a non-measurable long-term goal was stated as, "Will return to [his/her] group home with safe behavior."

5. Patient 10-treatment plan dated 5/10/17

For the problem of, "Anxiety as evidenced by believes [s/he] is pregnant despite multiple negative test [sic]," a non-measurable long-term goal was stated as, "Will be thinking clearly and able to function safely in the community."

A short-term goal was stated as, "Will work with Dan to find stable housing and plan discharge." This was a treatment compliance goal, rather than a goal that directed interventions to assist the patient to reduce/resolve stated problem.

6. Patient 11-treatment plan dated 5/3/17

For the problem of, "Confusion as evidenced by sad, feels medications do not work, hearing command voices, threatening others in the community, states [s/he] is feeling confused, exposed self to others," a short-term goal was stated as, "Will identify 1 goal [s/he] can work on while waiting for transfer." This goal did not correlate with the stated problem. Another goal was, "Will spend time out of bed demonstrating good social interactions." "Good social interactions" was a non-measurable behavioral statement.

7. Patient 13-treatment plan dated 5/8/17

For the problem of, "Disorganized thinking as evidence by altercation with a peer at previous hospital, some disorganized communication," a non-measurable long-term goal was stated as, "Will have a clear thinking so that s/he can function safely in the community."

A short-term goal was stated as, "Will attended [sic] at 2 groups [sic] daily and engage in a calm conversation with peers and staff for at least 5 minutes." This goal was not correlated with stated problem.

8. Patient 14-treatment plan dated 5/10/17

For the problem of, "Depressed mood as evidenced by disgusted with everything, not getting out of bed, decreased interest in pleasurable activities, feeling hopeless, difficult concentrating, want to die with no plan," a non-measurable long-term goal was stated as, "Will return home feeling hopeful and safe."

A non-measurable short-term goal was stated as, "Will spend increased time out of bed ..."

B. Interview

During an interview, with the review of treatment plans on 5/16/17 at 9:45 a.m., the DON acknowledged that some of the goals were non-measurable.

Based on record review and interview, the facility failed to develop treatment plans that clearly delineated interventions to address the specific treatment needs of seven (7) of eight (8) active sample patients (1, 5, 8, 10, 11, 13 and 14). Instead, treatment plans included interventions that were routine, generic discipline functions. In addition, there was a failure to include interventions to guide personnel in the care of patients presenting safety issues in the clinical areas. This failure results in treatment plans that failed to reflect a comprehensive, integrated, and individualized approach to multidisciplinary treatment.

Findings include:

A. Record Review

1. Patient 1-treatment plan dated 5/2/17

For the problem of, "Discharge planning as evidenced by upset about discharge from Taunton and unwilling to upset [sic] recommended services in the community ...," a physician intervention was stated in generic terminology as, "Will meet with [Patient] and assess current regimen of medication making changes if needs and assess mental status, educate about treatment plan and encourage active discharge planning with case manager."

A nursing intervention was stated as, "RN will meet with [Patient] every shift, administer medication, educate about treatment and assess for any side effects of medications to report to MD, assess for safety and encourage [Patient] to continue to interact with staff and peers."

There were no identified interventions for staff to assist the patient to deal with his/her feelings about discharge.

2. Patient 5-treatment plan dated 5/10/17

For the problem of, "Suicidal thoughts as evidenced by looks depressed. States [s/he] does not want to look at self at [sic] the mirror ...stated I wish someone will shoot me," a physician intervention was stated as a role function: "Will meet with [Patient] 5x a week during rounds to assess for mental status, review medications and make changes if necessary, educate about treatment, and assess for therapeutic response."

A nursing intervention stated as generic role functions was, "RN will meet with [Patient] to assess mental status and safety, encourage participation in unit routines, administer medications and report to MD any concerns, provide with list of medications, generic name, indications for use and administration times as per [his/her] request." There were no nursing interventions to address the safety of this patient with suicidal thoughts based on patient needs/findings.

A generic/role function social work intervention was stated as, "Will meet with [Patient] to obtain consent to talk to outside providers ...assess for the need for referrals and services needed after discharge."

3. Patient 8-treatment plan dated 5/10/17

For the problem of, "Threatening behavior in group home as evidenced by staff report increased paranoia and agitation, attempted to punch the staff, refused some of [his/her] medication," a nursing intervention was stated as, "Will meet with client every shift to assess safety, encourage polite interactions on the unit, encourage med [medication] compliance and inform MD of any concerns/changes in mental status." This intervention was a statement of generic role functions. There were no nursing interventions to address the safety of this patient presentation of threatening, paranoid and agitated behaviors based on patient needs/findings.

A social work intervention stated as, "Will provide support to focus on [his/her] own treatment and communicate with guardian and outpatient providers," was a statement of generic role functions.

Even though this patient was acutely ill and unable to tolerate groups, an occupational therapy intervention stated, "Encourage attendance to Expressive Therapy, Sensory (groups) ..."

4. Patient 10-treatment plan dated 5/10/17

For the problem of, "Anxiety as evidenced by believes [s/he] is pregnant despite multiple negative test [sic] ..." a physician intervention was stated as, "Will meet with [Patient] 5 times a week to assess mental status, discuss thoughts and feelings, will review treatment regimen and make adjustments as needed." This intervention was a statement of role functions.

A nursing intervention was stated as, "RN and staff will meet with [Patient] 5 times a week to assess any changes in mental status, encourage medication compliance and educate about treatment plan, encourage participation in unit activities and address any concerns that [Patient] may have." This was a statement of nursing role functions. Even though this patient was acutely ill, this intervention states that mental status will be conducted only five (5) times/week. There were no interventions to direct nursing personnel in responding to this patient's paranoia and delusional statements.

Even though this patient was acutely ill, an occupational therapy intervention stated, "Encourage continued attendance to all groups offered for daily routine, opportunity to practice coping skills and build insight into [his/her] symptoms."

5. Patient 11-treatment plan dated 5/3/17

For the problem of, "Confusion as evidenced by sad, feels medications do not work, hearing command voices, threatening others in the community, states [s/he] is feeling confused, exposed self to others," a generic physician intervention stated, "Will meet with [Patient] during rounds to assess treatment effectiveness, review medications, make changes as indicated, will contact DDS to arrange for therapeutic activities while [Patient] is on the unit."

A generic nursing intervention was stated as, "Will encourage [Patient] to participate in unit activities, answer any questions about medications or treatment plan, assess changes in mental status and collaborate with the team to identify goals that better address [Patient's] needs, monitor for safety ..." There were no interventions to direct nursing personnel in responding to this patient's presentation of hallucinations and potential aggression in the clinical area.

A generic social work intervention was stated as, "Will meet with [Patient] and case manager to continue working on discharge disposition and assist with paperwork as needed for DDS."

6. Patient 13-treatment plan dated 5/8/17

For the problem of, "Disorganized thinking as evidence by altercation with a peer at previous hospital, some disorganized communication," a physician intervention stated as a generic role function was, "Will meet with [Patient] during rounds to assess mental status, review medications, make changes if necessary and encourage participation in unit milieu."

A generic nursing intervention was stated as, "RN and nursing staff will administer prescribed medications as ordered, monitor for side effects, assess mental status and encourage [sic] [Patient] in a calm conversation, and encourage participation in groups/unit activities." There were no specific interventions to guide staff in how to respond to patient's presenting behaviors (disorganized thinking and previous aggression) in the clinical area.

A generic social work intervention was stated as, "Will meet with [Patient] to compete [sic] Psychosocial assessment, obtain consent to talk to outside providers and family ..."

7. Patient 14-treatment plan dated 5/10/17

For the problem of, "Depressed mood as evidenced by disgusted with everything, not getting out of bed, decreased interest in pleasurable activities, feeling hopeless, difficult concentrating, want to die with no plan," a generic physician intervention was stated as, "Will meet with [Patient] 5x weekly to assess safety, discuss side effects [s/he] is experiencing and establish a medication regimen [Patient] would be comfortable with,"

A generic nursing intervention was stated as "RN and nursing staff will administer medications, assess for safety ...assess mental status, and provide a therapeutic milieu ..." Other than, "Provide 1:1 when [Patient] is feeling unsafe," there was no specific intervention to guide staff regarding his/her suicidal ideation

A generic social work intervention was stated as, "Will meet with [Patient] to gather releases for outpatient providers ...to build support and gather collateral information."

B. Interview

During an interview with the review of treatment interventions on 5/16/17 at 9:45 a.m., the DON acknowledged that the nursing interventions were role functions and failed to include specific nursing interventions for safety issues.

Based on observation, interview, and record review, the facility failed to:

I. Provide active treatment for five (5) of eight (8) active sample patients (7, 8, 11, 13, and 14) based on their individual needs. These patients were too acutely ill and/or not motivated to attend the treatment groups as prescribed in their treatment plan. Although the treatment plans for these patients included several group therapies/activities, these patients regularly and repeatedly did not attend these groups. This failure negates the clinical effectiveness of the patient's treatment goals and objectives, potentially delaying the patient's improvement.

II. Provide sufficient numbers of structured therapeutic groups to meet the needs of the patient population. For many days there were no scheduled treatment groups after 3:30 p.m. and for three (3) days of the week, there were only one to two (1-2) groups conducted by professional staff. This failure hinders patient's participation in active treatment and results in patients roaming the wards, sleeping in their bedrooms, and idly sitting around on the units.

Findings include:

I. Failure to provide individualized active treatment:

A. Patient 7 was admitted on 2/3/17.

1. According to the psychiatric evaluation (2/6/17), the patient, aged 52, was admitted for "psychotic decompensation in the context of medication non-adherence" and with a "primary complaint related to a parasitic infection which occurred when [s/he] was 15," a "chronic delusion of parasitic infection."

2. During an interview on 5/15/17 at 11:00 a.m., the patient perseverated on "crimes" committed against him/her; documentation that s/he was taped on "a reality TV program against my will;" and concerns that his/her parasitic infection was not being addressed. He indicated that he did not attend many groups.

3. Observation of Patient 7 throughout the day by the surveyor revealed that the patient remained in the common areas talking to him/her and carrying many papers and his/her cell phone. No staff interactions with the patient were observed.

4. Review of Patient 7's treatment plan (5/10/17) indicated that the patient was only able to engage in non-delusional conversation for up to "5 minutes." The psychiatric intervention included, "Monitor mental status, encourage to take Trilafon" - the patient was currently being prescribed fluphenazine, not Trilafon according to the MAR printed on 5/1/5/17. "The occupational therapy intervention was, "To engage in leisure activities for at least 15 minutes to distract from stressors" and "encourage participation in 1 group/activities [sic] daily for 15 minutes ...."

5. Review of OT, group, and leisure activity attendance notes for Patient 7 from 5/1/17-5/15/17 revealed that 87 out of 109 group/activities were refused. The patient was excused from another four (4) of the 109 groups/activities. Thirteen (13) of the 109 groups/activities attended were "Snack Social" sessions. Five (5) of the 109 groups/activities attended were "Community meetings." Four (4) of the groups/activities attended were "Leisure/recreational."

a. An OT Individual Treatment Note, dated 5/2/17, with a focus on "Function/Perform Skills" indicated that Patient 7 met with the OT for "45 minutes." However, the note stated, "As we progressed in the 1:1 [the patient] became more preoccupied with paranoia and delusions (video cameras taping, parasites) ..."

b. An OT Individual Treatment Note, dated 5/3/17, with a focus on "community integration" indicated that Patient 7, "Started out pleasant and voiced appreciation for assistance, however quickly became frustrated and focused on delusional beliefs ..."

c. An OT Individual Treatment Note, dated 5/5/17, with a focus on "SI Process Tech Training" stated that Patient 7 "was lying on the couch when the dog came to meet [the patient] ....took a minute to pet the dog and address the dog by his name ...."

d. An OT Individual Treatment Note dated 5/11/17 with a focus on "Community Integration" stated that Patient 7 "was bright upon approach" but in "approx. [approximately] 2 minutes then became frustrated ....thoughts became perseverative."

B. Patient 8 was admitted on 3/1/17.

1. According to the psychiatric evaluation (3/2/17), the patient was admitted with history of "chronic mental illness ... refused doses of medication ... tried to strike staff ... threatens to harm self and other [sic]."

2. During an interview on 5/15/17 at 10:55 a.m., Patient 8 was very agitated and hostile, refusing to talk. S/he got up and left the room.

3. Review of Patient 8's treatment plan (5/10/17), the staff was to encourage patient's "attendance to [sic] Expressive Therapy, Sensory and Unit activities ..." A social worker intervention was to "provide support to focus on [his/her] own treatment ..."

4. Review of the group attendance notes for Patient 8 from 5/1/17-5/15/17 revealed that s/he failed to attend 18 of 29 groups conducted by the occupational therapist and five (5) of seven (7) groups conducted by social work.

a. An OT group note (5/2/17) documented, "[Patient] attended ...however was angry throughout group, bringing up personal issues and was difficult to redirect."

b. An RN note (5/2/17) stated, "Did not attend group, [s/he] has been highly disruptive on the units. [S/he] received a handout but ripped it up, [sic] [s/he] [sic] was hostile and not receptive to teaching."

c. An OT group note (5/3/17) stated, "Was excused today from group. Just prior to group beginning s/he was banging walls, slamming doors and yelling."

d. An OT group note (5/10/17) stated, "Wandered in and out of group, could not be encouraged to participate."

e. An OT note (5/11/17) stated, "In and out (group room), loud and voicing his/her displeasure with staff, encouraged to participate ...verbally aggressive each time s/he entered the room."

5. Even though this patient was not able to tolerate groups and his/her frequent disruption of group process for other patients, as of 5/15/17 the treatment plan for Patient 8 had not been revised to ensure interventions that were more appropriate for this patient's treatment needs.

C. Patient 11 was admitted on 4/7/17.

1. According to the psychiatric evaluation (4/12/17), the patient required translator services due to limited English proficiency. The patient was described as "hearing voices" and repeating over and over "My mind is gone." The patient was further described by the translator as "difficult to understand and thinking seemed disjointed [sic]. Was not able to provide information in a linear fashion." The mental status section of the evaluation described the patient as, "Very limited with low IQ."

2. The surveyor attempted to interview the patient on two occasions on 5/15/17, at 11:20 a.m. and again at 3:00 p.m. Patient 11 was always in the bed with covers pulled up and refused to participate even for a brief hello.

3. A review of Patient 11's treatment plan (5/3/17) indicated that Nursing, "Will encourage [the patient] to participate in unit activities; that Occupational Therapy, "Will meet with [the patient] to engage in focusing activities to distract form [sic] AH (dominos, artwork) ... will provide a daily visual schedule to provide organization/orientation to the unit; that Social Work will, "Continue working on discharge disposition and assist with paperwork as needed for DDS."

4. A review of OT, group, and leisure activities notes from 5/1/17-5/15/17 for Patient 11 revealed that Patient 11 refused 79 out of 124 offered opportunities. The patient was excused from nine (9) of the 124 offerings. Four (4) of the groups attended were community meetings; Eleven (11) of the groups attended were for Snack/Social sessions.

a. An OT Individual Treatment Note (5/1/17) with a focus on "SI Process Tech Training" stated that Patient 11, "Engaged in tactile activity as an alerting technique."

b. An OT Individual Treatment Note (5/2/17) with a focus on "Function/Perform Skills" indicated that Patient 11, "Initially refused ....was able to focus and engage in polite social interactions."

c. An OT Individual Treatment Note (5/4/17) with a focus on "Function/perform Skills" indicated that Patient 11, "Was able to engage in leisure activity for 15 minutes."

d. An Education Group (5/7/17) with a focus on "Psycho-Education" indicated that Patient 11 showed, "Minimal participation ... interrupted group on several occasions to complain about dental pain and ask to go to the ER."

e. An OT Individual Treatment Note (5/9/17) with a focus on ADL/Self-Care" indicated that the OT met with the patient "for 10 minutes to assist with organizing [the patient's] daily and personal space."

f. An OT Individual Treatment Note (5/10/17) with a focus on ADL/Self-Care" indicated that the OT met with the patient "for 15 minutes to continue working on daily routine and increasing time out of bed."

g. An OT Individual Treatment Note (5/11/17) indicated that the OT met with the patient "for 5 minutes to engage in a leisure activity of [the patient's] choice to promote healthy social interactions and provide structure."

h. An Education Group Therapy Note (5/14/17) with a focus on "Psychiatry Psycho-Education" indicated that the patient, "Came in late to the group, sat down and only had two requests: being transferred to Taunton tomorrow and having second servings in the cafeteria. [S/he] lefts [sic] whenever [s/he] wanted only to come back again for brief periods. Did not contribute to a discussion about [his/her] condition."

D. Patient 13 was admitted on 5/5/17.

1. According to the psychiatric evaluation (5/8/17), the patient was transferred from another facility "because of a conflict there with another [male/female] patient ...with a perceived risk of escalation of the conflict between these two and hence for safety [Patient] has been transferred here." "Violence Risk Assessment: recent violent behaviors with [male/female] patient at Pocasset-hence [his/her] transfer here."

2. During observation of a group conducted by OT on 5/15/17 at 1:30 p.m., Patient 13 entered the group late and left after about five (5) minutes.

3. During an interview on 5/15/17 at 2:10 p.m., Patient 13 stated that s/he, "usually does not go to any groups."

4. Rounds of the unit on 5/16/17 at 11:10 a.m. revealed Patient 13 cover up asleep in his/her bed. The surveyor was not able to get the patient to respond to verbal approach.

5. Review of Patient 13's treatment plan (5/8/17), a nursing intervention stated, "Encourage participation in groups/unit activities" An OT intervention stated, "Encourage participation on [sic] ADLs [Activities of Daily Living] and unit activities."

6. Review of the group attendance notes for Patient 13 from 5/7/17-5/15/17 revealed that s/he failed to attend eight (8) of 16 groups conducted by the occupational therapist and three (3) of three (3) groups conducted by social work.

a. An OT group note (5/8/17) documented, "[Patient] was in [his/her] room sleeping, when awoken declined stating s/he need rest. Offered alternate activity which [s/he] also refused."

b. A social work group note (5/8/17) stated, "Actually came into the group as it was ending. Offered info [information] to discuss individually."

c. An OT group note (5/9/17) documented, "[Patient] was sleeping during exercise and did not acknowledge writer."

d. An OT group note (5/10/17) documented, "[Patient] was in bed sleeping. [S/he] had difficulty sleeping last evening..."
e. OT group notes (5/11/17) stated, "Patient was in bed at start of exercise group and refused both exercise group and alternative handout." And "[Patient] was sleeping in bed, did not respond to knock on door or verbal invite."

f. OT group notes (5/12/17) stated, "[Patient] was sound asleep in [his/her] room during exercise group." "[Patient] was in bed. Did not respond to knock on door or verbal invite."

g. An OT group note (5/15/17) documented, "[Patient] came into group late, was in and out and did not wish to participate ... Sat in group for about 5 minutes, no participation."

7. Even though this patient was not able to tolerate groups, as of 5/15/17 the treatment plan for Patient 13 had not been revised to ensure interventions that were more appropriate for this patient's treatment needs.

E. Patient 14 was admitted on 5/9/17.

1. According to the psychiatric evaluation ((5/10/17), Patient 14 had "become increasingly disinterested in things ... brain is not working properly ... It has been difficult for [the patient] to get out of bed in the morning ... spends day sitting ... no longer watches TV ... today could not get out of bed ... Male companion ... is recovering [sic] from some unknown condition in NH so [the patient] has virtually no human contact other than [the patient's] sister's visits." The plan section of the evaluation raised questions of "early dementia ... needs imaging to R/O [rule out] subcortical, vascular dementia from [the patient's] HTN [hypertension]."

2. During observation of the Motivation Group on 5/15/17 at 1:30 pm, Patient 14 was observed joining the group late, interrupting to state, "This place is making me worse ... it's making me sick ... it's a sin." Patient 14 then exited the group abruptly.

3. Review of Patient 14's treatment plan ((5/10/17) did not contain any problem related to the concern regarding dementia or its further evaluation. The Occupational Therapy intervention stated, "Encourage participation in task groups (Expressive Therapy, Sensory Exercise) to promote improved mood and provide distraction from upsetting thoughts."

4. A review of OT, group, and leisure activity notes from 5/10/17-5/15/17 revealed that Patient 14 refused 33 out of 43 offerings. Patient 14 was excused from two (2) of the offerings. Of the offerings attended, three (3) groups were a "Snack/Social" opportunity, two (2) were recreational activities, and two (2) groups were "Community meetings."

a. An Education Group Therapy note (5/12/17) with a focus on "Dietary-Healthy Lifestyles" indicated that Patient 14, "Arrived late to the group after the English muffin pizzas were finished ....chose a pizza and ate it with the group."

b. An OT Group Therapy note (5/15/17 with a focus on "Function/Perform Skills" indicated that Patient 14, "Was invited to group ...agreed but did not follow through, writer reinvited [sic] [the patient] ... participated in 2 10 minute intervals, difficult focusing on task, repeatedly voiced "I'm getting words being here."

II. Failure to ensure scheduled treatment based on the needs of the patient population:

A. Review of treatment schedule for the Adult Unit revealed that there were no treatment groups offered after 3:30 p.m. other than on Monday and Wednesday when an RN group was conducted from 7:00 p.m. to 7:45 p.m.

In addition, on Wednesday, Saturday, and Sunday, there were only one to two (1-2) groups conducted by professional staff members. All other groups/ activities were delegated to and conducted by non-professional staff (Mental Health Technicians). These activities were leisure-oriented, rather than therapeutic treatment based on individualized needs of the patient population.

B. During an interview on 5/15/17 at 11:15 a.m. HCT W2 reported that when the leader for the "Peer Support Group" did not come, the patients were given an alternative activity that was patients' choice such as games, puzzles, or a physical exercise. When asked if he received direction from the RN about the content for assigned groups (exercise, open studio, orientation), he responded, "No, when giving the patients a choice. We are more flexible on Saturday; we can do mazes, draw."

C. During an interview on 5/15/17 at 11:30 a.m., when asked if the group led by the dietitian occurred today, the DON responded "The nutrition group was not held today as the dietitian is not here. When she is not here we offer an alternative." When asked what the alternative would be, she reported, "It might be an open recreation group as puzzles games, word search."

D. During an interview on 5/15/17 at 10:55 a.m., when asked what groups/activities s/he enjoys on the unit, Patient 1 responded, "There's not much going on."

E. During the interview with the Director of Nursing and W3 (MSW covering for the Director of Social Work out on sick leave) on 5/16/17 at 4:15 pm, both indicated that, "Every morning, the OT-Rs select which groups the patients will attend." In addition, both indicated that, "We used to have an OT on weekends, but the person retired, and the position was removed."

F. During an interview, with a review of the Unit programming schedule, on 5/17/17 at 11:15 a.m., the Director of Nursing reported that the staff had stated, "We have been talking about this issue." She reported that the facility would like to have Occupational Therapy and Social Work offered on weekend days. She added, "Maybe we need to do programming based on tracks or levels (of functioning)."

Based on record review and policy review, the facility failed to complete the Discharge Summary in one (1) of five (5) sampled discharge summaries (D5) and the patient death reviewed (E1) by the required date. Failure to complete discharge summaries in a timely fashion impedes the provision of continuity of care by recipient providers due to an absence of critical patient treatment and response information. In the case of a patient death, the absence of a discharge summary compromises the facility's database on the assessment and care provided and does not include a professional description of the circumstances surrounding the patient's death.

Findings include:

A. Record Review:

1. Patient D5 was discharged on 3/3/2017 - there was no discharge summary in the medical record.

2. E1 was triaged to Charlton Memorial Hospital on 4/26/2017 and the death was reported on 4/29/17 - there was no discharge summary in the medical record.

B. Policy Review:

The Fall River Site Protocol on the topic "Discharge Procedures" with an effective date of 10/23/03 and a revision date of 5/29/2014 stated, "Discharge Summary is completed electronically by Psychiatrist within 15 days of discharge."

Based on record reviews, observations, and interviews, the Medical Director failed to monitor the quality and appropriateness of clinical care provided. Specifically, the Medical Director failed to:

I. Ensure that the history and physical examinations of one (1) of eight (8) active sample patients (13) was completed and enumerated active medical problems to be pursued during the hospital course. Failure to provide sufficient medical data and treatment recommendations on active medical conditions compromises the patient's well-being and safety.

Findings include:

A. Record Review:

The History and Physical (date of exam - 5/6/17) of Patient 13 did not describe the physical findings on examination of each organ system in sufficient detail (all body areas described as "negative") and did not provide a final assessment and recommendations based on the review of systems and physical examination.

B. Policy Review:

The Dr. John C. Corrigan Mental Health Center Medical Staff Organization Bylaws dated July 2015, "Rules and Regulations Appendix C (pages 55-6) delineates the details to be completed in the history and physical, including the specific body areas to be examined in each organ system."

C. Staff Interview:

The Area Medical Director and MD2 (Inpatient Medical Director covering for the Site Medical Director who was on vacation) were interviewed on May 16, 2017 at 3:00 p.m. Medical staff documentation was reviewed. Both MDs concurred that the History and Physical Examination needed to be completed by the internist in order to delineate any active medical problems that needed to be addressed in the patient's treatment plan. Both MDs agreed ("yes they should be complete") that all content areas in the History and Physical Examination needed to be completed by the evaluating physician.

II. Ensure that (1) the Comprehensive Psychiatric Evaluations for three (3) of eight (8) sample patients (1, 5, and 11) were completed in a timely fashion; and (2) all required content areas of the Comprehensive Psychiatric Evaluation for one (1) of eight (8) active sample patients (7) was completed. Failure to complete the Comprehensive Psychiatric Evaluation in a timely fashion and failure to address all content areas in the Comprehensive Psychiatric Evaluation hampers the ability of the treatment team to develop a comprehensive treatment plan based on the findings and recommendations of the psychiatrist. Lack of this basic clinical information can negatively affect decision-making on the need for further evaluation. Without more detailed information about a patient's orientation, memory functioning, capacity for abstraction, fund of knowledge, and level of intellectual functioning, it is not possible to know the specific extent of the patient's capacity or impairment so that appropriate treatment modalities can be chosen, and/or so that changes in response to treatment can be measured. This can lead to an incomplete plan of care and insufficient delineation of active treatment interventions, prolonging the patient's hospital stay and discharge to a less restrictive level of care.

Findings include:

A. Record Review:

1. Patient 1 was admitted on 7/26/16. The Comprehensive Psychiatric Evaluation was signed and dated on 7/31/16.

2. Patient 5 was admitted on 5/2/17. The Comprehensive Psychiatric Evaluation was signed and dated on 5/8/17.
3. The mental status section in Patient 7's Comprehensive Psychiatric Evaluation was missing clinical data on ability to recall, memory description, attention/concentration, abstract thinking, fund of knowledge, and estimated intelligence; the AIMS examination for tardive dyskinesia; and the examination for extrapyramidal side effects.

4. Patient 11 was admitted on 4/7/17. The Comprehensive Psychiatric Evaluation was signed and dated on 4/12/17.

B. Policy Review:

The Corrigan Mental Health Center Admission Workflow, dated 4/7/10, indicated that the attending psychiatrist must complete the Comprehensive Psychiatric Assessment "within 4 days of admission," putting the facility's policy in conflict with the CMS standard that psychiatric assessments be completed within 60 hours of the patient's admission.

C. Staff Interviews:

1. The Director of Medical Records and the Risk Manager/Quality manager were interviewed on 5/16/2017 at 9:10 a.m. The Director of Medical Records stated that the electronic medical records are considered completed when they are "signed and dated," and "not when dictated." She confirmed where this is indicated on printed copies of the treatment plans. The Risk Manager/Quality Manager agreed. The facility's Risk Manager/Quality Manager was not able to produce a specific policy delineating when Comprehensive Psychiatric Assessments were due. He did produce the afore-mentioned Corrigan Mental Health Center Admission Workflow, indicating that Comprehensive Psychiatric Assessments were due "within 4 days of admission."

2. The Area Medical Director and MD2 (Inpatient Medical Director covering for the Site Medical Director who was on vacation) were interviewed on May 16, 2017 at 3:00 p.m. Medical staff documentation was reviewed. Both MDs concurred that the Comprehensive Psychiatric Evaluations needed to be completed prior to conducting a treatment planning meeting. Both MDs agreed ("yes they should be complete") that all content areas in the Comprehensive Psychiatric Evaluations needed to be completed by the evaluating psychiatrist.

III. Ensure that the Treatment Plans for four (4) of eight (8) active sample patients (1, 5, 7, and 11) were completed in a timely fashion. Failure to complete treatment plans in a timely fashion prevents the unit staff from appreciating the individualized problems of the patients and limits their ability to carry out problem-driven patient-specific treatment interventions that will assist the patients in meeting their goals for discharge and return to the community. This can prolong the patient's hospital stay and readiness for discharge to a less restrictive level of care.

Findings include:

A. Record review:

1. Patient 1 was admitted on 7/26/16 and the treatment planning meeting was held on 7/27/17. The Treatment Plan was not signed and dated until 7/31/16.

2. Patient 5 was admitted on 5/2/17 and the treatment planning meeting was held on 5/9/17. The Treatment Plan was not signed and dated until 5/10/17.

3. Patient 7 was admitted on 2/3/217 and the treatment planning meeting was held on 2/6/17. The Treatment Plan was not signed and dated until 3/13/17.

4. Patient 11 was admitted on 4/7/17 and the treatment planning meeting was held on 4/10/17. The Treatment Plan was not signed and dated until 4/12/17.

B. Policy Review:

The Fall River Site Protocol "Treatment planning - Inpatient Unit" effective 4/24/14 and revised 4/27/17 stated on page 3 that, "The comprehensive treatment plan is completed within seventy-two hours of admission ..."

C. Staff Interviews:

1. The Director of Medical Records and the Risk Manager/Quality manager were interviewed on 5/16/17 at 9:10 a.m. The Director of Medical Records stated that the electronic medical records are considered completed when they are "signed and dated," and "not when they are dictated." She confirmed where this is indicated on printed copies of the treatment plans. The Risk Manager/Quality Manager agreed.

2. The Area Medical Director and MD2 (Inpatient Medical Director covering for the Site Medical Director who was on vacation) were interviewed on May 16, 2017 at 3:00 p.m. Medical staff documentation was reviewed. Both MDs concurred that the facility's policy was that Treatment Plans be completed within 72 hours of the patient's admission, as stipulated in the facility's policy on treatment planning.

IV. Ensure that the Treatment Plans for five (5) of eight (8) active sample patients (7, 8, 11, 13 and 14) were revised when the patients failed to participate in the prescribed treatment. This failure impedes the provision of active treatment to meet the specific treatment needs of patients. (Refer to B118)

V. Ensure that treatment plans clearly delineated interventions to address the specific treatment needs of seven (7) of eight (8) active sample patients (1, 5, 8, 10, 11, 13 and 14). Instead, treatment plans included interventions that were routine, generic discipline functions. In addition, there was failure to include interventions to guide personnel in the care of patients presenting safety issues in the clinical areas. This results in treatment plans that failed to reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment. (Refer to B122)

VI. Ensure that active treatment was provided for five (5) of eight (8) active sample patients (7, 8, 11, 13, and 14) based on their individual needs. These patients were too acutely ill and/or not motivated to attend the treatment groups as prescribed in their treatment plan. Although the treatment plans for these patients included several group therapies/activities, these patients regularly and repeatedly did not attend these groups. This failure negates the clinical effectiveness of the patient's treatment goals and objectives, potentially delaying the patient's improvement. (Refer to B125, Section I)

VII. Ensure that the facility offered sufficient numbers of structured therapeutic groups to meet the needs of the patient population. This failure hinders patient's participation in active treatment and results in patients roaming the wards, sleeping in their bedrooms, and idly sitting around on the units. (Refer to B125, Section II)

VIII. Ensure that the Discharge Summaries for one (1) of five (5) sampled discharge summaries (D5) and the patient death reviewed (E1) were completed by the required date. Failure to complete discharge summaries in a timely fashion impedes the provision of continuity of care by recipient providers due to an absence of critical patient treatment and response information. In the case of a patient death, the absence of a discharge summary compromises the facility's database on the assessment and care provided and does not include a professional description of the circumstances surrounding the patient's death. (Refer to B133)

IX. Ensure that use of private equipment as cell phones did not hinder active treatment or impede patient confidentiality in the clinical area. Policy allowed patients to carry and use their personal cell phones 24 hours/day. This practice potentially hinders active treatment for these patients and was a confidentiality issue for all patients due to the phone's cameras.

Findings include:

A. Observation and Interview:

1. Patient 7 was observed carrying a cell phone in the unit dayroom on 5/15/17 at 11:00 a.m. During an interview held at the same time, Patient 7 used his/her personal cell phone to show the surveyor alleged pictures of the ventral surface of his/her foot in order to "prove" that a worm or parasite had entered it. Patient 7 stated that he/she "used my cell phone" to call various outside parties regarding being hospitalized against his/her will and various other conspiracies.

2. During an interview on 5/15/17 at about 11:15 a.m., non-sample Patient 12 stated, "Where is my cell phone. I'm always losing it." Patient 12 found his/her cell phone in with some papers that s/he was carrying.

3. During an interview on 5/17/17 at 11:30 a.m., when asked about patient cell phones, the DON and Risk Manager/Quality Manager reported, "We have some concerns about confidentiality (cell phone cameras). We do feel that the use of these phones may affect the patients' treatment." They reported that Patient's Rights at the hospital has stressed the right of patients to carry their private phones even though they have unit phones available for patients' use on the unit.

C. Review of policy

Facility policy, "Use of Electronic Devices on Inpatient Unit," with revised date of 2/23/17, stated, "It is the responsibility of the treatment team to determine if it clinically appropriate for a patient to obtain, use and maintain an electronic device ..." This policy requires that the patient signed an agreement for the use of the electronic device as a cellular phone, IPad, etc. This agreement outlined requirements for use as, "I will not use my electronic devices(s) for illegal purposed ..." I will respect the privacy of all patients, staff and visitors at JCCMHC by not photographing or making video or audio recordings of anyone ..." "I will not loan my electronic devices(s) to others." However, another part of the policy states, "Patients with electronic devices will not be reimbursed by JCCMHC for charges accrued by unauthorized use by other patients."

Based on record review and interview, the Director of Nursing failed to:

I. Ensure that treatment plans for seven (7) of eight (8) active sample patients (1, 5, 8, 10, 11, 13 and 14) included nursing interventions based on the patients' needs. Instead, treatment plans included interventions that were routine, generic functions. In addition, there was a failure to include interventions to guide nursing personnel in the care of patients presenting safety issues in the clinical areas. This results in treatment plans that failed to reflect a comprehensive, integrated, individualized approach to treatment.

Findings include:

A. Record Review

1. Patient 1-treatment plan dated 5/2/17

For the problem of, "Discharge planning as evidenced by upset about discharge from Taunton and unwilling to upset [sic] recommended services in the community ...," a nursing intervention was stated as, "RN will meet with [Patient] every shift, administer medication, educate about treatment and assess for any side effects of medications to report to MD, assess for safety and encourage [Patient] to continue to interact with staff and peers."

2. Patient 5-treatment plan dated 5/10/17

For the problem of, "Suicidal thoughts as evidenced by looks depressed. States [s/he] does not want to look at self at [sic] the mirror ...stated I wish someone will shoot me," a nursing intervention stated as generic role functions was, "RN will meet with [Patient] to assess mental status and safety, encourage participation in unit routines, administer medications and report to MD any concerns, provide with list of medications, generic name, indications for use and administration times as per [his/her] request." There were no nursing interventions to address the safety of this patient with suicidal thoughts based on patient needs/findings.

3. Patient 8-treatment plan dated 5/10/17

For the problem of, "Threatening behavior in group home as evidenced by staff report increased paranoia and agitation, attempted to punch the staff, refused some of [his/her] medication," a nursing intervention was stated as, "Will meet with client every shift to assess safety, encourage polite interactions on the unit, encourage med [medication] compliance and inform MD of any concerns/changes in mental status." This intervention was a statement of generic role functions. There were no nursing interventions to address the safety of this patient presentation of threatening, paranoid and agitated behaviors based on patient needs/findings.

4. Patient 10-treatment plan dated 5/10/17

For the problem of, "Anxiety as evidenced by believes [s/he] is pregnant despite multiple negative test [sic] ..." a nursing intervention was stated as, "RN and staff will meet with [Patient] 5 times a week to assess any changes in mental status, encourage medication compliance and educate about treatment plan, encourage participation in unit activities and address any concerns that [Patient] may have." This was a statement of nursing role functions. Even though this patient was acutely ill, this intervention states that mental status will be conducted only 5 times/week. There were no interventions to direct nursing personnel in responding to this patient's paranoia and delusional statements.

5. Patient 11-treatment plan dated 5/3/17

For the problem of, "Confusion as evidenced by sad, feels medications do not work, hearing command voices, threatening others in the community, states [s/he] is feeling confused, exposed self to others," a generic nursing intervention was stated as, "Will encourage [Patient] to participate in unit activities, answer any questions about medications or treatment plan, assess changes in mental status and collaborate with the team to identify goals that better address [Patient's] needs, monitor for safety ..." There were no interventions to direct nursing personnel in responding to this patient's presentation of hallucinations and potential aggression in the clinical area.

6. Patient 13-treatment plan dated 5/8/17

For the problem of, "Disorganized thinking as evidence by altercation with a peer at previous hospital, some disorganized communication," a generic nursing intervention was stated as, "RN and nursing staff will administer prescribed medications as ordered, monitor for side effects, assess mental status and encourage [sic] [Patient] in a calm conversation, and encourage participation in groups/unit activities." There were no specific interventions to guide staff in how to respond to patient's presenting behaviors (disorganized thinking and previous aggression) in the clinical area.

7. Patient 14-treatment plan dated 5/10/17

For the problem of, "Depressed mood as evidenced by disgusted with everything, not getting out of bed, decreased interest in pleasurable activities, feeling hopeless, difficult concentrating, want to die with no plan," a generic nursing intervention was stated as, "RN and nursing staff will administer medications, assess for safety ...assess mental status, and provide a therapeutic milieu ..." Other than, "Provide 1:1 when [Patient] is feeling unsafe," there were no specific interventions to guide staff regarding his/her suicidal ideation.

B. Interview

During an interview on treatment interventions on 5/16/17 at 9:45 a.m., the DON acknowledged that the nursing interventions were role functions and failed to include specific nursing interventions for safety issues.

II. Ensure that use of private equipment as cell phones did not hinder active treatment or impede patient confidentiality in the clinical area. Policy allowed patients to carry and use their personal cell phones 24 hours/day. This practice potentially hinders active treatment for these patients and is a confidentiality issue for all patients due to the phone's cameras.

Findings include:

A. Observation and Interview:

1. Patient 7 was observed carrying a cell phone in the unit dayroom on 5/15/17 at 11:00 a.m. During an interview held at the same time, Patient 7 used his/her personal cell phone to show the surveyor alleged pictures of the ventral surface of his/her foot in order to "prove" that a worm or parasite had entered it. Patient 7 stated that he/she "used my cell phone" to call various outside parties regarding being hospitalized against his/her will and various other conspiracies.

2. During an interview on 5/15/17 at about 11:15 a.m., non-sample Patient 12 stated, "Where is my cell phone. I'm always losing it." Patient 12 found his/her cell phone in with some papers that s/he was carrying.

3. During an interview on 5/17/17 at 11:30 a.m., when asked about patient cell phones, the DON and Risk Manager/Quality Manager reported, "We have some concerns about confidentiality (cell phone cameras). We do feel that the use of these phones may affect the patients' treatment." They reported that Patient's Rights at the hospital has stressed the right of patients to carry their private phones even though they have unit phones available for patients' use on the unit.

C. Review of policy

Facility policy, "Use of Electronic Devices on Inpatient Unit" with revised date of 2/23/17, states "It is the responsibility of the treatment team to determine if it clinically appropriate for a patient to obtain, use and maintain an electronic device ..." This policy requires that the patient signed an agreement for the use of the electronic device as a cellular phone, IPad, etc. This agreement outlines requirements for use as "I will not use my electronic devices(s) for illegal purposed ..." I will respect the privacy of all patients, staff and visitors at JCCMHC by not photographing or making video or audio recordings of anyone ..." "I will not loan my electronic devices(s) to others." However, another part of the policy states, "Patients with electronic devices will not be reimbursed by JCCMHC for charges accrued by unauthorized use by other patients."

Based on record review and interview, the Director of Clinical Social Work failed to monitor and evaluate the quality and appropriateness of treatment provided by social work. Specifically, the Director of Social Work failed to:

I. Ensure that the social work assessments for eight (8) of eight (8) active sample patients (1, 5, 7, 8, 10, 11, 13, and 14) were completed before treatment planning occurred so that critical information could be provided for the development of the comprehensive treatment plan. Completion of social work assessments after the treatment planning meeting has taken place does not allow for essential psychosocial information to be integrated into the care planning process. (See B108)

II. Ensure that the social work assessments for five (5) of eight (8) active sample patients (8, 10, 11, 13, and 14) included recommendations regarding the role of the social worker in treatment and discharge planning. The absence of specific recommendations on the role of the social worker in treatment provision and discharge planning does not allow the treatment team to integrate the social worker into the delivery of care and prevents the treatment team from clarifying treatment interventions and goals related to the patient's psychosocial needs. (See B108)

III. Ensure that social work interventions were included in the treatment plans for five (5) of eight (8) active sample patients (5, 8, 11, 13 and 14). Instead, these treatment plans included interventions that were routine, generic discipline functions. This results in treatment plans that failed to reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment. (Refer to B122)