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Based on observation, interview, and record review, the hospital failed to ensure the Governing Body was responsible for the conduct of the hospital as evidenced by:

1. The Governing Body failed to ensure professional and supportive staff provided intensive and comprehensive active treatment programs to promote the physical and mental health of patients in the BHU. Cross reference to A- 083.

2. The Governing Body failed to provide oversight of their contracted hemodialysis service regarding cleaning of the hemodialysis equipment and checking of the RO systems prior to each treatment. Cross reference to A-084.

3. The Governing Body failed to ensure services to BHU patients were provided in a safe manner. Vulnerable patients were admitted to the unit who did not meet established criteria for a voluntary admission to the unit as they were unable to give informed consent for treatment due to confusion and poor judgment. Cross reference to A-0131.

4. The Governing Body failed to ensure patients received care in a safe environment in the BHU. One of the 16 patients reviewed in the BHU had multiple documented instances of aggression toward other patients and the patient was not provided with a 1:1 (one to one) monitoring to ensure he did not threaten other patients. Cross reference to A- 0144.

5. The Governing Body failed to develop, implement, and maintain an effective QAPI program. Cross reference to A- 0263.

6. The Governing Body failed to have an effective, organized nursing service to provide quality care to patients. Cross reference to A- 0385.

7. The Governing Body failed to ensure complete reappraisal of the medical staff. In addition, one physician was not reassessed after repeated medical records deficiencies. This created the risk of substandard services provided by members of the medical staff. Cross reference to A- 0340.

8. The Governing Body failed to ensure the medical staff bylaws regarding the medical record were implemented when multiple physician's progress notes for three of 38 sampled patients (Patients 7, 8, and 9) were not entered into the medical record in a chronological and timely fashion. Cross reference to A- 0353.

The cumulative effect of these systemic failures resulted in the hospital's inability to provide quality healthcare in a safe environment to the patients.

Based on interview and document review, the hospital's GB failed to provide for patients in the BHU:

1. A Director of Social Services to monitor and evaluate the quality and appropriateness of the social services care provided for two of the 16 patients (Patients 12 and 13) reviewed in the BHU.

2. At least one staff member in the BHU qualified by education and experience in social services. This had the potential for social services to be performed by an inexperienced employee.

3. A Therapeutic Activities Program that was appropriate to the needs and interests of three of the 16 BHU patients reviewed (Patients 12, 13, and 14). In addition, there was no treatment program during morning hours for the 16 patients in the BHU. Patients were observed as idle during that time.

This had the potential for the quality of services provided to patients in the BHU to be negatively affected and created the risk of poor health outcomes for those patients.

Findings:

1. Review of the hospital's P&P titled Case Management/Social Service Manual last reviewed on 3/13, showed a social worker shall have overall responsibility for the service. A social worker is defined as a "person who is licensed as a clinical social worker by the Board of Behavioral Science Examiners." The social service staff shall be sufficient in number and qualifications to effectively provide the service needed.

Social Service means assisting patients and their families to understand and cope with emotional and social problems which affect their health status, with appropriately organized staff. Social Service staff shall be involved in orientation and in-service training of the staff to assist in identifying social and emotional problems of patients. Periodically, an appropriate committee of the medical staff shall evaluate the service provided and make appropriate recommendations to the executive committee of the medical staff and administration.

During an interview with the hospital's DON on 7/8/14 at 1600 hours, the DON was asked to name the current inpatient Director of Social Services. The DON stated the Director was LCSW 1. The DON stated the inpatient Behavioral Health Unit employed two social workers: ASW 1 (ASW is a social worker who has the associate status until such time as they have completed 3,200 hours of supervised work experience and are eligible for licensure) and AT 1.

The DON stated the hospital also employed an AT who also performed social services such as discharge planning as well as her duties as the recreational therapist. The DON acknowledged the AT position and the Recreational Therapist Position would normally be two full time positions.

The DON stated LCSW 1 shared her working hours between the inpatient BHU and the outpatient partial program (located across the street). The DON stated the LCSW 1 worked seven hours for the outpatient partial program and one hour for the hospital's inpatients BHU.

Review of the LCSW 1's job description showed her position title was "Outpatient Social Worker III." LCSW 1 reported to the director and gave supervision to the ASW and for the MFT. The job summary failed to show documentation LCSW 1 was providing monitoring and evaluation of the quality and appropriateness of the social services furnished for the inpatient behavioral health.

During an interview with LCSW 1 on 7/7/14 at 1610 hours, she was asked if she was the Director of Social Services for the BHU. LCSW 1 stated "No, I'm not, I sign off the competencies" for ASW 1.

The LCSW 1 stated she discussed, validated, and signed off ASW 1's psychosocial assessments of the patients on the BHU and reviewed discharge planning; however, LCW 1 stated she did not directly observe or supervise the ASW 1's work performance on the BHU. LCSW 1 stated she reviewed only the written work of the ASW.

Review of ASW 1's job description showed the ASW 1 was hired on 3/5/14 (approximately three months ago) as Inpatient Behavioral Health Social Worker I. ASW 1 reported to the "Director." The job description did not show she was to supervise.

During an interview with ASW 1 on 7/8/14 at 1400 hours, ASW 1 confirmed she did not review the quality of services and treatment provided by social services for the inpatient BHU.

2a. Review of the Psychosocial Assessment for Patient 12 completed on 6/13/14, by a MFT showed no evidence the assessment was reviewed by a master's level social worker.

b. Medical Record Review was initiated on 7/7/14, for Patient 13. The patient was admitted on 6/27/14, from the ED.

Review of the Psychosocial Assessment for Patient 13 completed on 6/28/14, by a MFT showed no evidence the assessment was reviewed by a master's level social worker.

On 7/7/14 at 0945 hours, Patient 13 was observed in front of the nursing station in a wheelchair. The patient appeared thin and disheveled. The patient was very difficult to understand due to the fact she had no teeth (fully edentulous) and she was hard of hearing; however, the patient was pleasant and cooperative.

During an interview with the ASW on 7/7/14 at 1400 hours, the ASW stated Patient 13 was admitted without dentures and hearing aids. The ASW stated she was unable to initiate any referral for dental or an audiologist for the hearing aids as of yet. The ASW stated the referrals were in the discharge plan.

Review of Patient 13's Treatment Plan to address Potential Discharge Placement/Inadequate Social Resources dated 6/29/14, showed the long-term goals were to obtain placement, medication compliance, positive coping skills, decrease delusions, and reality orientation. There was no evidence to a show medically related social services such as dentures and hearing aids were addressed.

During an interview with ASW 1 on 7/7/14 at 1410 hours, she was asked where Patient 13 was going to be discharged. ASW 1 stated Patient 13 was to return to the SNF where she was living previously. However, in a follow-up interview with ASW 1 on the same day, the ASW stated when she called the SNF and staff stated Patient 13 was not transferred from their facility.

Review of the Psychosocial Assessment dated 6/27/14, showed Patient 13's current living situation was in her house.

Additional record review found no other documentation to show the ASW made any other attempts, or pursued other avenues to locate Patient 13's family members.

During an interview with the ASW 1 on 7/9/14 at 0800 hours, she stated Patient 13 was discharged to a SNF the previous day.

ASW 1 (ASW is a social worker who has the associate status until such time as they have completed a certain number of supervised work experience and are eligible to obtain licensure) was interviewed on 7/8/14 at 1400 hours. ASW 1 stated she holds a master's degree in social work; however, she is working under LCSW 1's supervision.

Review of ASW 1's personnel record with the Human Resources Manager and the DON on 7/9/14 at 0850 hours, showed ASW 1 was hired by the hospital on 3/24/14. ASW 1 received her Master's in Social Work in September, 2013; however, this was her first position in an inpatient BHU.

3. On 7/7/14 at 0850 hours, during a tour of the BHU with the Nursing Director of Psychiatric Services, he stated "there are activities every day."

During multiple observations of patients on the BHU during morning hours on 7/7, 7/8, and 7/9/14 between 0830 hours and 1100 hours, approximately 15 patients were observed lying in their beds, walking the hallways, sitting in the day room watching television, or sitting in the activity room at various times. CNAs were observed doing rounds for the 15 minutes checks of patients and the nurses were observed inside the nurses' station most of the time. There were no observable activities for the patients during this time.

Review of the BHU schedule showed the following activities and time frames:

* 0900 hours to 0915 hours - Fresh Air Break (smoke break)
* 0930 hours to 1000 hours - Goals Group
* 1015 hours to 1100 hours - ADL group
* 1045 to 1100 hours - Daily Exercise
* 1100 to 1200 hours- Psychotherapy Group
* 1345 hours to 1430 hours - Creative Therapy Group
* 1430 hours 1515 hours - Leisure Time
* 1530 hours to 1615 hours - Current Events
* 1615 to 1630 hours - Refresh Air (smoke break)
* 1630 hours to 1715 hours - Symptom Management
* 1830 hours to 2000 hours - Visiting
* 2030 hours to 2100 hours - Fresh Air (smoke break)
* 2100 to 2130 hours - Wrap-Up Group

During an interview with the Nursing Director of Psychiatric Services on 7/8/14 at 1600 hours, he stated basically the unit provided five groups of activities a day (psychotherapy, activity group, ADL, and nursing group (start and wrap-up groups). The Director stated the ADL group consisted of the nurses in the morning giving hygiene care for the patients, such as shaving and grooming. The Director stated nursing staff reviewed the patient's goals for the day in the morning and evening.

During an interview with RN K on 7/8/14 at 1200 hours, she was asked to explain the ADL group. RN K stated basically the CNAs provided grooming, showers, and shaving, etc.

During an interview with RN D, she was asked to explain the start-up and wrap-up groups. RN D stated when she made her rounds in the mornings she asked the patients what their goals were for the day.

During an interview with the AT on 7/8/14 at 1130 hours, the AT stated she was pretty busy in the unit. She shared her working time between recreation therapy and social work. The AT stated there was no Activity Director, she reported to the Nursing Director of Psychiatric Services.

The AT was asked to show the therapeutic activity plan for the week. The AT stated she did not have one. She stated she planned what she was going to do in the morning based on the patients' needs.

The AT was asked to explain the afternoon activities schedule (creative therapy group, current events, and symptom management). The AT stated the time frame on the schedule was 45 minutes for each group (total 2.25 hours); however, she stated she "combined" these three groups into one group, one hour long.

a. During an interview with Patient 12 on 7/8/14 at 0845 hours, the patient stated "there's nothing to do here, they don't have activities I enjoy. I basically stay in my room all day. "

Medical record review for Patient 12 was initiated on 7/7/14. Patient 12 was admitted on 5/30/14, with a diagnosis including schizophrenia (mental disorder often characterized by abnormal social behavior and failure to recognize what is real).

Review of the Activity Therapy Assessment dated 6/2/14, showed Patient 12 enjoyed reading and the patient was withdrawn and isolative. The initial treatment goal was for the patient to attend group two times a day and be able to focus on and compete one task.

Patient 12's Master Treatment Plan dated 5/30/14, showed a pre-printed form on which five of six preprinted short-term "measurable desired outcomes" were checked off, including Problem #1 to address "Alteration In Mood." Nursing interventions listed were generic tasks that would be performed by any patient.

Patient 12 was refusing group therapy; however, the treatment plan was not reviewed and with new interventions added to address his refusal. There was no Patient's signature on any of the treatment meetings documentation to show the patient was actively engaged in the treatment milieu (supportive environment).

Review of the Social Services Notes showed Patient 12 was refusing to attend groups despite prompts from staff.

During an interview with the AT on 7/8/14 at 1130 hours, she confirmed Patient 12 refused to attend group therapy.

Further review of the medical record did not show documentation to indicate any alternative treatment was provided for Patient 12.

b. During an interview with Patient 13 on 7/8/14 at 1000 hours, she stated "I just want to go home."

Medical record review for Patient 13 was initiated on 7/7/14. Patient 13 was admitted on 6/27/14, with a diagnosis including psychosis (when the patient loses contact with reality).

Review of the Activity Therapy Assessment dated 6/30/14, showed Patient 13 enjoyed nothing right now, patient was hard of hearing, and her speech was slurred and difficult to understand. The initial treatment goal was for the patient to attend group two times a day and be able to focus on group task for 10 minutes by discharge.

Patient 13's Master Treatment Plan dated 5/30/14, showed a pre-printed form on which five of six preprinted short-term "measurable desired outcomes" were checked off, including Problem #1 to address "Alteration Thought Process." Nursing interventions listed were generic tasks that would be performed by any patient. There was no treatment plan developed to address activity therapy.

c. During an interview with Patient 14 on 7/8/14 at 0845 hours, she stated "Sometimes I go to the activities, but they don't mean too much to me."

Medical record review for Patient 14 was initiated on 7/7/14, and showed the patient was admitted on 6/11/14, with diagnoses including bipolar disorder (disorder associated with mood swings that range from the lows of depression to the highs of mania).

Review of the Activity Therapy Assessment dated 6/13/14, showed Patient 14 enjoyed painting, crafts, music, television, coffee, and going to the movies. The initial treatment goal was for the patient to attend group three times a week and be able to identify two coping skills to deal with depression.

Patient 14's Master Treatment Plan dated 5/30/14, showed a pre-printed form on which five of six preprinted short-term "measurable desired outcomes" were checked off, including Problem #1 to address "Alteration Thought Process" Nursing interventions listed were generic tasks that would be performed by any patient. The treatment plan did not include any individualized interventions related to activity therapy.

Based on observation, interview, and record review, the hospital failed to provide oversight of their contracted hemodialysis service (hemodialysis is a method used to achieve the removal of waste products from the blood when the kidneys are in a state of failure) regarding cleaning of the hemodialysis equipment and checking of the RO systems (reverse osmosis is a system used to purify water for dialysis) prior to each treatment. These failures pose the potential of the spread of infections and could affect the patients' safety and treatment.

Findings:

The hemodialysis equipment storage area was observed on 7/8/14 at 1425 hours, with the Infection Control RN. The following was identified:

1. Review of the hemodialysis supplier's P&P titled Single Pass Dialysis Machine-Cleaning and Disinfection effective date 1/10, showed the cleaning procedure is to be done immediately following each dialysis treatment.

Observation of Dialysis Machines 1 and 2 showed water in white buckets hung from the back of the RO system and attached to the back of the dialysis machine.

The Infection Control RN stated the buckets were used to collect the residual dripping from the machine.

2. Review of the Hemodialysis Cleaning and Disinfection Log for Dialysis Machine 1 for June, 2014, showed one dialysis treatment was performed on 6/11/14 at 0315 hours, for an unnamed patient.

3. Review of the hemodialysis supplier's P&P titled RO System, Check Change in Delta Pressure reviewed date 1/12, showed the purpose of the RO system check is to determine if enough water source goes to the RO delivery system. The nurse will check the inlet and outlet pressure pre-dialysis.

Review of the Hemodialysis Cleaning and Disinfection Log for Dialysis Machine 1 for the month of June, 2014, showed Dialysis Machine 1 was used to provide hemodialysis treatment to two patients on 6/3/14 at 1300 and 1730 hours.

The Equipment Operation Log Sheet for Dialysis Machine 1 for the month of June, 2014, show the RO system was checked on 6/3/14 at 1000 hours. However, the Equipment Operation Log Sheet failed to show the RO system was checked prior to the second use of Dialysis Machine 1.

4. Review of the hemodialysis supplier's P&P titled RO System Check Change in Delta Pressure reviewed on 1/12, showed the nurse will check the inlet and outlet pressure pre-dialysis. If the delta pressure is greater than 10, the biomedical company will be notified to replace the tank or filter (the delta pressure is the difference between the inlet and outlet pressure).

The hemodialysis company's Equipment Operation Log Sheet, used prior to every patient treatment for documentation of the pressure of the water supply, showed the difference in the pressure going into the filter and coming out of the filter should be more than or equal to 10 pounds per square inch (this is to determine if there is enough water pressure to provide a hemodialysis treatment).

Review of the Equipment Operation Log Sheet for Dialysis Machine 1 for June, 2014, showed the delta pressure was greater than 10 on multiple times.

For example, on 6/1/14, the inlet pressure of the RO system was 25 and the outlet pressure of the RO system was 10. The difference between the inlet and out let pressure was 15.

According to the hemodialysis supplier's P&P, if the difference between the inlet and outlet pressure was 15, the company would be notified for the replacement of the tank or filter. However, according to the Equipment Operation Log Sheet, the difference between the inlet and outlet pressure was more than 10, and it was 15. There was no documentation the biomedical company was notified.

During an interview and documentation review with the DON on 7/9/14 at 0840 hours, the DON was informed the above findings.

On 7/9/14 at 1345 hours, RN J stated the hemodialysis provider's P&P titled RO System Check Change in Delta Pressure was outdated and needed to be revised.

Based on interview and record review, there was no documentation to show 16 of the 16 patients on the BHU were included or were asked for input in treatment planning(Patients 7, 8, 9, 10, 11, 12, 13, 14, 31, 32, 33, 34, 35, 36, 37, and 38). This had the potential for the patients' psychological and medical needs not to be met.

Findings:

The hospital's P&P titled Treatment Planning: Interdisciplinary Treatment Team Meeting, last reviewed on 6/13, showed each patient will have a written individualized interdisciplinary treatment plan which is based on an assessment of their needs. Upon completion of the admission assessments, nursing staff will initiate a preliminary plan of care based on psychiatric and medical needs. The treatment team is facilitated by the Medical Director or designee and includes the physician, nurse, social worker, activity therapist, or relevant members of other disciplines. The patient will be an active participant in identifying goals and problems. The medical history and physical examination performed by the physician will be included in the Interdisciplinary Treatment Team.

During medical record review beginning on 7/8/14, for 16 of the 16 patients in the BHU (Patients 7, 8, 9, 10, 11, 12, 13, 14, 31, 32, 33, 34, 35, 36, 37, and 38), no patient signatures were found on the treatment weekly meeting forms. There was no documentation to show the treatment plan was explained to the patients and/or the patients were given the opportunity to ask questions and make suggestions. The space for patient signature was left blank in each instance, and the box "declined" was checked.

During interviews with Patients 7, 27, and 28 on 7/8/14 between 1100 and 1120 hours, the patients all demonstrated some ability to discuss their treatment and all expressed some concerns about the care provided at the hospital.

Based on observation, interview, and record review, the hospital failed to ensure one of 16 patients reviewed in the BHU (Patient 13) was able to give informed consent for admission and consent for psychotropic medications. Patient 13, an elderly vulnerable patient, signed as a "voluntary admission;" however, Patient 13 did not meet the established criteria for voluntary admission and was be able to consent to the use of psychotropic medication.

The patient's mentally capability was not evaluated to determine the ability to give informed consent, and the medical record showed the patient had cognitive deficits, confusion, disorientation, and severe dementia (dementia causes long term loss of the ability to think and reason clearly that is severe enough to affect a person's daily functioning), creating the risk of a poor health outcome for that patient.

Findings:

Review of the hospital's P&P titled Criteria for Admission last reviewed on 4/14, showed the patient must be willing to consent to a voluntary admission to the unit, have a conservator, or a power of attorney.

The admission criterion included:

*Be age 45 or above, or an adult with functional limitations to the degree that fit in appropriately with the population.
*Be deemed clinically appropriate for the unit.
*Be medically stable.

Review of the hospital's P&P for Informed Consent for Psychotropic Medication last reviewed on 2/14, showed the purpose of the P&P is to involve patients in the treatment. Informed consent must be obtained prior to the administration of any antipsychotic medication. The physician must discuss with the patient specific information regarding the nature and effect of antipsychotic medication to enable the patient to make an "informed" decision.

Medical Record Review for Patient 13 was initiated on 7/7/14. The patient was admitted the BHU on 6/27/14, from the ED.

On 7/7/14 at 0945 hours, Patient 13 was observed in front of the nursing station. The patient was in a wheelchair. The patient appeared thin and disheveled. It was very difficult to understand her speech pattern as she had no teeth (fully edentulous) and she was and hard of hearing, but appeared pleasant and cooperative. When Patient 13 was asked why she was in the hospital, she stated "I think I have a urinary infection, I just want to go home."

Review of the physician's H&P dated 6/27/14, showed Patient 13 was admitted due to increased agitation and was uncooperative with staff. The patient was refusing to eat and refusing care. The assessment showed acute uncontrolled psychosis, dementia, hypertension, congestive heart failure, UTI, and depression.

Review of the Psychiatric Evaluation dated 6/27/14, showed Patient 13 was awake, confused, disoriented, disorganized, dependent, calling out and disruptive at times. The patient was eating poorly. The patient was currently under evaluation for UTI and has a very primitive social, communication, and cognitive function.

The Diagnostic Issues were severe dementia, possible psychotic features, depression, possible mood/psychotic/cognitive dysfunction, not otherwise specified or secondary to medical issues. The physician began the patient on Remeron to help with depression and Exelon (medication used for Alzheimer's disease to improve overall function & cognition) to help with cognitive dysfunction (loss of intellectual functions such as thinking, remembering, and reasoning).

Review of the Voluntary Admission Behavioral Health dated 6/27/14, showed Patient 13 signed the area for patient's signature.

Review of the Patient Informed Consent to Receive Psychotherapeutic Medications form dated 6/28/14, showed Patient 13 signed the area for patient's signature.

There is no documentation to show the physician evaluated the patient and determined the patient's competency to consent to medical treatment.

On 7/8/14 at 1155 hours, the Nursing Director of the Psychiatric Services was interviewed. The Director was asked how Patient 13's safety was maintained as some of the patients in the unit, for example, Patient 9 was disruptive, unpredictable, and aggressive. The Director stated they had enough staff around. The Director stated the admission was up to the physician.

During the IDT meeting held on 7/8/14 at 1200 hours, MD F (psychiatrist) stated Patient 13 wanted to be discharged; however, she had a bad combination of dementia and psychosis. Patient 13 was focused on going home; however, she did not know where home was.

MD F stated Patient 13 was confused and disoriented when she came in, now she is less isolative and more spontaneous. MD F stated the psychosis is much better now as the urinary tract infection was resolved.

Based on interview and record review, the hospital failed to ensure patients received care in a safe environment in the BHU. One of the 16 patients reviewed in the BHU (Patient 9) had multiple documented instances of aggression toward other patients; however, the patient was not provided with a one to one monitoring to ensure he did not threaten other patients. This had the potential of creating an unsafe and disruptive environment to other patients in the BHU.

Findings:

During interviews with RN G beginning at 1045 hours on 7/7/14, the RN stated Patient 9 became aggressive easily and he had three episodes of violence the previous week and scared the other patients. RN G stated she heard in report that the patient became aggressive and threatening overnight; however, she was not sure what staff had done in response.

The medical record of Patient 9 was reviewed beginning on 7/7/14. Documentation showed the patient was observed at 15 minute intervals. The nursing note dated 6/21/14 at 0950 hours, showed "pt agitated in the hallway, is cursing @ staff, agitation level is escalating, conts to be responding to internal stimuli, is gesturing towards peers, has antagonizing behavior towards peers, peers in milieu are coming to the nurses station c/o being scared."

Documentation on 6/21/14 at 1417 hours, showed Patient 9 "wandering in & out of peers rooms, peers are getting upset with pt ..." and on 6/22/14 at 0234 hours, "noted to be wandering into peers' rooms. And found laying on empty beds. Pt is dishevel. Frequently observed removing clothing. Standing naked or in pullups."

Documentation on 6/22/14 at 0234 hours, showed Patient 9 "..No insight. No judgment. Verbal altercation with peer 0230. Pt had been going into peer's room and apparently removed some of peer's clothes. Potential for physical altercation by both patients."

Documentation on 6/22/14 at 1400 hours, showed Patient 9 "very disorganized, anxious, flight of ideas, responding to internal stimuli, poor grooming, striking out at staff and patients. Urinating on floors and wandering in other pt.'s rooms and urinating in their bathrooms." At 1834 hours, "Pt also going to other pt's room and getting other pt scared. Pt also touching staff and peers inappropriately and can be intrusive with personal space ..."

Documentation on 6/26/14 at 1703 hours, showed Patient 9 "Pt agitated, attempting to hit another peer in his stomach ..."

Notes from subsequent dates indicated Patient 9 continued to be aggressive, attempted inappropriate touching, and entered other patients' rooms daily.

On multiple occasions, a dose of medication was ordered by the psychiatrist; however, there was no documentation to show a sitter was assigned to monitor the patient or that the patient had been placed on 1:1 monitoring.

There was no treatment plan for aggressive behavior until 6/28/14. The plan included to continue to monitor the patient every 15 minutes for safety, give medications per MD's order, and allow the patient to express feelings and/or identify stressors, 1:1 each shift. The pre-printed intervention set included an item for "place patient on 1:1 for safety;" however, that intervention was not checked off for Patient 9.

During an interview with the DON on 7/7/14 at 1054 hours, the DON stated when a patient became aggressive, the CNA might monitor the patient, or they might get a sitter to watch the patient. The DON stated Patient 9 had aggressive behavior at baseline, and the hospital had difficulty discharging the patient.

The Nursing Director of Psychiatric Services was interviewed on 7/8/14 at 1450 hours. The Director stated he believed Patient 9 was only aggressive towards the staff, not his peers. The Director reviewed the treatment plans for the patient and concurred there was no treatment plan for aggression until 6/28/14, 12 days after the patient's admission, and that the patient was not on 1:1 monitoring by staff.

Documentation showed Patient 9 was discharged to a lower level of care in the early afternoon of 7/7/14, the first day of the survey.

Based on observation, interview, and medical record review, the hospital failed to ensure nursing staff on the BHU followed the hospital's P&P related to the use of seclusion/restraint to provide a safe and therapeutic environment for one of the 16 sampled psychiatric patients reviewed on the BHU (Patient 9). This resulted in a failure to ensure patients were free from excessive use of seclusion and restraints.

Findings:

Review of the hospital's P&P titled Restraint and Seclusion revised on 4/14, showed "Time Out" for behavioral health patients is when a patient is "restricted from leaving" an unlocked room for 30 minutes and is part of their treatment plan.

"Seclusion," is the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others, and must be discontinued at the earliest possible time. The use of restraint or seclusion is in accordance with the order of a physician or other licensed independent practitioner.

Review of the hospital's P&P titled "Time Out" last reviewed on 6/13, showed the seclusion room is not punitive or used for disciplinary purpose. It's a place to calm down after experiencing difficulties with personal issues.

The seclusion room with doors unlocked can be used as a time out room. During "Time Out" the patient is observed at a minimum every 15 minutes until the patient's behavior is appropriate to return to the therapeutic milieu; however, the P&P did not address how long the patient should be kept in the "Time Out room," any change in condition, notification of the physician, and as a part of the patient's treatment plan.

Patient 9's medical record review was initiated on 7/7/14, and showed the patient was admitted to the BHU on 6/28/14, with diagnoses including schizophrenia, paranoid type.

During an initial tour of the BHU starting at 0835 hours, accompanied by the Nursing Director of Psychiatric Services, inspection of room 221 (identified as the seclusion room, an involuntary confinement of a patient alone in a room) was conducted.

When the Director unlocked the double doors of the seclusion room, warm air with strong smell of stale urine came out of the room. The room had a wood bed frame with a vinyl plastic mattress covered with fitted linen. The bed linen had multiple brown stains. The floor of the room was badly soiled and stained with multiple debris of white foam. Brown marks were observed on the wall next to the bed.

The Director stated the marks were fecal matter. The Director stated the air conditioning unit for the room had not been working since last week.


On 7/7/14 at 0950 hours, Patient 9 was observed in a wheelchair in front of the nursing station. The patient was moving around, wearing two torn gowns, was incoherent, and seemed to be confused.

Review of a Psychosocial Assessment dated 6/18/14, showed Patient 9 was admitted to the hospital from a TRC for agitation and psychotic behavior. The assessment was completed and the patient currently presented hyper verbal, delusional, incoherent speech. The symptoms associated with the current admission listed violence/aggression.

Patient 9's activity was documented as follows:

* On 6/29/14, "221" (room 221) from 1000 hours until 115 hours (one hour and 15 minutes).
* On 6/29/14, "221" from 1400 hours until 1830 hours (four hours and 30 minutes).
* On 6/29/14, "221" from 2100 hours until 2315 hours (two hours and 15 minutes).
* On 7/4/14, "221" from 1530 hours until 1645 hours (one hour and 15 minutes).
* On 7/4/14, "221" from 1930 hours until 2315 hours (three hours and 45 minutes).
* On 7/5/14, "221" from 2300 hours until 0000 hours (one hour) and from 0045 hours until 0130 hours (45 minutes).
On 7/6/14, "221" from 0815 hours until 1015 hours (two hours).
* On 7/6/14, "221" from 1345 hours until 2315 hours (9 hours and 30 minutes).
* On 7/7/14, "221" from 0800 hours until 0815 hours (15 minutes).

During an interview with RN D on 7/8/14 at 1400 hours, when asked what "open seclusion" was, she stated the quiet room was the same as seclusion, but in open seclusion, the patient was able to open the door.

During an interview with RN F on 7/8/14 at 0900 hours, the RN stated Patient 9 had hit and injured multiple staff members on the unit.

During an interview with the DON on 7/7/14 at 1054 hours, the DON stated the observation room was the same as the seclusion room. The DON stated the seclusion/observation room was not used for seclusion for Patient 9. The DON stated when a patient became aggressive, the CNA might monitor the patient or they might get a sitter to watch the patient.

Review of the Patient Care Inquire, Patient Notes dated 6/29/14 at 0942 hours, showed documentation the patient became undirectable, was slamming doors, yelling, and was aggressive to staff. The patient was placed in room "221."

At 1154 hours, documentation showed the patient was resting in room "221." At 1342 hours, documentation showed the patient was very disorganized, anxious, had poor grooming, was throwing objects at staff and other patients, was urinating and defecating on the floors, and wandering into other patients' rooms.

A Code Gray (a message announced over the hospital's public address system, indicating the need for an emergency management response due to a combative patient) was called. Documentation showed Patient 9 was resting in the seclusion room.

Review of the Patient Care Inquire, Patient Notes dated 6/29/14 at 1423 hours, showed Patient 9 required intervention, entered into two other patients' rooms, and held the door closed. In room "221" the patient was given Haldol (antipsychotic medication) 10 mg, Ativan (medication used to treat anxiety) 2 mg and Benadryl (medication used to treat allergy, also causes drowsiness) intramuscular per physician's order.

Review of the Patient Care Inquire, Patient Notes dated 7/4/14 at 0700 hours, documentation showed patient found in a female patient's bathroom, sitting on the toilet, and urinating on the floor. Female patient was upset. At 2203 hours, the patient was trying to break his bed and was escorted to room "221." The physician was called and Geodon (antipsychotic medication) intramuscular was given. At 2300 hours, patient was still in room "221," with door closed but unlocked, resting quietly, in direct continuous video observation, "221" will prevent him from hurting others.

Review of the Patient Care Inquire, Patient Notes dated 7/5/14 at 0208 hours, documentation showed the patient urinated "all over the place," remained in room "221." At 0628 hours, the patient remained agitated, cursing, yelling, elbowing staff, hitting window, removing his clothes. The patient was not safe to come out of room "221," continuous video monitoring was in place.

At 1340 hours, documentation showed the patient was agitating peers, wandering in and out peers rooms, taking belongings, was not compliant with medications, had urinated all over the floor, had dried feces on his fingers nails, patient was malodorous, and behavior was getting worse. Concerns were communicated to MD A.

Review of the Patient Care Inquire, Patient Notes dated 7/6/14 at 0138 hours, showed the patient woke up severely agitated towards staff and peers. Security and the house supervisor were called along with other staff nurses to direct the patient to room "221."

Emergency medications were given. At 0900 hours, received the patient in "observation room." At 1000 hours, the patient attempted to leave the observation room; however, he became agitated again, threatening staff. Patient 9 was escorted to the observation room by staff. Patient was combative and uncooperative with staff. At 1857 hours, received patient in the "quiet room."

During an interview with the Security Guard on 7/7/14 at 1155 hours, he stated he was called to a "code gray" on 7/6/14 (for combative patient). He and other staff walked a patient to the isolation room, and the staff provided a chemical restraint to the patient and left room. The Security Guard reported the door was locked, so the patient could not get out.

Patient 9's Master Treatment Plan dated 6/28/14, showed Problem #4 to address assaultive behavior, threatening behavior manifested by striking and kicking staff. The interventions did not list instructions for the staff on how to manage the patient's aggressive behavior and did not include use of seclusion and/or time out.

During an interview with MD A on 7/8/14 at 1600 hours, she stated Patient 9 was unmanageable. The MD stated it seemed psychotropic medications did not work for him anymore. MD A stated she was aware Patient 9 was placed in the seclusion room multiple times; the MD stated staff could not control his aggressive behavior in the unit. MD A stated Patient 9 hit and injured staff members.

During an interview with the RN E on 7/8/14 at 1000 hours, she stated Patient 9 needed a quiet room to calm down, instead of his private room. The RN stated we needed him to go to the seclusion room which has a "surveillance camera," so he could be monitored from the nursing station with the seclusion door closed. The RN stated Patient 9 locked himself in the seclusion room. RN E stated she was unaware the P&P for Time Out was limited to 30 minutes.

The medical record for Patient 9 did not show nursing documentation of the patient being placed in the seclusion room. The record showed on 7/6/14 at 1045, a "code gray" was paged overhead regarding Patient 9. The patient was placed in the "observation room."

On the morning of 7/7/14 at approximately 0200 hours, the nursing notes showed the patient was again the subject of a "code gray." Documentation showed the patient was to be transferred to the ED for evaluation; however, there was no documentation so show that transfer occurred or that the patient was placed in the seclusion room. There was no documentation to show a sitter was assigned to monitor the patient, or that the patient was placed on 1:1 monitoring. There was no documentation to show a physician's order was obtained for the patient to be placed in seclusion.

During an interview, on 7/7/14 at 1050 hours, the Nursing Director of Psychiatric Services reviewed Patient 9's medical record. The Director stated it was unclear if Patient 9 was in the seclusion room or what time he was in the room.

During an interview with RN G beginning at 1045 hours on 7/7/14, the RN stated she usually put notes in the chart when a patient was in the seclusion room. RN G stated Patient 9 became aggressive easily and had three episodes of violence the previous week and scared the other patients. RN G stated she heard in report that the patient became aggressive and threatening overnight; however, she was not sure what staff had done in response.

The video surveillance of 7/6/14 at 1855 hours, was viewed with the Nursing Director of Psychiatric Services, the hospital's Security Technologist, and RN D. One hour of recording showed Patient 9 was pacing in room "221." The video showed Patient 9 attempted to open the door of the seclusion room three times; however, the door was locked. The Director confirmed the door of the seclusion room was closed and locked, and in this case a physician's order was needed.

There was no documentation found in Patient 9's record to show a physician's order was obtained for the patient to be placed in seclusion.

Based on observation, interview, and record review, the hospital failed to develop, implement, and maintain an effective QAPI program as evidenced by:

1. Failure to ensure the quality program assessed the effectiveness of the processes of treatment planning, patient assessment and care delivery in the BHU and failed to ensure data regarding the use of patient seclusion and code gray were reviewed for the appropriateness of care provided to the patients. Cross reference to A- 0273.


2. Failure to ensure the QAPI program identified opportunities for improvement and changes that would lead to improvement of patient care in the BHU regarding assessing the effectiveness of the processes of treatment planning, patient assessment and care delivery, and the timeliness and accuracy of the medical records in the BHU; failure to identify cares issues such as the use of seclusion and appropriateness of admissions to the BHU; and failure to use data collected to evaluate or identify opportunities for improvement in the use of insulin drip for the patients admitted to the ICU. Cross reference to A- 0283.

The cumulative effect of these systemic failures resulted in the hospital's inability to provide quality healthcare in a safe environment to the patients.

Based on observation, interview, and record review, the hospital failed to ensure the quality program assessed the effectiveness of the processes of treatment planning, patient assessment, and care delivery in the BHU and failed to ensure data regarding the use of patient seclusion and code gray were reviewed for the appropriateness of care provided to the patients. These failures created the increased risk of substandard health outcomes for the patients subject to code gray or placed in seclusion.

Findings:

The hospital's Performance Improvement Plan revised on 12/13, read in part, "The process of improvement includes: 1. Identification of critical patient care and services components; 2. Application of performance measures that are predictive of quality outcomes that would result from delivery of the patient care and services; 3. Continuous use of a method of data collection and evaluation that identifies or triggers further opportunities for improvement."

The medical staff bylaws (undated, page 30), read in part, "Each department shall conduct regular patient care reviews and studies of practice within the department in conformity with the Hospital's general quality improvement plan and shall review complaints and practice-related incidents."

1. During a review of the medical records in the BHU from 7/7-7/9/14, the treatment planning process was found deficient. Treatment plan documents were left partially incomplete and were stereotypical. The plans were filled out, including patient responses to treatment, in advance of the treatment being given; did not address all psychiatric and medical conditions; did not show an active physician and patient role in the treatment process; and did not reflect whether assessments were done to evaluate the patients' response to treatment plans.

In addition, the treatment team meeting documentation did not accurately reflect the patients' progress as it did not indicate what progress the patients were making towards the goals and did not reflect changes in strategy or changes in goals to address patient needs. Cross references to A- 0395, examples #7c and #7d; A- 0396, examples #6; B- 0137; B- 0138; and B- 0139.

During an interview with the Nursing Director of Psychiatric Services on 7/7/14 at 0940 hours, he stated the quality indicators for the BHU included timeliness of the H&P, use of seclusion and restraints, handwashing, and patient return rates.

During a review of quality department documents with the PI Staff on 7/7/14 at 1505 and on 7/9/14 at 0930 hours, he stated the effectiveness of treatment in the BHU was measured by patient self-report of improvement at the time of discharge. The PI Staff stated additional goals for assessing the effectiveness of treatment were planned, however, had not yet been implemented.

During interviews with Department Directors from the ICU, Med-Surg, and BHUs on 7/9/14 at 1045 hours, the Directors of the ICU and Med-Surg stated they performed random record reviews monthly to ensure the quality of the services and the medical records.

The Nursing Director of Psychiatric Services stated he was new to his position and had not yet initiated random record reviews. The Director concurred quality measures were not yet in place to ensure the quality of nursing care or social services on the psychiatry unit.

2. During an interview with the Nursing Director of Psychiatric Services on 7/7/14 at 0940 hours, he stated the quality assurance indicators for the BHU included the use of seclusion and restraints.

The Medical Restraint log for the BHU was reviewed. The log showed no use of restraints for patients during June or July, 2014. However, review of seclusion room videotape, interviews with hospital staff, and review of the patient monitoring data showed Patient 9 was locked in the seclusion room and placed in the seclusion room for extended periods on multiple occasions during June and July, 2014. Cross reference to A- 0167.

During an interview with PI Staff on 7/9/14 at 1100 hours, he stated he collected data regarding restraints from the medical restraints log and from speaking with the Nursing Director of Psychiatric Services. The PI Staff concurred the use of seclusion should be recorded in the medical restraints log; however, there was no use of seclusion documented. The PI Staff was not aware seclusion was not recorded in the Medical Restraints Log.

The Code Gray log for June, 2014, was also reviewed. The log showed of 19 codes gray in the hospital, 12 were on the second floor (the location of the BHU).

Review of security document dated 7/7/14, showed a code gray in the BHU was logged that involved assisting with medicating a patient in the seclusion room.

During an interview with the PI Staff on 7/9/14 at 1100, he stated code gray documentation was compiled by the security chief and was forwarded to the EOC committee, but in tabular form. He stated code gray should give rise to an incident report and the incident would be reviewed.

During an interview with the DON on 7/9/14 at 1110 hours, she stated the physician should be informed of a code gray regarding the patient's behavior; however, the staff might not be reporting them in the incident reporting system.

Based on interview and record review, the hospital failed to ensure the QAPI program identified opportunities for improvement and changes that would lead to improvement of patient care in the BHU as evidenced by:

1. Failure to assess the effectiveness of the processes of treatment planning, patient assessment and care delivery and the timeliness and accuracy of the medical records in the BHU.

2. Failure to identify cares issues such as the use of seclusion and appropriateness of admissions to the BHU.

3. Failure to use data collected to evaluate or identify opportunities for improvement in the use of an insulin infusion for the patients admitted to the ICU.

These failures created the risk of substandard health outcomes for the patients in the hospital.

Findings:

The hospital's Performance Improvement Plan revised on 12/13), read in part, "The process of improvement includes: 1. Identification of critical patient care and services components; 2. Application of performance measures that are predictive of quality outcomes that would result from delivery of the patient care and services; 3. Continuous use of a method of data collection and evaluation that identifies or triggers further opportunities for improvement."

1.a. Review of medical record documentation by physicians on the BHU showed the H&P and progress notes of patient treatment and response to treatment were missing or placed in the medical records late for multiple patients. Cross reference to A- 0353, examples #1 and #2.

b. Physician documentation was stereotypical and did not reflect the treatments planned and administered for some patients. Cross reference to A- 0353 #3.

During an interview with the PI Staff on 7/9/14 at 1440 hours, he stated he was aware of the delays in medical record completion by MD A. The PI Staff stated the Medical Director had communicated with MD A in April, 2014. The PI Staff stated he thought medical records was following up the issue and that it had improved. The PI Staff stated he was not aware the problem with timely medical records completion was ongoing.


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2. The quarterly Quality Council Meeting Minutes dated 5/21/14, were reviewed with the PI Staff on 7/8/14 at 1130 hours. The PI Staff provided the quality measures reviewed for the BHU. The measures were as follows:

* Timeliness of physician notification by staff of admission.

* H&P dictated within 24 hours of admission.

* Patients perceived condition as improved at discharge (determined by survey of the patient at discharge).

* Seclusion and Restraint Audit is compliant with acceptable quality parameters with the community.

When asked, the PI Staff stated no other measures were identified for study for the BHU.

Review of the Quality Council Meeting Minutes from 2013, showed these same measures were also reviewed for the past year and a half. The PI Staff stated the measures were continued as they had not reached their benchmarks. There was no information to show if any changes were made to staff practice to improve performance.

A meeting was held with members of the Quality Committee on 7/9/14 at 1020 hours.

a. The PI Staff was asked if the appropriateness of admissions was reviewed. The example of Patient 13 was presented who was admitted with a diagnosis of severe dementia; however, the patient was asked to give informed consent for admission and treatment, including antipsychotic medications. Cross reference to A- 0131.

The PI Staff stated admissions had not been reviewed for appropriateness as there had been no trigger, "like an incident." The committee stated they encouraged staff to report out of norm events. The PI Staff stated BHU staff could question an admission

The Nursing Director of Psychiatric Services was asked how a patient with dementia, who was confused at admission, could sign a voluntary admission informed consent The Director stated they could talk to them and explain and if they did not object, they had given consent.

b. Review of the Seclusion and Restraint Audit showed for 2013, staff was 100% compliant. The first quarter of 2014 showed N/A (non-applicable). The PI Staff explained there was no use of seclusion and restraints during that time. When asked, he stated he reviewed logs on the BHU for his data.

The use of the seclusion room for Patient 9 without a physician's order was discussed with the Quality Committee. Cross reference to A- 0167.

The PI Staff stated he would be unaware of the use of the seclusion room unless it was added to the log for him to know about.

The frequent use of code gray for Patient 9 was also discussed with the committee. The members acknowledged the codes were reported as incidents; however, the codes were looked at in real time, the physicians were notified regarding the patient's behavior, and the codes were not looked at for frequency or pattern.


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3.a. Review of Patient 5's Insulin Drip Monitoring Form showed when the patient was receiving insulin drip the patient required rescue medication, one ampule of Dextrose 50% (a medication used to treat low blood sugar) for low blood sugars three times between 6/19/14 at 0007 hours and 0827 hours.

b. Review of Patient 16's medical record was initiated on 7/7/14. The following was identified:
* Nursing staff failed to check Patient 16's blood sugar as ordered. Cross reference to A- 0395, example #3.

* Nursing staff failed to notify the physician when the patient required Dextrose 50% for a low blood sugar during administration of an insulin drip. Cross reference to A- 0395, example #3.

* Nursing staff failed to report a suspected ADR for Patient 16 when nursing staff concurrently administered Dextrose 50% and insulin to the patient. In addition, the suspected ADR was not investigated by the pharmacist. Cross reference to A- 0410.

An interview and documentation review was conducted with the Director of Pharmacy and the Director of ICU on 7/9/14 at 0855 hours. The staff was asked about the hospital's process of identifying a suspected ADR.

The Director of ICU stated nursing staff would report a suspected ADR to QI. The QI staff would distribute the report to the pharmacy; however, the Director of Pharmacy stated nursing reported a suspected ADR to the pharmacy. A pharmacist would evaluate or investigate and report to the MEC.

When asked about the process of monitoring patients on insulin drips, the Director Pharmacy stated the insulin drip was not used very often in the hospital. The Insulin Drip Monitoring Form would be used to monitor the use of insulin drip. The form was used to ensure nursing staff adjusted the rate of insulin in accordance to the physician's order. The Director of Pharmacy stated there was no P&P approved for the pharmacy or the nursing staff regarding to the use of insulin drip.

The Director of Pharmacy confirmed the above findings were suspected ADRs as Patient 5 and Patient 16 required Dextrose 50% while on IV insulin. However, the Director stated these suspected ADRs were not investigated.

The Director of ICU confirmed nursing staff did not report the suspected ADR for Patient 16 to the QI or the pharmacy.

During an interview with Quality Assurance representatives on 7/9/14 at 1015 hours, staff confirmed the data collected for the use of insulin drips on patients in the hospital was not evaluated and was not identified as an opportunity for improvement in patient care in the ICU.

Based on interview and record review, the hospital failed to ensure complete reappraisal of the medical staff. In addition, one physician was not reassessed after repeated medical records deficiencies. This created the risk of substandard services provided by members of the medical staff.

Findings:

The medical staff bylaws (undated, pages 7 and 30), read in part, "...The ongoing responsibilities of each member (licensed independent practitioner with appropriate privileges) of the Medical Staff include:...abiding by the Medical Staff Bylaws and Medical Staff rules and regulations ..." and "All members of the Medical Staff, regardless of status, shall be subject to potential routine monitoring."

1. The OPPE Competency Expectations and Indicators, Psychiatry Department worksheet was reviewed on 7/9/14. The worksheet included different parameters of competency and expectations. The indicators used to assess physician competency in patient care were "elopement" and "falls." The data for elopement and falls for one physician were discussed and showed "0" falls and elopements were attributed to the physician.

During a discussion with the PI Staff on 7/9/14 at 0930, he stated all falls were reviewed. Only falls that were felt to be due to physician error were attributed to a particular physician. The PI Staff stated there were falls in the psychiatry unit; however, the falls were discussed and they were thought to be due to other causes, such as medication effects.

The PI Staff stated about 90% of the falls in the psychiatry unit were related to use of the bathroom. The PI Staff stated none of the falls were attributed to the physician even though a physician ordered a medication that was thought to have contributed to the fall. All of the psychiatrists were given a perfect score, even though their patients fell.

Similarly, the PI Staff stated elopements had occurred but were not attributed to the physician if there were other factors contributing to the elopement. The criteria of "elopement" and "falls" as used by the hospital's medical staff and quality program did not provide physician performance information.

The second parameter for physician evaluation on the form was medical and clinical knowledge. The three criteria for evaluation were listed as "a) participation in continuing medical education pertinent to specialty, b) Board Certification Compliance with use of physician-relevant core measures, c) Outcome of Proctored Cases."

During an interview with the Director of Medical Staff Services on 7/9/14 at 0940 hours, indicator a) was discussed. The Director stated they were not tracking psychiatry-related continuing medical education. The Director concurred the physicians were required to take 50 units of continuing medical education; however, there was no determination made about whether any of the units were in the field of psychiatry.

The indicator b) in the medical and clinical knowledge category was "Board Certification Compliance with use of physician-relevant core measures." However, MD A's credential file showed the physician was never board certified in psychiatry.

During an interview with the Director of Medical Staff Services on 7/9/14 at 0942 hours, the Director concurred not all of the psychiatrists at the hospital were board certified; therefore, the criteria could not be applied to all psychiatrists.

Medical and clinical knowledge indicator c) was Outcome of Proctored Cases. During a review of the OPPE files for MD A and MD E, there was no evidence of proctoring.

During an interview with the Director of Medical Staff Services on 7/9/14 at 0945 hours, the Director stated none of the psychiatrists was proctored, so there was no proctoring data available.

The next competency parameter on the OPPE form was practice-based learning and improvement, assessed via the indicator, "peer review outcomes."

The medical staff bylaws (undated, pages 30 and 31), read in part, "Each department shall conduct regular patient care reviews and studies of practice within the department in conformity with the Hospital's general quality improvement plan and shall review complaints and practice-related incidents."

Medical records from the BHU were selected at random for review on 7/7/14 and 7/8/14. Several deficient practices, including physicians writing progress days to weeks after the date an inpatient was seen. Cross reference to A- 0353, example #1.

During an interview with the Director of Medical Staff Services on 7/9/14 at 0950 hours, the Director stated there was no routine peer review done in the psychiatry department, only event triggered.

During interviews with the Director of Med/Surg/Tele, the Director of ICU and the Director of Psychiatric Services on 7/9/14 at 1050 hours, the Director of Med/Surg/Tele and the Director of ICU stated they performed random medical record reviews for quality. The Director of Psychiatric Services stated he was new to his position and had not initiated random medical record reviews for quality as yet.

On 7/9/14 at 0930 hours, PI Staff stated new criteria was being implemented to ensure the quality of performance of the psychiatrists; however, it was based on sampled cases, and there was no data sampled for MD E. The PI Staff was asked to provide data on other psychiatrists; however, no data was provided.

2. The Medical Staff Bylaws (undated, page 7), read in part, "...the ongoing responsibilities of each member (licensed independent practitioner with appropriate privileges) of the Medical Staff include: ...preparing and completing in timely fashion for all patients to whom the member provides care in the hospital ..."

Open medical records from the BHU were selected at random for review on 7/7 and 7/8/14. Several deficient practices, including a psychiatrist, MD A, showed progress notes for several patients (Patients 7, 8, and 9) were written after the date of service and up to 16 days after the date an inpatient was seen. Cross reference to A- 0353, example #1.

The credential file of MD A was reviewed on 7/9/14. The file contained documentation indicating the physician had medical records deficient practices in January, 2014, and again in April, 2014. Written communication was sent to the physician regarding the medical records practices by the medical staff. However, there was no follow-up documentation seen.

During an interview with the PI Staff on 7/9/14 at 1440 hours, he stated he thought the problem was followed up by medical records and was resolved.

During an interview with the CNO on 7/9/14 at at 1400 hours, the CNO stated the medical records tardiness of MD A was left up to the medical staff to resolve earlier in the year.

Based on interview and record review, the hospital failed to enforce the medical staff bylaws regarding the medical record were implemented as evidenced by:

1. Multiple physician's progress notes for three of 38 sampled patients (Patients 7, 8, and 9) were not being entered into the medical record in a chronological and timely fashion.

2. The H&P examinations for two of 38 sampled patients (Patients 8 and 9) were entered into the record more than 24 hours after admission

3. The progress notes for three of 38 sampled patients (Patients 7, 8, and 9) were stereotypical and did not reflect the treatments planned and provided.

These failures created the risk of lack of communication between health care providers and poor health outcomes for those patients.

Findings:

1. The Medical Staff Rules and Regulations (undated, page 15), read in part, "Entries should be made as soon as possible after clinical events occur, to ensure accuracy and to provide information relevant to the patient's continuing care."

a. The electronic medical record of Patient 9 was reviewed with the Director of ED on 7/7/14. Review of the record did not show documentation of notes by MD 1, the psychiatrist, for some dates.

The record contained an initial psychiatric evaluation for Patient 9 dated 6/18/14. At the bottom of the page a date and time indicated it was not dictated until 6/19/14 at 1217 hours.

Progress notes dated at the top of the pages for 6/20, 6/21, 6/22, 6/22, 6/23, 6/24, 6/25, 6/26, 6/27, 6/28, 6/30, 7/1, 7/2, 7/3, 7/4, and 7/5/14, all had a dictation date at the bottom of the pages of 7/6/14, between 0841 and 0912 hours. There was no psychiatrist's notes in the record for 7/6/14. There was a note dated 6/9/14, prior to the patient's hospital stay, dictated on 7/6/14.

The internal medicine physician's (MD C) notes for Patient 9 were also reviewed. The progress notes dated 6/30 and 7/1/14, were both dictated on 7/2/14 at 0910 and 0912 hours, respectively.

During an interview with the Director of ED on 7/7/14 at 1335 hours, she stated progress notes for MD 1 were missing from the electronic health record. There must be handwritten notes in the medical record.

The paper record for Patient 9 was reviewed on 7/7/14. The record did not contain handwritten progress notes.

During an interview with RN G on 7/7/14 at 1410 hours, she stated the psychiatrists did not place handwritten progress notes in the patients' records. RN G reviewed the progress notes for Patient 9 and stated she was unable to comment on why the notes for 16 previous days were dictated on 7/6/14 by the psychiatrist.

b. Patient 7's medical record was reviewed on 7/8/14. The patient had a psychiatric evaluation dated 6/26/14, which was dictated on 6/27/14. Psychiatric progress notes for 6/27 and 6/28/14 were dictated on 6/29/14. Psychiatric progress notes for 6/29, 6/30, 7/1, 7/2, 7/3, 7/4 and 7/5/14 were all dictated by MD A on 7/6/14 between 1154 and 1216 hours.

The internal medicine consultant's progress notes from 6/30 and 7/1/14 were dictated by MD C on 7/2/14 at 0915 and 0917 hours, respectively. No handwritten progress notes were found in the medical record.

c. Patient 8's medical record was reviewed on 7/8/14. The patient had a psychiatric evaluation dated 6/16/14, which was dictated on 6/17/14.

Patient 8's electronic medical record showed progress notes dated daily for 6/18, 6/19, 6/20, 6/21, 6/22, 6/23, 6/24, 6/25, 6/26, 6/27 and 6/28/14. All of the notes were dictated by MD A on 6/29/14 between 1115 and 1530 hours.

There were also psychiatric progress notes for 6/29, 6/30, 7/1, 7/2, 7/3, 7/4, and 7/5. All were dictated on 7/6/14 between 1016 and 1027 hours.

The internal medicine consultant's progress notes from 6/30 and 7/1/14, were dictated by MD C on 7/2/14 at 0906 and 0908 hours, respectively. No handwritten progress notes were found in the medical record.

During an interview with the Nursing Director of Psychiatric Services on 7/8/14 at 1450 hours, he stated physicians were to place their treatment notes in the medical records promptly. The Director stated he was surprised they had not done so.

During an interview with the Chief Medical Officer on 7/8/14 at 0920 hours, he stated there needed to be a psychiatrist's note in the medical record daily for all patients in the Behavioral Health Unit. If the notes were being entered late it was a problem.

2. The Medical Staff Bylaws (undated, page 30), read in part, "Every patient receives a history and physical within twenty-four hours of admission, unless a previous history and physical was performed within thirty days of admission is on the record, in which case that history and physical will be updated and patient examined within twenty-four hours of admission."

a. Review of the medical record for Patient 9 on 7/7/14, showed the patient was admitted on 6/18/14. The history and physical for Patient 9 was dictated on 6/20/14 at 0010 hours, more than 24 hours after admission.

b. Review of the medical record for Patient 8 on 7/8/14, showed the patient was admitted on 6/16/14. The history and physical was dictated on 6/18/14 at 2233 hours, more than 24 hours after admission.

During an interview with the Director of ED on 7/8/14 at 0940 hours, she concurred the history and physical exams for Patients 8 and 9 appeared to have been completed more than 24 hours after admission.

3. The hospital's P&P Plan for Assessment/Reassessment of Patients revised 7/14, read in part, "The patient's status and response to treatment is reassessed and documented by the physician daily in the progress notes." "H&P, Psychiatric Evaluations, Physician Orders, Consults and Progress Notes serve as mechanisms for the medical staff to communicate the patient's care, treatment needs and response to treatment, patient instructions, discharge plans and continued care requirements as appropriate."

The medical records for Patients 7, 8, and 9 showed the notes contained internal inconsistencies and did not reflect the condition of the patient, treatment provided to the patient, and the patient's response to treatment. The notes contained two or three lines containing new observations at the top, followed by several pages of review of systems, physical exam, assessment and plan that appeared to be reprinted from the initial history and physical examination, along with tables containing vital signs and medications.

a. The medical record for Patient 8 was reviewed on 7/8/14. The patient was admitted on 6/16/14, with depression. The 6/19/14, internal medicine progress notes showed "Exacerbation of the asthma, rule out pneumonia. We will monitor the patient's pulmonary status closely. We will start the patient on Zosyn at this time. We may also add the azithromycin treatment.(Zosyn and azithromycin are antibiotics.) We will continue with the nebulizer treatment as well as the chest PT (physiotherapy) and cough syrup. If the patient's symptoms does not improve, we will obtain a pulmonary consultation for further evaluation and workup." The same plan was repeated on the internal medicine progress notes on 6/20, 6/21, 6/22, 6/23, 6/24, and 6/25/14.

Other medical problems identified on the history and physical for Patient 8 were sinusitis and rhinitis, reflux disease, osteoarthritis, hypertension, constipation, and chronic back and lower leg pain.

On admission on 6/16/14, a red rash was seen in the abdominal, breast, and groin folds. According to the progress notes, the plan for treatment of sinusitis and rhinitis included "Continue with the spray and decongestant."

For the reflux disease, the plan included "Continue with the Protonix." For the arthritis the plan included "Continue with the NSAIDS (non-steroidal pain medication) PRN (as needed)."

For constipation, the plan included to "Continue with the MiraLax and the stool softeners." The same plan was repeated on the internal medicine progress notes on 6/20, 6/21, 6/22, 6/23, 6/24, and 6/25/14.

Patient 8's medication orders were reviewed. An Advair discus and Ventolin inhaler (both devices that give lung medication without nebulization), not nebulized medications, were ordered. No antibiotics, chest physiotherapy or cough syrup were ordered, even though they were in the physician's plan. No decongestant or nasal spray was ordered for sinus and nasal symptoms and no medicine was ordered for reflux.

Amitzia, not Miralax, was ordered for constipation. No medication was ordered for pain until Tylenol was ordered on 6/24/14. The assessment and plan repeated in the progress notes from 6/20-6/25/14, did not reflect the patient's treatment or response to the treatment actually provided.

On 6/22/14, documentation showed Patient 8 complained of frequent urination. Laboratory testing was undertaken and Detrol LA was ordered for her symptom. There was no change made in the documented plan by the physician to reflect the treatment and labs that were initiated. The documented review of systems for Patient 8 persisted as "Genitourinary No symptoms reported."

b. Patient 7's medical record was reviewed on 7/8/14. The patient was admitted on 6/26/14 with schizophrenia, anorexia, sore throat, chronic obstructive pulmonary disease, weight loss, anemia, hepatitis C, and constipation, among other concerns.

The physician's plan included hydration, energy drinks, antibiotics, iron supplementation and stool softeners. However, no orders for iron supplementation were placed. Other medications and tests were ordered for the patient, but these were not reflected in the plan.

The same review of systems, physical exam and plan were reprinted on the patients' progress notes on 6/26 and 6/27/14, the last day he was seen by that physician and did not reflect the treatments provided or response to treatments provided.

c. Patient 9's medical record was reviewed on 7/7/14. The patient was admitted on 6/18/14, with schizophrenia, cellulitis, high blood pressure, and a history of asthma, among other concerns.

The physician's review of systems, physical exam, assessment and plan from the history and physical dated 6/20/14, was reprinted on the patient's progress notes dated 6/21, 6/22, 6/23, 6/24, 6/25 and 6/26/14.

These treatments included whirlpool, nebulizer therapy and leg elevation. The medical record did not show the patient received whirlpool or nebulizer therapy, only that he was unable to cooperate with leg elevation. The physician's progress notes did not reflect treatments provided or the patient's response to the treatments provided.

The Nursing Director of Psychiatric Services was asked to review the medical record for Patient 8 on 7/8/14 at 1450 hours. The Director concurred the plan in the internal medicine physician's progress notes did not reflect the treatment provided to the patient.

Based on observation, interview, and record review, the hospital failed to have an effective, organized nursing service to provide quality care to patients as evidenced by:

1. Failure to ensure the needs of 16 of the 16 patients in the BHU and three additional patients of 38 total sampled patients (Patients 7, 8, 9, 10, 11, 12, 13, 14, 17, 19, 23, 31, 32, 33, 34, 35, 36, 37, and 38) were met when the patient's assessments were not accurate and complete. Cross Reference A- 0392.

2. Failure to ensure RN supervision and evaluation of the nursing care provided and ensure the hospital's P&Ps for patient care were implemented. Cross Reference A- 0395.

3. Failure to ensure nursing staff developed individualized nursing care plans. Cross Reference A- 0396.

4. Failure to ensure nursing staff were provided with appropriate specialized qualifications and competency when assigned to the BHU. Cross Reference A- 0397.

5. Failure to ensure nursing staff administered medications following physician's orders and pharmaceutical standards. Cross Reference A- 0405.

6. Failure to ensure nursing staff reported a suspected ADR when nursing staff concurrently administered Dextrose 50% and insulin. Cross Reference A- 0410.

The cumulative effect of these systemic failures resulted in the hospital's inability to provide quality healthcare in a safe environment to the patients.

Based on observation, interview and record review the hospital failed to ensure the needs of 16 of the 16 patients in the BHU and three additional patients of the 38 total sampled patients reviewed (Patients 7, 8, 9, 10, 11, 12, 13, 14, 17, 19, 23, 31, 32, 33, 34, 35, 36, 37, and 38) were met as evidenced by:

1. Nursing staff failed to accurately assess and document Patient 17's sedation level during administration of propofol (sedative); and failed to notify the physician of the patient's change of condition or sedation level as per hospital's P&P.

2. Nursing staff failed to assess Patient 23 for pain characteristic and location and failed to assess if Patient 23 had difficulty urinating based on the patient's condition.

3. Nursing staff failed to completely conduct a pain assessment for Patient 19 when the patient was admitted to the hospital, when the patient complained of pain, and when the patient requested pain medication.

4. Comprehensive nursing assessments were not conducted for Patient 13. Eight days after admission, nursing staff documented Patient 13 had a 17 pound weight loss. There was no documentation to show accurate nutritional screening was completed at the time of admission.

5. Complete nursing shift assessments of patients' medical and psychiatric conditions and assessments of progress towards measurable goals were not documented for 16 of 16 patients (Patients 7, 8, 9, 10, 11, 12, 13, 14, 31, 32, 33, 34, 35, 36, 37, and 38) in the BHU.

These failures created the risk of substandard health outcomes for the patients in the hospital.

Findings:

1. Review of the hospital's P&P titled Standards of Care ICU-CCU revised on 9/13, showed the following:

* Serial assessment/reassessment will be based on the patient's problem/needs, physician's order and/or as warranted by the patient's condition.

* Appropriate physical examination techniques will be used to collect information at the beginning of each shift and as often as indicated by gravity of the patient's condition.

* Staff will facilitate the availability of pertinent data to all health team members.

* All pertinent data or changes in condition of the patient will be documented in the patient's medical record.

* Care will be provided so as to minimize complications and life-threatening situation.

* Assure the relevance of nursing intervention to identify patient problems/health care needs.

* Collect data for evaluation within an appropriate time interval after intervention.

Review of Patient 17's medical record was initiated on 7/8/14. The patient was admitted to the hospital on 7/3/14. The patient has a history of diabetes (high blood sugar).

Review of the physician's H&P dictated on 7/3/14 at 1456 hours, showed Patient 17 was brought into the ED by the paramedics. The patient was admitted to the ICU.

Review of the hospital's P&P titled Propofol Infusion Guidelines for Ventilator Patients revised 9/13, (medication used for sedation during procedures and for sedation in intubated, mechanically-ventilated ICU patients) showed the following:

* A physician's order must related to a therapeutic goal (RASS, or Richmond Agitation Sedation Scale; a scale used to assess the patient's sedation level) sedation level or the desired level of sedation (usual desire RASS score is minus two). Notify the physician for RASS score of minus four or minus five.

* RASS Score is determined by the following:

- Score of minus two indicates slight sedation when the patient is briefly awake with eye contact to voice less than 10 seconds.

- Score of minus three indicates moderate sedation when the patient moves or opens eyes, and has no eye contact.

- Score of minus four indicates deep sedation when the patient had no response to voice, but movement or eye opening to physical stimulation.

- Score of minus five indicates the patient is unarousable, or has no response to voice or physical stimulation.

* The RN must document the patient's response or RASS scale.

Review of the physician's order for Patient 17 dated 7/3/14 at 1521 hours, showed IV propofol to run at 24 ml per hour; Propofol drip to start at 10 mcg per kg per minute and titrate up to 100 mcg per kg per minute; and titrate to a sedation RASS score of minus two.

Review of the Neurological Assessment dated 7/6/14 at 1041 hours, documented by RN D showed Patient 17 was lethargic (drowsy)/somnolent (sleeping) on 7/6/14 at 0800 hours. The patient opened eyes and tracked when name was called. The patient was sedated on propofol with a RASS Score of minus two.

Review of the Neurological Assessment dated 7/7/14 at 1030 hours, documented by RN D, showed Patient 17 was lethargic/somnolent on 7/7/14 at 0800 hours. The patient's eyes were closed and swollen. The patient opened eye with tactile (touching, or physical) stimulation. Patient 17 was sedated with propofol with RASS Score of minus two.

However, according to the hospital's P&P for Propofol Infusion Guidelines for Ventilator Patients, Patient 17 would be assessed as having a RASS score of minus four when the patient opened his eye with tactile stimulation.

Nursing staff assessed Patient 17 as sedated with a RASS score of minus two on 7/7/14 at 0800 hours. The RASS score of minus two did not accurately reflect the patient's sedation condition at that time.

Review of the IV Drip Monitoring form showed Patient 17 continued to receive propofol 40 mcg per kg per minute (or 24 ml per hour) on 7/7/14 at 0700 hours, at 0800 hours, and at 0900 hours.

Multiple observations of Patient 17 were conducted on 7/7/14, accompanied by RN D. The following was identified and was confirmed by the RN:

* At 0905 hours, Patient 17 was lying on his bed with his eyes closed. Propofol was infusing at 40 mcg per kg per minute or 24 ml per hour.

* At 1355 hours, Patient 17 lying on the bed with his eyes closed. Propofol was infusing at 40 mcg per kg per minute or 24 ml per hour. RN D used a lancet (a device, same as a needle, used to stick into the patient's finger) to check his blood sugar. The patient did not open his eyes and no grimace of pain was observed on his face. The patient did not respond when the RN stuck his finger with the lancet.

* At 1405 hours, RN D called Patient 17's name, touched and shook the patient's hands, and pushed on the patient's chest by using her hand. The patient did not open his eyes and no grimace of pain was observed on his face. The patient did not respond to the physical stimulation from the RN. The RN decreased the rate of propofol to 35 mcg per kg per minute.

* At 1409 hour, RN D called Patient 17's name, shook the patient's hands, and suctioned the patient's mouth. The patient did not respond, open his eyes and no grimace of pain was observed on his face. The RN again decreased the rate of propofol this time to 30 mcg per kg per minute.

* At 1413 hours, the RN called the patient and shook the patient's hand. The patient did not respond or open his eyes and no grimace of pain was observed on his face. The RN again decreased the rate of propofol to 20 mcg per kg per minute.

* At 1445 hours, the RN called the patient's name. The patient opened his eyes. Propofol was infusing at 20 mcg per kg per minute.

According to the above observations from 1355 to 1413 hours, and the hospital's P&P, Patient 17 was sedated with RASS score of minus five as the patient was unarousable and did not respond to voice or physical stimulation.

A follow-up medical record review for Patient 17 was conducted with the Director ICU on 7/8/14 at 1020 hours. The following was identified:

* Review of the RASS Score showed Patient 17 was assessed as having a RASS Score of minus two on 7/7/14 at 1400 hours; however, the RASS Score of minus two did not accurately reflect Patient 17's condition at that time.

* There was no documented evidence to show the above observations were documented in the patient's medical record as per hospital's P&P and no documented evidence to show Patient 17 was assessed as having a RASS Score of minus five as per hospital's P&P on 7/7/14 at 1400 hours. There was no documented evidence to show the physician was notified as per hospital's P&P. There was no documented evidence to show the patient was assessed for changes in condition, including neurological assessment on 7/7/14 at 1400 hours.

The Director of ICU confirmed the above findings.

2. Review of the hospital's P&P titled Pain Management reviewed on 9/13, showed the following:

* To obtain a complete pain history on admission for all patients with diagnoses of acute or chronic pain, or those at an increased risk for experiencing pain.

* Information to be obtained during pain assessment included precipitating factors, quality, radiation, severity, time onset, duration and variation, aggravating and relieving factors, previous treatment modalities, observation of the pain site, and the patient's pain goal.

* To conduct reassessment with each report of pain, thirty minutes post parenteral drug administration, one hour post oral pain medication, and with each vital signs.

* Staff will respond to the patient's request for pain relief or assessed need for pain relief with pain reducing intervention.

* Adjustment in dosage and frequency will be based on assessment of pain relief

Review of Patient 23's medical record was initiated on 7/8/14. The patient came to the ED on 7/7/14 at 1939 hours, and was admitted to the hospital on 7/8/14 at 0100 hours.

a. Review of the Visit Summary Report (an ED record) showed Patient 23 received morphine (a narcotic medication) 4 mg on 7/7/14 at 2212 hours, for a pain level of 8 out of 10 on a pain scale of 0-10 (0 was represented no pain and 10 represented the worst pain).

Review of Patient 23's physician's Admission Orders dated 7/8/14 at 0100 hours, showed morphine 4 mg IV (a medication injected directly into the blood vessel) every four hours as needed.

Review of the List Patient Notes showed an entry dated 7/8/14 at 0255 hours, showed Patient 23 arrived on the nursing unit from the ED on 7/8/14 at 0100 hours. The patient complained of pain and nausea at that time, morphine was previously administered in the ED.

Review of the List Patient Notes dated 7/8/14 at 0255 hours, showed Patient 23 complained of pain on 7/8/14 at 0220 hours. Morphine was given to the patient.

Further review failed to show nursing staff assessed Patient 23 for pain location or pain characteristics when the patient complained of pain on 7/8/14 at 0220 hours, as per the hospital's P&P.

b. Review of the Vital Signs dated 7/8/14 at 0400 hours, showed Patient 23 reported her pain level was 3 out of 10.

There was no documented evidence to show the patient was assessed for pain location or pain characteristics when the patient complained of pain as per the hospital's P&P.

An interview and concurrent medical record review was conducted with the Director of ICU on 7/8/14 at 0935 hours. When asked, the Director confirmed the above findings.

c. Review of the hospital's P&P titled Plan for Assessment/Reassessment of Patients reviewed 12/13, showed the patient will be reassessed by RN anytime as deemed necessary.

Review of the Genitourinary Reproductive Assessment dated 7/8/14 at 0400 hours, showed Patient 23 voided by using bathroom. The patient had no urgency in urination. At 0151 hours, Patient 23's urine was cloudy, and the patient had no complaint of voiding problems.

Review of the Output form dated 7/8/14 at 0600 hours, showed Patient 23 went to the bathroom twice; however, there was no documentation to show Patient 23 was assessed as to whether or not the patient was able to urinate.

During an observation and interview on 7/8/14 at 0850 hours, Patient 23 stated she tried but was unable to urinate since she arrived to the unit.

An interview and concurrent medical record review was conducted with the Director of ICU on 7/8/14 at 0935 hours. When asked, the Director was unable to show nursing staff assessed whether or not the patient was able to urinate and empty her bladder.

3. Review of Patient 19's medical record was initiated on 7/7/14. The patient was admitted to the ICU on 7/5/14 at 1740 hours, and transferred to the telemetry unit on 7/6/14 at 1925 hours. The patient had a history of chronic pain.

Review of the Neuromuscular Assessment dated 7/5/14 at 1943 hours, showed Patient 19 was lethargic and arousable to deep stimuli only when admitted to the ICU on 7/5/14 at 1740 hours.

a. Review of the nurses' notes dated 7/6/14 at 1533 hours, showed Patient 19 complained of pain on 7/6/14 at 1531 hours. The patient's pain level was 7 out of 10. The patient was medicated as per documentation on the MAR; however, there was no documentation to show Patient 19 was assessed for pain location or pain characteristics.

b. Review of the nurses' notes dated 7/6/14 at 2058 hours, showed Patient 19 transferred from ICU on 7/6/14 at 1930 hours. The patient was alert and oriented. The patient denied pain.

Review of the nurses' notes recorded on 7/7/14 at 0055 hours, showed Patient 19 asked for a morphine dose that was not given to the patient as scheduled at 1700 hours, for chronic pain.

However, there was no documented evidence to show a pain assessment was conducted for Patient 19 when the patient asked for morphine on 7/7/17 at 0054 hours.

c. There was no documented evidence to show a complete pain history and pain assessment was conducted as per hospital's P&P when Patient 19 was admitted.

During an interview and concurrent medical record review with the Director of ICU on 7/7/14 at 1510 hours, the Director confirmed the above findings for Patient 19.

4. Review of the hospital's P&P titled Nutrition Screening reviewed on 11/13, showed in order to identify patients who require an in depth nutritional assessments, all patients admitted to the hospital shall be screened for nutritional status by nursing with referral to Nutritional Services.

Criteria for screening by nursing include refusing to eat greater than three days, vomiting/nausea/diarrhea greater than three days, dysphagia (difficulty swallowing), and weight loss, unintentional greater than 10 pounds in one month.

Review of Patient 13's medical record was initiated on 7/7/14. Patient 13 was admitted to the hospital on 6/27/14, due to increased agitation and refusal to eat. Patient 13 had diagnoses including severe dementia.

On 7/7/14 at 0945 hours, Patient 13 was observed in front of the nursing station, up in a wheelchair. The patient appeared very thin, dishelved, was hard of hearing, and was difficult to understand her speech pattern as she had no teeth; however, she was pleasant and cooperative.

Review of Patient 13's Weight Record dated 6/27/14, showed an admission height of 4 feet and 11 inches, weight of 101 pounds (equivalent to 45.8 kg), and a BMI of 20 (healthy weight).

Review of the Weight Record dated 7/5/14, showed the following weight variance for Patient 13 as 83 pounds (lost 17 pounds or 17.8%) and BMI of 16.8 (underweight).

An interview and concurrent medical record review was conducted with the Director of Psychiatric Services and RN D on 7/7/14 at 1030 hours. RN D stated on 7/5/14 Patient 13 weight was 83 pounds (17 pounds less than the admission weight).

A follow-up weight was conducted on 7/7/14 at 1045 hours, and showed the patient's weight was 87.7 pounds.

Review of the laboratory report dated 6/28/14, showed Patient 13's albumin (a protein, low level may be related to malnutrition) was 3.2 (normal range 3.4 - 5.0 g/dL)

Review of Patient 13's Nutrition Assessment dated 7/1/14, showed the assessment was not conducted until four days after Patient 13's admission. The patient's height was 4 feet and she weighed 100 pounds. The RD documented the weight status was appropriate.

The RD documented the patient seen and visited. The RD stated the patient did not have teeth or dentures; however, per the CNA the was tolerating mechanical soft diet. The RD noted per the RN and MD's notes, the patient was uncooperative, confused, and refusing care. The RD noted since the patient appeared thin and underweight, she questioned if the admission weight was an actual weight versus estimated weight. The RD documented the patient was at low nutritional risk at this time.

The RD was unable to find documented evidence to show Patient 13's weight was reassessed.

During an interview with the RD on 7/7/14 at 1000 hours, the RD acknowledged a incomplete and inaccurate nutritional status of Patient 13 at the time of admission resulted in a delayed nutritional assessment and interventions by the RD.

The RD stated since Patient 13's weight was 83 pounds she should have received a nutritional assessment no later than 1-2 days. The RD stated Patient 13 was a high priority for assessment as she was malnourished and underweight.

5. The hospital's P&P titled Plan for Assessment/Reassessment of Patients revised 7/12, read in part, "A registered nurse shall assess the patient's need for nursing care in all settings where nursing care is provided." "Care decisions will be based upon data and information gathered in assessments and reassessments." and "The patient will be reassessed by a Registered Nurse: ...minimally every shift and at unit specified intervals related to the care setting course of treatment..." and "Documentation of the reassessment will be in patient's chart."

For the 16 BHU patients (Patients 7, 8, 9, 10, 11, 12, 13, 14, 31, 32, 33, 34, 35, 36, 37, and 38) reviewed, the Interdisciplinary Treatment Plan Updates and the "measurable desired outcomes" on the treatment plans did not reflect reassessments of the patients' progresses as there was inadequate documented evidence to show information about the patients' responses to interventions was collected and considered. For example:

a. Patient 9 was admitted to the BHU on 6/18/14, with diagnoses including schizophrenia with bipolar disorder, cellulitis (bacterial infection of the skin) of the lower extremities, hypertension (high blood pressure), a seizure disorder, and a history of asthma.

One of three active problems identified for the patient was altered thought process. On 6/18/14, the "measurable desired outcomes" for that problem included to improve orientation to person, place, date, and time at discharge, state and/or exhibit decrease in response to internal stimuli daily and be 100% medication complaint for six consecutive days, with the target date of 6/23/14.

The 6/23/14, Interdisciplinary Treatment Plan Update showed the patient had "altered thought process, delusional, word salad, very disorganized." There was no information documented to show whether the patient had improved or deteriorated orientation to person, place or time. There was no information to show whether there was an increased or decreased response to internal stimuli and no information about changes in rate of medication compliance since the goal was formulated five days prior.

Review of the nurse's progress notes for the dates 6/18 to 6/23/14, showed the patient's orientation was assessed once on 6/21/14 at 0730 hours. Comments about responding to internal stimuli appeared in the notes on 6/21/14 at 0950 and 1417 hours, on 6/22/14 at 1400 hours, and on 6/23/14 at 1838 hours as "Pt (patient) responding to internal stimuli as evidenced by continuously talking word salad." On other dates and times, it was unclear if the patient was assessed for responding to internal stimuli.

Patient 9's nursing notes showed the patient refused to take medications on the evenings of 6/19 and 6/21/14. A note on 6/24/14 at 1429 hours, showed "He was more compliant with his medications today;" however, it was not clear what previous non-compliance was being used for comparison.

During an interview with the Nursing Director of Psychiatric Services on 7/8/14 at 1450 hours, he reviewed the "Patient progress toward goals" comments on the Interdisciplinary Treatment Plan Update for Patient 9. The Director confirmed it was not clear in the documentation as to how much progress the patient made towards the measurable desired outcomes associated with his altered thought process.

Review of the physician's plan for Patient 9 documented on 6/20/14 included: "We will continue with wound care, leg elevation, and whirlpool therapy;" "We will monitor the patient's blood pressure status closely;" "Monitor pulmonary status closely;" and "We will encourage ambulation."

During observations of Patient 9 in the BHU on 7/7/14, the patient was seated in a wheelchair. His feet were on or near the floor.

The nursing notes for Patient 9 dated from 6/18 to 6/25/14, were reviewed. Documentation showed nursing notes were written on all 21 shifts during that week. However, there were few nursing assessments of the patient's lower extremity cellulitis or pulmonary status.

On 6/21 at 2200 hours the nurse wrote, "RLE (right lower extremity) cellulitis." On 6/22/14 at 1834 hours, the nurse wrote, "swollen R (right) leg that is red but no c/o (complaints) pain nor tenderness. Skin intact with no observed drainage."

On 6/23/14 at 1838 hours the nurse wrote, "swollen right leg that is intact." Observations of the cellulitis were recorded on only three out of the 21 shift assessments. Multiple notes indicated Patient 9 had edema (swelling) of the legs; however, no assessment of whether there was discoloration, discharge or discomfort was found.

Documentation on 6/21/14 at 0515 hours, showed the patient's respirations were "even and unlabored." On 6/24 at 0705 hours, nursing notes showed "respirations even and unlabored, no signs of any acute distress or SOB (shortness of breath) noted" On 6/24/14 at 1904 hours, the nurse recorded, "respirations are even and unlabored, No SOB." Although the physician's plan was for closely observing the patient's pulmonary status, respirations were observed by the nursing staff on only three of 21 shift assessments during the week of 6/18 to 6/25/14.

b. The medical record for Patient 8 was reviewed beginning on 7/7/14. The patient was admitted to the BHU on 6/16/14, with depression. One of two active problems identified for the patient was alteration in mood.

The "measurable desired outcomes" for that problem included for the patient to sleep 7-8 hours for six night(s), eat 75% of each meal and shower daily for six days, and be 100% medication complaint for six consecutive days, with the target date of 6/23/14.

However, the "Patient progress toward goals" on 6/23/14, read, "depressed, poor ADL's and self- care." There was no evidence an assessment of Patient 8's sleep and oral intake or medication compliance was made by the treatment team to help determine the patient's progress.

Review of the internal medicine progress note dated 6/19/14, showed "Exacerbation of the asthma, rule out pneumonia. We will monitor the patient's pulmonary status closely." Other medical problems identified included sinusitis and rhinitis, reflux disease, osteoarthritis, hypertension, constipation, and chronic back and lower leg pain. On 6/16/14, a red rash was seen in abdominal, breast, and groin folds.

The nursing notes for Patient 8 dated from 6/1 to 6/23/14 were reviewed. Documentation showed notes were written on all 21 shifts during that week. However, there were few nursing assessments of the patient's pulmonary status, arthritis, or rash.

Review of the nursing documentation for Patient 8 regarding a red rash in the abdomen, breast, and groin folds showed the rashes were assessed on only from four of the 21 shifts, 6/16/14 at 2211 hours, 6/18/14 at 1856 hours, 6/19/14 at 1440 hours, and 6/21/14 at 2254 hours.

Review of the nursing documentation for Patient 8 regarding lung function showed a respiratory assessment was conducted and documented on only seven of the 21 shifts for the week on 6/16/14 at 2211 hours, 6/17/14 at 1530 hours, 6/19 at 0505 hours, 6/21/14 at 2254 hours, and 6/23/14 at 0446 hours. The patient requested breathing treatments from the Respiratory Therapist two times during that time period.

The nurses' notes for Patient 9 were reviewed with the Director of the ED on 7/9/14 at 1400 hours. The Director confirmed documentation of an assessment of the patient's skin and respiratory symptoms was not consistent.

The nurses' notes for Patients 8 and 9 were reviewed with the Nursing Director of Psychiatric Services on 7/8/14 at 1450 hours. The Director concurred the nursing shift assessment documentation did not reflect routine reassessment of the patients' pulmonary status and skin condition.

In an interview with the DON on 7/9/14 at 1400 hours, the DON concurred it appeared the nurses in the BHU were having difficulty remembering to document the patients' medical conditions.

Based on observation, interview, and record review, the hospital failed to ensure the RN supervised and evaluated nursing care for 12 of 38 sampled patients (Patients 1, 3, 4, 9, 12, 13, 14, 16, 17, 18, 19, and 23) and to ensure the hospital's P&Ps for patient care were implemented as evidenced by:

1. The Nursing Director of Psychiatric Services failed to provide adequate oversight to ensure standards of nursing care were provided in the BHU for the use of seclusion/restraints, the patients' treatment plans were individualized, and care was provided in a safe setting for an elderly vulnerable patient.

2. Nursing staff failed to ensure the physician was notified when Patient 17's blood sugar significantly decreased and failed to notify the physician of the patient's change of condition or sedation level as per hospital's P&P.

3. Nursing staff failed to check Patient 16's blood sugar as ordered by the physician and failed to notify the physician when the patient required Dextrose (a solution containing sugar which is used to rescue or treat for low blood sugar) 50% for a significant low blood sugar while on an insulin drip.

4. Nursing staff failed to ensure Patient 18's troponin levels (a blood test to detect heart attack) were obtained as ordered.

5. Nursing staff failed to provide medication or pain intervention for Patient 23's complaints of pain.

6. There was no documented evidence to show the RN directly conducted the nursing assessments for Patients 1, 3, 4, and 9 prior to delegating the care of the patients to an LVN.

These failures created the risk of substandard health outcomes for the patients in the hospital.

Findings:

1. The hospital's job description for the Nursing Director of Psychiatric Services was reviewed on 7/8/14. Documentation showed the Director has 24 hour responsibility to supervise, coordinate and evaluate nursing care in the BHU, in accordance with the RN Practice Act, Standard of Practice and facility P&Ps. The Director was to supervise /coordinate all nursing activities to achieve and maintain efficient and competent nursing practices. The Director oversees the provision of patient care for adults and older adult patients.

The Director was to direct and supervise complex patient care situations and complex patient care problems and ensure that basic care was provided promptly and efficiently in a holistic manner. In addition, the Director was to collaborate with the Program Director in the implementation of the philosophy and objectives for the BHU.

a. The Master Treatment Plan for four of 16 BHU patients (Patients 8, 9, 12, 13, and 14) included nursing interventions individualized (focused) for the patients. The treatment plan included nursing interventions which were generic and did not address the patients' individualized needs. Not addressing individualized interventions results in lack of guidance to staff in providing individualized nursing care. Cross Reference to A- 0396 #6, 7, 8, 9, and 10.

b. Review of the hospital's P&P titled Restraint and Seclusion revised on 4/14, showed "Time Out," for Behavioral Health Patients is when a patient is "restricted from leaving" an unlocked room for 30 minutes and is part of their treatment plan.

"Seclusion," is the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others, and must be discontinued at the earliest possible time.

Review of the hospital's P&P titled "Time Out," last reviewed 6/13, showed the seclusion room is not punitive or used for disciplinary purpose. It's a place to calm down after experiencing difficulties with personal issues. The seclusion room with doors unlocked can be used as a time out room. During "Time Out," the patient is observed at a minimum every 15 minutes until the patient's behavior is appropriate to return to the therapeutic milieu; however, the P&P did not address how long the patient should be kept in the "Time Out room," any change in condition, notification of the physician, and as a part of the patient's treatment plan.

Patient 9's medical Record Review was initiated on 7/7/14. Patient 9 was admitted to the BHU on 6/28/14, with diagnoses including paranoid schizophrenia.

Patient 9's Master Treatment Plan dated 6/28/14 showed Problem #4 to address Assaultive Behavior, Threatening Behavior, manifested by striking and kicking staff. The interventions did not list instructions for the staff on how to manage the patient's aggressive behavior and did not include use of seclusion and/or time out.

Review of the Patient Care Inquire, Patient Notes dated 7/6/14 at 0138 hours, showed the patient woke up severely agitated towards staff and peers. Security and the house supervisor were called along with other staff nurses to direct the patient to room "221." Emergency medications were given. At 0900 hours, received the patient in "observation room." At 1000 hours, the patient attempted to leave the observation room; however, he became agitated again, threatening staff. Patient 9 was escorted to the observation room by staff. Patient was combative and uncooperative with staff. At 1857 hours, received patient in the "quiet room."

The video surveillance of 7/6/14 at 1855 hours was viewed with the Nursing Director of Psychiatric Services, the facility's security technologist, and RN D. One hour of recording showed Patient 9 pacing in room "221."The video showed Patient 9 attempted to open the door of the seclusion room three times; however, the door was locked. The Director confirmed the door of the seclusion room was closed and locked, and in this case a physician's order was needed.

There was no documentation found in Patient 9's record to show a physician's order was obtained for the patient to be placed in seclusion. Cross reference to A- 0167.

c. Patient 13, an elderly vulnerable patient, signed in as "voluntary admission;" however, Patient 13 did not meet the established criteria for voluntary admission and for the ability to consent to treatment and the use of psychotropic medication due to cognitive deficits, confusion, disorientation, and severe dementia. Cross reference to A- 0131.

During an interview with the DON on 7/8/14 at 0900 hours, the personnel record for the Nursing Director of the Psychiatric Services was reviewed. The Nursing Director's date of hire was 5/19/14. When asked who the Director was previously, the DON stated the last Nursing Director of Psychiatric Services resigned on 5/28/13, a year ago. The DON confirmed she provided the oversight for the BHU during the last year; however, when asked she stated she had no background in psychiatric nursing.

2. Review of the hospital's P&P titled Standards of Care ICU-CCU revised on 9/13, showed the following:

* Serial assessment/reassessment will be based on the patient's problem/needs, physician's order and/or as warranted by the patient's condition.

* Appropriate physical examination techniques will be used to collect information at the beginning of each shift and as often as indicated by gravity of the patient's condition.

* Staff will facilitate the availability of pertinent data to all health team members.

* All pertinent data or changes in condition of the patient will be documented in the patient's medical record.

* Care will be provided so as to minimize complications and life-threatening situation.

* Assure the relevance of nursing intervention to identify patient problems/health care needs.

* Collect data for evaluation within an appropriate time interval after intervention.

* Report significant changes and abnormal findings.

Review of Patient 17's medical record was initiated on 7/8/14. The patient was admitted to the hospital on 7/3/14. The patient has a history of diabetes (high blood sugar).

Review of the physician's H&P dictated on 7/3/14 at 1456 hours, showed Patient 17 was brought into the ED by the paramedics. The patient had a low blood sugar and was given glucose (sugar) in the field. The patient was intubated and would be admitted to the ICU.

a. Review of the physician's order dated 7/4/14 at 1039 hours, showed to check the patient's blood sugar by using fingerstick every hour. If the blood sugar level was 80 mg per dl (normal blood sugar is between 70 to 110 mg per dl) and above two times, perform blood sugar checks every two hours.

Review of the physician's order dated 7/4/14, showed to give 50 ml Dextrose 50% every one hour as needed for a blood sugar of 60 mg per dl or less.

Review of the physician's order dated 7/6/14 at 1225 hours, showed IV Dextrose 10% was to infuse at 150 ml per hour.

Review of a subsequent physician's order dated 7/7/14 at 0901 hours, showed to decrease the IV solution to Dextrose 5% with normal saline and infuse at 80 ml per hour.

Review of Patient 17's IV Drip Monitoring Form showed the patient received Dextrose 10% at 150 ml per hours on 7/7/14 at 0700 hours and at 0800 hours. At 0900 hours, the IV solution was decreased to Dextrose 5% and normal saline at 80 ml per hour.

Review of the Glucose POC (point of care) testing dated 7/7/14, showed Patient 17's blood sugar was documented as 121 mg per dl at 0551 hours, and 116 mg per dl at 1008 hours. At 1258 hours, the patient's blood sugar decreased to 65 mg per dl.

There was no documented evidence to show the physician was notified when Patient 17's blood sugar decreased to 65 mg per dl from 116 mg per dl on 7/17/14 at 1258 hours.

At 1355 hours, RN D was observed checking Patient 17's blood sugar. The result was 60. The RN administered one ampule of Dextrose 50% to the patient for the blood sugar of 60.

Review of the physician's order dated 7/7/14 at 1447 hours, showed Dextrose 5% normal saline was increased to be run at 125 ml per hour.

An interview and concurrent medical record review was conducted with the Director ICU on 7/8/14 at 1020 hours. When asked, the Director was unable to find documented evidence to show the physician was notified when Patient 17's blood sugar decreased to 65 mg per dl from 116 mg per dl on 7/7/14 at 1258 hours.

b. Review of the hospital's P&P titled Propofol Infusion Guidelines for Ventilator Patients revised 9/13, (medication used for sedation during procedures and for sedation in intubated, mechanically-ventilated ICU patients) showed the following:

* A physician's order must related to a therapeutic goal (RASS, or Richmond Agitation Sedation Scale; a scale used to assess the patient's sedation level) sedation level or the desired level of sedation (usual desire RASS score is minus two). Notify the physician for RASS score of minus four or minus five.

* RASS Score is determined by the following:

- Score of minus two indicates slight sedation when the patient is briefly awake with eye contact to voice less than 10 seconds.

- Score of minus three indicates moderate sedation when the patient moves or opens eyes, and has no eye contact.

- Score of minus four indicates deep sedation when the patient had no response to voice, but movement or eye opening to physical stimulation.

- Score of minus five indicates the patient is unarousable, or has no response to voice or physical stimulation.

* The RN must document the patient's response or RASS scale.

Review of the physician's order for Patient 17 dated 7/3/14 at 1521 hours, showed IV propofol to run at 24 ml per hour; Propofol drip to start at 10 mcg per kg per minute and titrate up to 100 mcg per kg per minute; and titrate to a sedation RASS score of minus two.

Review of the Neurological Assessment dated 7/6/14 at 1041 hours, documented by RN D showed Patient 17 was lethargic (drowsy)/somnolent (sleeping) on 7/6/14 at 0800 hours. The patient opened eyes and tracked when name was called. The patient was sedated on propofol with a RASS Score of minus two.

Review of the Neurological Assessment dated 7/7/14 at 1030 hours, documented by RN D, showed Patient 17 was lethargic/somnolent on 7/7/14 at 0800 hours. The patient's eyes were closed and swollen. The patient opened eye with tactile (touching, or physical) stimulation. Patient 17 was sedated with propofol with RASS Score of minus two.

However, according to the hospital's P&P for Propofol Infusion Guidelines for Ventilator Patients, Patient 17 would be assessed as having a RASS score of minus four when the patient opened his eye with tactile stimulation.

Nursing staff assessed Patient 17 as sedated with a RASS score of minus two on 7/7/14 at 0800 hours. The RASS score of minus two did not accurately reflect the patient's sedation condition at that time.

Review of the IV Drip Monitoring form showed Patient 17 continued to receive propofol 40 mcg per kg per minute (or 24 ml per hour) on 7/7/14 at 0700 hours, at 0800 hours, and at 0900 hours.

Multiple observations of Patient 17 were conducted on 7/7/14, accompanied by RN D. The following was identified and was confirmed by the RN:

* At 0905 hours, Patient 17 was lying on his bed with his eyes closed. Propofol was infusing at 40 mcg per kg per minute or 24 ml per hour.

* At 1355 hours, Patient 17 lying on the bed with his eyes closed. Propofol was infusing at 40 mcg per kg per minute or 24 ml per hour. RN D used a lancet (a device, same as a needle, used to stick into the patient's finger) to check his blood sugar. The patient did not open his eyes and no grimace of pain was observed on his face. The patient did not respond when the RN stuck his finger with the lancet.

* At 1405 hours, RN D called Patient 17's name, touched and shook the patient's hands, and pushed on the patient's chest by using her hand. The patient did not open his eyes and no grimace of pain was observed on his face. The patient did not respond to the physical stimulation from the RN. The RN decreased the rate of propofol to 35 mcg per kg per minute.

* At 1409 hour, RN D called Patient 17's name, shook the patient's hands, and suctioned the patient's mouth. The patient did not respond, open his eyes and no grimace of pain was observed on his face. The RN again decreased the rate of propofol this time to 30 mcg per kg per minute.

* At 1413 hours, the RN called the patient and shook the patient's hand. The patient did not respond or open his eyes and no grimace of pain was observed on his face. The RN again decreased the rate of propofol to 20 mcg per kg per minute.

* At 1445 hours, the RN called the patient's name. The patient opened his eyes. Propofol was infusing at 20 mcg per kg per minute.

According to the above observations from 1355 to 1413 hours, and the hospital's P&P, Patient 17 was sedated with RASS score of minus five as the patient was unarousable and did not respond to voice or physical stimulation.

A follow-up medical record review for Patient 17 was conducted with the Director ICU on 7/8/14 at 1020 hours. The following was identified:

* Review of the RASS Score showed Patient 17 was assessed as having a RASS Score of minus two on 7/7/14 at 1400 hours; however, the RASS Score of minus two did not accurately reflect Patient 17's condition at that time.

* There was no documented evidence to show the above observations were documented in the patient's medical record as per hospital's P&P. There was no documented evidence to show the physician was notified as per hospital's P&P.

The Director of ICU confirmed the above findings.

3. Review of Patient 16's medical record was initiated on 7/7/14. The patient was admitted to the hospital's ICU on 7/6/14. The patient had a history of diabetes.

Review of the physician's Admission Order form dated 7/6/14 at 0725 hours, showed Patient 16 had a diagnosis of acute DKA (diabetic ketoacidosis, a potentially life-threatening complication in a patient with diabetes, one of the specific signs of diabetic ketoacidosis is high blood sugar level).

Review of the nurses' notes recorded on 7/6/14 at 1128 hours, showed Patient 16 was admitted from the ED on 7/6/14 at 0840 hours. The patient was receiving a regular insulin drip infusion (a medication used to treat high blood sugar) at 6 units per hour. The patient's blood sugar level would be checked every hour.

Review of the physician's order dated 7/6/14 at 0840 hours, showed to start regular insulin at 9 ml per hour and adjust the dose with each blood sugar check as follows:

* If the blood sugar is less than 80 mg per dl, decrease the drip by 2 units per hour, inject one ampule of a Dextrose 50% IVP (intravenous push, an injection of medication directly into the blood vessel) times one, and repeat the blood sugar check in 30 minutes;

* If the blood sugar is between 80 mg per dl and 110 mg per dl, decrease the drip by 1 unit per hour;

* If the blood sugar is between 111 mg per dl and 160 mg per dl, continues the same rate;

* If the blood sugar is between 161 mg per dl and 200 mg per dl, increase the drip by 1 unit per hour;

* If the blood sugar is between 201 mg per dl and 250 mg per dl, increase the drip by 1 unit per hour and give 2 units regular insulin IVP once;

* If the blood sugar is between 251 mg per dl and 300 mg per dl, increase the drip by 2 unit per hour and give 2 units of regular insulin IVP once;

* If the blood sugar is between 301 mg per dl and 350 mg per dl, increase the drip by 3 unit per hours and give 2 units of regular insulin IVP once;

* If the blood sugar is greater than 350 mg per dl, call the physician.

Review of Patient 16's physician's order dated 7/6/14 at 1000 hours, showed to check the patient's blood sugar every one hour.

Review of the physician's order dated 7/6/14 at 1616 hours, showed to check the patient's blood sugar every two hours, starting at 1800 hours.

a. Review of the Insulin Drip Monitoring Form showed on 7/6/14, Patient 16's blood sugar was 308 mg per dl at 0846 hours, 126 mg per dl at 1000 hours, 186 mg per dl at 1100 hours, 276 mg per dl at 1300 hours, 341 mg per dl at 1400 hours, and 82 mg per dl at 1730 hours.

Review of a laboratory report collected on 7/6/14 at 1630 hours, showed Patient 16's blood sugar was 137 ml per dl.

There was no documented evidence to show Patient 16's blood sugar was checked every hours as there was no documentation to show a blood sugar recorded at 1200 hours, 1500 hours, and at 1600 hours as ordered.

b. Review of Patient 16's Insulin Drip Monitoring Form showed the following:

* On 7/6/14 at 1400 hours, Patient 16's blood sugar was 341. Documentation showed the patient had no IV site at this time and the physician was aware; however, there was no documented evidence to show insulin was given to the patient when the patient's blood sugar was 341.

* On 7/6/14 at 1523 hours, two units of regular insulin IVP was administered to the patient. The insulin drip was restarted to run at 15 units per hour.

There was no documented evidence to show the patient's blood sugar was rechecked prior to restart insulin drip, or prior to administer the regular insulin IVP to the patient on 7/6/14 at 1523 hours.

c. Review of Patient 16's Insulin Drip Monitoring Form showed the blood sugar was 82 mg per dl on 7/6/14 at 1730 hours. At 1950 hours, the patient's blood sugar was 23 mg per dl. The rate of insulin drip was decreased to 6 units per hour and one ampule of Dextrose 50% was given to the patient.

There was no documented evidence to show Patient 16's blood sugar was checked every two hours (or at 1930 hours) as ordered.

d. Review of Patient 16's Insulin Drip Monitoring Form showed the following:

* The patient's blood sugar was 23 mg per dl on 7/6/14 at 1950 hours, 27 mg per dl at 2150 hours, 28 mg per dl on 7/7/14 at 0000 hours, and 53 mg per dl at 0200 hours.

* One ampule of Dextrose 50% was administered to Patient 16 on 7/6/14 at 1950 and 2150 hours, and 7/7/14 at 0000 and 0200 hours, while the patient was receiving insulin drip.

* The insulin drip was discontinued on 7/7/14 at 0900 hours.

There was no documented evidence to show the physician was notified about Patient 16's condition when nursing staff concurrently administered Dextrose 50% and insulin to the patient as documented above.

During an interview and concurrent medical record review with the Director of ICU and RN F on 7/8/14 at 1100 hours, they confirmed the above findings.

3. Review of Patient 18's medical record was initiated on 7/7/14. The patient was admitted to the hospital on 6/30/14, and was in ICU on 7/7/14. The patient had a history of diastolic heart failure (condition in which the heart is not properly functioning).

Review of Patient 18's physician's progress notes dictated on 7/6/14 at 1305 hours, showed Patient 18 had difficulty breathing last night and had some abdominal and chest discomfort on and off.

Review of the physician's order dated 7/6/14 at 1114 hours, showed troponin I levels were to be drawn every eight hours times three, starting on 7/6/14 at 1113 hours.

According to the physician's order, the troponin I level should be obtained for Patient 18 on 7/6/14 at 1114 hours and 1914 hours, and on 7/7/14 at 0314 hours.

Review of the laboratory reports showed the following:

* On 7/6/14 at 0600 hours, Patient 18's troponin level was 0.18 (normal range is between 0 - 0.07, and when the troponin level is between 0.08 to 0.59, the patient's heart muscle is possibly damaged).

* On 7/7/14 at 0500 hours, the patient's troponin level was 0.12.

Further medical record review failed to show Patient 18's troponin levels were obtained as ordered.

An interview and medical record review was conducted with the Director of ICU and RN I on 7/8/14 at 1600 hours. The staff was asked if Patient 18's troponin level was obtained every eight hours as ordered. RN I stated she did not know. The Director confirmed the patient's troponin levels were not obtained as ordered.

5. Review of the hospital's P&P titled Pain Management reviewed on 9/13, showed the following:

* To obtain a complete pain history on admission for all patients with diagnoses of acute or chronic pain, or those at an increased risk for experiencing pain.

* Information to be obtained during pain assessment included precipitating factors, quality, radiation, severity, time onset, duration and variation, aggravating and relieving factors, previous treatment modalities, observation of the pain site, and the patient's pain goal.

* To conduct reassessment with each report of pain, thirty minutes post parenteral drug administration, one hour post oral pain medication, and with each vital signs.

* Staff will respond to the patient's request for pain relief or assessed need for pain relief with pain reducing intervention.

* Adjustment in dosage and frequency will be based on assessment of pain relief

* Report unrelieved pain to the physician when indicated.

Review of Patient 23's medical record was initiated on 7/8/14. The patient came to the ED on 7/7/14 at 1939 hours, and was admitted to the hospital on 7/8/14 at 0100 hours.

a. Review of the Visit Summary Report (an ED record) showed Patient 23 received morphine (a narcotic medication) 4 mg on 7/7/14 at 2212 hours, for a pain level of 8 out of 10 on a pain scale of 0-10 (0 was represented no pain and 10 represented the worst pain).

Review of Patient 23's physician's Admission Orders dated 7/8/14 at 0100 hours, showed morphine 4 mg IV (a medication injected directly into the blood vessel) every four hours as needed.

Review of the List Patient Notes showed an entry dated 7/8/14 at 0255 hours, showed Patient 23 arrived on the nursing unit from the ED on 7/8/14 at 0100 hours. The patient complained of pain and nausea at that time; morphine was administered previously in the ED.

Review of the Pain/Comfort documentation dated 7/8/14 at 0151 hours, showed Patient 23 currently complained of pain and had intermittent abdominal pain at 4 out of 10. Medication would relieve her pain. The patient's goal for pain relief scale was 0.

However, there was no documented evidence to show medication or nursing interventions were provided to Patient 23 when the patient arrived to the unit from the ED and complained of pain. There was no documented evidence to show nursing staff notified the physician of the patient's pain.

An interview and concurrent medical record review was conducted with the Director of ICU on 7/8/14 at 0935 hours. When asked, the Director confirmed the above findings.

6. Review of Patient 19's medical record was initiated on 7/7/14. The patient was admitted to the ICU on 7/5/14 at 1740 hours, and transferred to the telemetry unit on 7/6/14 at 1925 hours. The patient had a history of chronic pain.

Review of the Neuromuscular Assessment dated 7/5/14 at 1943 hours, showed Patient 19 was lethargic and arousable to deep stimuli only when admitted to the ICU on 7/5/14 at 1740 hours.

a. Review of the nurses' notes dated 7/6/14 at 2058 hours, showed Patient 19 transferred from ICU on 7/6/14 at 1930 hours. The patient was alert and oriented. The patient denied pain.

Review of the nurses' notes recorded on 7/7/14 at 0055 hours, showed Patient 19 asked for a morphine dose that was not given to the patient as scheduled at 1700 hours, for chronic pain.

During an interview and concurrent medical record review with the Director of ICU on 7/7/14 at 1510 hours, the Director confirmed the above findings for Patient 19.



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7. The hospital's P&P Plan for Assessment/Reassessment of Patients reviewed 12/13, showed a registered nurse shall assess the patient's need for nursing care in all settings where nursing care is provided. The initial assessment will be performed by a registered nurse. Reassessments will be done by the "registered nurse to determine response to treatment/procedures...minimally every shift." Documentation of the reassessment will be in patient's chart.

a. Record review for Patient 9 was initiated on 7/7/14. Patient 9 was admitted on 6/18/14, with diagnoses including schizophrenia (a mental disorder, often characterized by abnormal social behavior and failure to recognize what is real).

Review of the Psychiatric Shift Assessment dated 7/7/14 at 0627 hours, showed the LVN completed and documented the night shift assessment for Patient 9. The RN cosigned the assessment and documented she reviewed, discussed the data collected by LVN, and approved it; however, there was no documentation to show the RN directly assessed the patient to determine the patient's care needs.



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b. The electronic medical records for Patients 1, 3, and 4 were reviewed with the Director of Medical Surgical on 7/7/14 at 1340 hours, and showed the following:

* Review of the day shift nursing assessments for Patient 3 dated 7/5 and 7/6/14, showed the assessments were completed and documented by the LVN. The assessments were not conducted by an RN. The RN signed the data was collected by the LVN.

* Review of the day shift nursing assessments for Patient 1 dated 7/6/14, showed the assessments were completed and documented by the LVN. The assessments were not conducted by an RN. The RN signed the data was collected by the LVN.

* Review of Patient 4's initial admission nursing assessment dated 7/6/14, and the night shift nursing assessments dated 7/6 and 7/7/14, showed the assessments were completed and documented by the LVN. The assessments were not conducted by an RN. The RN signed the data was collected by the LVN.

During a concurrent interview with the Director of Medical Surgical, the Director stated she expected the RN to do the nursing shift system assessment of the patients on the unit; however, the Director confirmed if the LVN documented the assessment, there was no way to show the RN conducted an assessment prior to delegating the care of the patients to the LVN.



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c. During a review of the medical record of Patient 9 on 7/8/14, the admitting H&P examination showed the patient was admitted to the hospital on 6/18/14, with diagnoses including schizophrenia with bipolar disorder, cellulitis (bacterial infection of the skin) of the lower extremities, hypertension (high blood pressure), a seizure disorder, and a history of asthma.

The physician's plan documented on 6/20/14 included: "We will continue with wound care, leg elevation, and whirlpool therapy;" "We will monitor the patient's blood pressure status closely;" "Monitor pulmonary status closely;" and "We will encourage ambulation."

During observations of Patient 9 in the BHU on 7/7/14, the patient was seated in a wheelchair. His feet were on or near the floor.

The nursing notes for Patient 9 dated from 6/18 to 6/25/14, were reviewed. Documentation showed nursing notes were written on all 21 shifts during that week. However, there were few nursing assessments of the patient's lower extremity cellulitis or pulmonary status.

On 6/21 at 2200 hours the nurse wrote, "RLE (right lower extremity) cellulitis." On 6/22/14 at 1834 hours, the nurse wrote, "swollen R (right) leg that is red but no c/o (complaints) pain nor tenderness. Skin intact with no observed drainage."

On 6/23/14 at 1838 hours the nurse wrote, "swollen right leg that is intact." Observations of the cellulitis were recorded on only three out of the 21 shift assessments. Multiple notes indicated Patient 9 had edema (swelling) of the legs; however, no assessment of whether there was discoloration, discharge or discomfort was found.

Documentation on 6/21/14 at 0515 hours, showed the patient's respirations were "even and unlabored." On 6/24 at 0705 hours, nursing notes showed "respirations even and unlabored, no signs of any acute distress or SOB (shortness of breath) noted" On 6/24/14 at 1904 hours, the nurse recorded, "respirations are even and unlabored, No SOB." Although the physician's plan was for closely observing the patient's pulmonary status, respirations were observed by the nursing staff on only three of 21 shift assessments during the week of 6/18 to 6/25/14.

d. The medical record for Patient 8 was reviewed beginning on 7/7/14. The patient was admitted to the BHU on 6/16/14, with depression.

The internal medicine progress note dated 6/19/14, showed "Exacerbation of the asthma, rule out pneumonia. We will monitor the patient's pulmonary status closely." Other medical problems identified included sinusitis and rhinitis, reflux disease, osteoarthritis, hypertension, constipation, and chronic back and lower leg pain. On 6/16/14, a red rash was seen in abdominal, breast, and groin folds.

The nursing notes for Patient 8 dated from 6/1 to 6/23/14 were reviewed. Documentation showed notes were written on all 21 shifts during that week. However, there were few nursing assessments of the patient's pulmonary status, arthritis, or rash.

Review of the nursing documentation for Patient 8 regarding a red rash in the abdomen, breast, and groin folds showed the rashes were assessed on only from four of the 21 shifts, 6/16/14 at 2211 hours, 6/18/14 at 1856 hours, 6/19/14 at 1440 hours, and 6/21/14 at 2254 hours.

Review of the nursing documentation for Patient 8 regarding lung function showed a respiratory assessment was conducted and documented on only seven of the 21 shifts for the week on 6/16/14 at 2211 hours, 6/17/14 at 1530 hours, 6/19 at 0505 hours, 6/21/14 at 2254 hours, and 6/23/14 at 0446 hours. The patient requested breathing treatments from the Respiratory Therapist two times during that time period.

The nurses' notes for Patient 9 were reviewed with the Director of the ED on 7/9/14 at 1400 hours. The Director confirmed documentation of an assessment of the patient's skin and respiratory symptoms was not consistent.

The nurses' notes for Patients 8 and 9 were reviewed with the Nursing Director of Psychiatric Services on 7/8/14 at 1450 hours. The Director concurred the nursing shift assessment documentation did not reflect routine reassessment of the patients' pulmonary status and skin condition.

In an interview with the DON on 7/9/14 at 1400 hours, the DON concurred it appeared the nurses in the BHU were having difficulty remembering to document the patients' medical conditions.

Based on observation, interview, and record review, the hospital failed to ensure nursing staff developed individualized nursing care plans for ten of 38 sampled patients (Patients 2, 8, 9, 12, 13, 14, 16, 17, 18, and 19). A lack of comprehensive care plan development may result in interventions not developed which can further compromise the patients' medical status.

Findings:

The hospital's P&P Plan for Assessment/Reassessment of Patients revised on 7/12, read in part, "Care decisions will be based upon data and information gathered in assessments and reassessments. This data will be utilized in prioritizing patient care needs and selecting appropriate interventions."

1. Review of Patient 16's medical record was initiated on 7/7/14. The patient was admitted to the hospital on 7/6/14, with a history of diabetes.

Review of the nurses' notes recorded on 7/6/14 at 1128 hours, for an event which occurred on 7/6/14 at 0840 hours, showed Patient 16 was admitted from the ED receiving regular insulin via an IV drip at 6 units per hour. Documentation showed the blood sugar levels would be done every hour.

Review of the physician's order dated 7/6/14 at 0840 hours, showed to start regular insulin at 9 ml per hour and adjust the insulin dose with each blood sugar check.

Review of the Insulin Drip Monitoring Form showed the following:

* Patient 16's blood sugar was 23 on 7/6/14 at 1950 hours (normal blood sugar is between 70-110 mg per dl), 27 mg per dl at 2150 hours, 28 mg per dl on 7/7/14 at 0000 hours, and 53 mg per dl on at 0200 hours.

* One ampule of Dextrose 50% was administered to Patient 16 on 7/6/14 at 1950 and at 2150 hours, and again on 7/7/14 at 0000 and 0200 hours, while the patient was receiving insulin.

* The insulin drip was discontinued on 7/7/14 at 0900 hours.

Review of the Patient's Patient Care Plan-Hyperglycemia (high blood sugar) failed to show a care plan was specifically developed to address the use of insulin drip, including when to notify the physician regarding the patient's blood sugar.

During an interview and medical record review with the DON on 7/9/14 at 1410 hours, the DON was informed of the finding.

2. Review of Patient 17's medical record was initiated on 7/8/14. The patient was admitted to the hospital on 7/3/14.

Review of the H&P dictated on 7/3/14 at 1456 hours, showed Patient 17 was brought into the ED by the paramedics. The patient was intubated and would be admitted to the ICU.

Review of the physician's order dated 7/3/14 at 1521 hours, showed propofol was to infuse at 24 ml per hour and propofol drip was to start at 10 mcg per kg per minute, titrate up to 100 mcg per kg per minute, and titrate to sedation of a RASS score of minus two.

During observations on 7/7/14 at 0905 hours and at 1355 hours, Patient 17 received propofol at a rate of 40 mcg per kg per minute or 24 ml per hour.

Review of the Patient's Patient Care Plan-Respiratory Failure on Vent (Ventilator, a machine assisted the patient for breathing) failed to showed a nursing care plan was developed to address the use of propofol for sedation.

During an interview and medical record review with the Director of ICU on 7/9/14 at 1430 hours, the Director confirmed the above finding.

3. Review of Patient 18's medical record was initiated on 7/7/14. The patient was admitted to the hospital on 6/30/14. The patient had a history of diastolic heart failure (the condition in which the heart is not properly functioning).

Review of the progress notes dictated 7/6/14 at 1305 hours, showed documentation Patient 18 had difficulty breathing last night and had some abdominal and chest discomfort on and off.

Review of the physician's order dated 7/6/14 at 1114 hours, showed troponin I level was ordered drawn every eight hours for three times; start on 7/6/14 at 1113 hours.

According to the physician's order, the troponin I level would be obtained for Patient 18 on 7/6/14 at 1114 hours, at 1914 hours, and on 7/7/14 at 0314 hours.

Further review failed to show a care plan was developed to address the patient's chest discomfort and/or to show a blood test would be obtained for Patient 18.

An interview and medical record review was conducted with the DON on 7/9/14 at 1410 hours. The DON was informed of the finding.

4. Review of Patient 19's medical record was initiated on 7/7/14. The patient was admitted to the ICU on 7/5/14 at 1740 hours, and transferred to the telemetry unit on 7/6/14 at 1925 hours. The patient had a history of chronic pain.

Review of the Nurse's Notes dated 7/6/14 at 1533 hours, for an event which occurred on 7/6/14 at 1531 hours, showed Patient 19 complained of pain. The patient's pain level was 7 out of 10. Documentation on the MAR showed the patient was medicated.

Review of the MAR showed Patient 19 received morphine and Dilaudid (a narcotic medication) three times a day.

Further review failed to show a care plan was developed to address Patient 19's chronic pain.

During an interview and concurrent medical record review with the Director of ICU on 7/7/14 at 1510 hours, the Director confirmed the finding.



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5. Patient 2 was observed on 7/7/14 at 0920 hours. The patient was positioned on his back. A sign outside the door showed the patient was on contact isolation.

The medical record for Patient 2 was reviewed with the Director of ED on 7/7/14 at 0955 hours. The patient was admitted to the hospital on 7/3/14, with a history of right sided paralysis from a stroke. The patient was identified at admission with a Stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle; slough or eschar may be present on some parts of the wound bed; often include undermining and tunneling) to the sacrum (lower back).

a. Review of the nursing care plan showed a plan of care for "skin integrity, Impaired" was initiated for Patient 2 on 7/5/14, two days after admission.

Further review of the care plan showed the patient had "pre-existing skin breakdown." There was no documentation to show the care plan was individualized for the patient to show a pre-existing Stage IV pressure ulcer on the sacrum.

Interventions listed for skin protection measures included to reduce pressure on bony prominences with a bed cradle and heel/elbow protectors; however, there were no interventions to turn side to side only to avoid pressure on the patient's pressure ulcer on his back.

RN B, Patient 2's primary RN, was interviewed on 7/7/14 at 1100 hours. The RN confirmed the patient's care plan for skin impairment did not show a Stage IV pressure ulcer on the sacrum. The RN stated staff were unable to add free text to the care plan, only the "canned text" already available in the electronic record.

During an interview with the WCN on 7/7/14 at 1050 hours, the WCN stated she initiated Patient 2's care plan for skin impairment after a consult of the patient's wound on 7/5/14. When asked regarding an intervention to not position the patient on his back with pressure on the wound, the WCN stated the nurses should know not to position the patient on the back.

Patient 2 was again observed on 7/7/14 at 1315 hours, with the Director of Medical Surgical. The patient was lying slightly turned to the left side; however, the patient's sacrum was in full contact with the mattress. The patient's bilateral feet were in protective boots; however, the heels were in contact with the mattress surface.

b. Further review of the medical record showed Patient 2 was on contact isolation for MRSA of the nares identified on admission.

Review of the care plan did not show a care plan was developed with interventions to address the MRSA infection.

During an interview with the Infection Control RN on 7/7/14 at 1110 hours, the RN confirmed there was no care plan for the MRSA infection. When asked how a care plan could be individualized for a patient, the RN demonstrated how free text could be added by the RNs to the care plan.


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6. During a review of the treatment plans for Patient 8 in the BHU, no nursing care plans were found to address medical problems identified on admission in addition to the psychiatric diagnoses.

The Interdisciplinary Master Treatment Plan for Patient 8 dated 6/16/14, showed sections for "active problems" and "inactive problems." Two active problems and four inactive problems were listed. The patient was provided medication for several medical problems such as chronic asthma, a fungal infection with rashes present on admission, and urinary frequency. These conditions did not appear on the treatment plan in either the active or inactive problem section and did not appear on the Interdisciplinary Treatment Plan Update forms.

In an interview with the Director of the ED on 7/9/14 at 1415 hours, she reviewed the care plans for Patient 8. the Director confirmed there were no care plans for Patient 8's rashes or respiratory issues.

7. Record review for Patient 9 was initiated on 7/7/14. Patient 9 was admitted on 6/18/14, with diagnoses including schizophrenia (a mental disorder, often characterized by abnormal social behavior and failure to recognize what is real).

a. Patient 9's Master Treatment Plan dated 6/18/14, contained three active problems- altered thought process, risk for falls, and infection/inflammation (added on 6/20/14). Two inactive problems were also included hypertension (high blood pressure) and seizure disorder.

Review of the Interdisciplinary Treatment Plan Update for Patient 9 dated 6/23, was limited to the same three active issues. The Interdisciplinary Treatment Plan Update dated 6/30/14, added item 4, "Continues to be physically aggressive and threatening."

Despite aggression and violence known to be an issue for Patient 9 since admission, the issue was never added to the master treatment plan and was not added to the Interdisciplinary Treatment Plan Update until 12 days after admission.

The care plan did not contain elements addressing aggressive behavior. The treatment plan consisted of a pre-printed form on which five of six preprinted short-term "measurable desired outcomes" were checked off, including Problem #4 to address Assaultive Behavior, Threatening Behavior, manifested by striking and kicking staff.

The nursing notes in the medical record of Patient 9 were reviewed. Documentation showed the patient was admitted on 6/18/14, and observed at 15 minute intervals. The nursing note dated 6/21/14 at 0950 hours, read, "pt agitated in the hallway, is cursing @ staff, agitation level is escalating, conts (continues) to be responding to internal stimuli, is gesturing towards peers, has antagonizing behavior towards peers, peers in milieu are coming to the nurses station c/o (complaining) being scared." At 1417 hours, nursing notes showed Patient 9 "wandering in & out of peers rooms, peers are getting upset with pt ..."

Nursing notes on 6/22/14 at 0234 hours, showed Patient 9 "noted to be wandering into peers' rooms. And found laying on empty beds. Pt is dishevel. Frequently observed removing clothing. Standing naked or in pullups." "...No insight. No judgment. Verbal altercation with peer 0230. Pt had been going into peers' room and apparently removed some of peers' clothes. Potential for physical altercation by both patients."

Nursing notes on 6/22/14 at 1400 hours, showed "Pt. very disorganized, anxious, flight of ideas, responding to internal stimuli, poor grooming, striking out at staff and patients. Urinating on floors and wandering in other pt.'s rooms and urinating in their bathrooms." At 1834 hours,"Pt also going to other pt's room and getting other pt scared. Pt also touching staff and peers inappropriately and can be intrusive with personal space ..."

Nursing notes on 6/26/14 at 1703 hours, showed "Pt agitated, attempting to hit another peer in his stomach ..."

Notes from subsequent dates showed Patient 9 continued to be aggressive, attempted inappropriate touching, and entered other patients' rooms daily. On multiple occasions, a dose of medication was ordered by the psychiatrist; however, there was no documentation to show a one to one staff or a sitter was assigned to monitor the patient.

During an interview with the Nursing Director of Psychiatric Services on 7/8/14 at 1450 hours, he reviewed the treatment plans for the patient. The Director concurred there was no treatment plan for aggression until 6/28/14, 10 days after the patient's admission, and that the patient was not on 1:1 monitoring.

Documentation showed Patient 9 was discharged to a lower level of care in the early afternoon on 7/7/14, the first day of the survey.

b. During a review of the treatment plans for Patient 9, no nursing care plans were found to address medical problems identified on admission in addition to their psychiatric diagnoses.

A Risk for Falls Treatment Plan was initiated upon admission to the BHU on 6/18/14. The long-term goal for the patient not to fall was checked off. The short-term goal checked off on the pre-printed list was "will be compliant with therapy/recommendations as per MD orders throughout hospitalization." To the right of the goal was the initial target date of 6/23, and to the right of that, target dates of 6/30 and 7/7, indicating the goal was continued throughout the patient's hospitalization.

Review of the medical record showed the physician's plan on the H&P exam dated 6/20/14 was for "leg elevation" and "We will encourage ambulation."

No interventions for falls risk were initiated for Patient 9 until 6/23/14, when the specific nursing interventions identified were monitoring each 15 minutes, providing a safe and supportive environment, non-skid slippers and therapy/medication per MD order.

Review of Patient 9's nursing notes from the date of admission, 6/18/14, showed the patient was frequently uncooperative and had "unsteady gait and c/o weak legs."

The nursing notes dated 6/20/14 at 1540 hours, read the room "has had to be cleaned up several times due to urine all over the floor."

The nursing notes dated 6/21/14 at 0730, showed the patient did not wear shoes or slippers. Some nurses took the initiative to begin fall precautions, such as placing the patient's bed in a low position or encouraging the patient to stay in a wheelchair; however, those interventions were not seen on the falls care plan.

During an interview with the Director of Psychiatric Services on 7/7/14 at 1035 hours, he stated Patient 9 had fallen the previous week.

In an interview with the DON on 7/9/14 at 1410 hours, she concurred most of the patients in the BHU did not have care plans for their chronic conditions.

8. Review of Patient 13's medical record was initiated on 7/7/14. Patient 13 was admitted to the hospital on 6/27/14, due to increased agitation and refusal to eat. Patient 13 had diagnoses including severe dementia.

On 7/7/14 at 0945 hours, Patient 13 was observed in front of the nursing station, up in a wheelchair. The patient appeared very thin, dishelved, was hard of hearing, and was difficult to understand her speech pattern as she had no teeth; however, she was pleasant and cooperative.

Review of Patient 13's Weight Record dated 6/27/14, showed an admission height of 4 feet and 11 inches, weight of 101 pounds (equivalent to 45.8 kg), and a BMI of 20 (healthy weight).

Review of the Weight Record dated 7/5/14, showed the following weight variance for Patient 13 as 83 pounds (lost 17 pounds or 17.8%) and BMI of 16.8 (underweight).

The RD documented the patient seen and visited. The RD stated the patient did not have teeth or dentures; however, per the CNA the patient was tolerating a mechanical soft diet. The RD noted per the RN and MD's notes, the patient was uncooperative, confused, and refusing care. The RD noted since the patient appeared thin and underweight, she questioned if the admission weight was an actual weight versus estimated weight.

There was no documentation to show a care plan was developed to address Patient 13's problem of nutrition (weight loss), refusal to eat, and lack of dentures.

9. Patient 14's Behavioral Health Altered Thought Process Treatment Plan dated 6/11/14, consisted of a pre-printed form. Five of six preprinted short-term "measurable desired outcomes" were checked off to address "Suicidal Ideation" "manifested by she wants to kill herself." The nursing interventions included to be 100% with medication compliance for five consecutive days, contract for safety, verbalize positive ways to cope with depression and/or stress daily, identify three triggers that cause self-harm behaviors daily, and not to exhibit self-harm behaviors for five consecutive days.

There were no interventions to determine suicidality, mood, mental status, medications effectiveness, contraband checks, to monitor visitors, or to show Patient 14 was on constant observation of a staff member (one to one) for suicidal ideation and precaution.

10. Patient 12's Master Treatment Plan dated 5/30/14, consisted of a pre-printed form on which five of the six preprinted short-term "measurable desired outcomes" were checked off, including Problem #1 to address "Alteration In Mood." The nursing interventions listed were generic tasks that would be performed by any patient. Documentation showed Patient 12 was refusing group therapy; however, the plan was not reviewed and revised with new interventions added for the patient.

Based on interview and record review, the hospital failed to ensure nursing staff were provided with appropriate specialized qualifications and competency when assigned to the BHU, creating the risk of not meeting the patients' needs.

Findings:

During an observation on the BHU on 7/7/14 at 1100 hours, RN X was assigned to care for five patients with psychiatric issues. During an interview, RN X stated she floated to the BHU from the telemetry unit, her home unit.

Review of the Nursing Cross Training Skills Self-Assessment Form for the Psychiatric assigned unit, completion date of 10/12/11, for RN X showed she self-assessed herself as being competent in the admission, discharge, documentation forms, electrical safety, evacuation plan, fire plan, clinical pair protocol, equipment location, physical layout, medication protocol, monitoring equipment, and department specific skills checklist on the BHU.

During an interview with the DON on 7/8/14 at 1600 hours, the DON was asked to provide the BHU's department specific skills checklist for review. The DON stated she was unable to locate a skills checklist for the BHU for RN X.

Based on observation, interview, and medical record review, the hospital failed to ensure nursing staff administered medications following physician's orders and pharmaceutical standards for three of 38 sampled patients (Patients 17, 19, and 23) as evidenced by:

1. Propofol was not titrated for Patient 17 as ordered.

2. Morphine was not administered to Patient 19 as ordered.

3. Chewable aspirin (an antiplatelet) was not administered to Patient 23 as per pharmaceutical standards.

These failures could lead to unsafe care and poor health outcomes for those patients.

Findings:

1. Review of the hospital's P&P titled Propofol Infusion Guidelines for Ventilator Patients revised on 9/13, showed the following:

* A physician's order must relate to a therapeutic goal (RASS, or Richmond Agitation Sedation, Scale; a scale used to assess the patient's sedation level), sedation level or the desired level of sedation (usual desired RASS score is minus two). Notify the physician for RASS score of minus four or minus five.

* RASS Score is determined by the following:

- Score of minus two indicates slight sedation when the patient is briefly awake with eye contact to voice less than 10 seconds.

- Score of minus three indicates moderate sedation when the patient moves or opens eyes, and has no eye contact.

- Score of minus four indicates deep sedation when the patient had no response to voice, but movement or eye opening to physical stimulation.

- Score of minus five indicates the patient is unarousable, or has no response to voice or physical stimulation.

Review of the physician's order for Patient 17 dated 7/3/14 at 1521 hours, showed IV propofol to run at 24 ml per hour; Propofol drip to start at 10 mcg per kg per minute and titrate up to 100 mcg per kg per minute; and titrate to a sedation RASS score of minus two.

Review of the Neurological Assessment dated 7/6/14 at 1041 hours, documented by RN D showed Patient 17 was lethargic (drowsy)/somnolent (sleeping) on 7/6/14 at 0800 hours. The patient opened eyes and tracked when name was called. The patient was sedated on propofol with a RASS Score of minus two.

Review of the Neurological Assessment dated 7/7/14 at 1030 hours, documented by RN D, showed Patient 17 was lethargic/somnolent on 7/7/14 at 0800 hours. The patient's eyes were closed and swollen. The patient opened eye with tactile (touching, or physical) stimulation. Patient 17 was sedated with propofol with RASS Score of minus two.

However, according to the hospital's P&P for Propofol Infusion Guidelines for Ventilator Patients, Patient 17 would be assessed as having a RASS score of minus four when the patient opened his eye with tactile stimulation.

Nursing staff assessed Patient 17 as sedated with a RASS score of minus two on 7/7/14 at 0800 hours. The RASS score of minus two did not accurately reflect the patient's sedation condition at that time.

Review of the IV Drip Monitoring form showed Patient 17 continued to receive propofol 40 mcg per kg per minute (or 24 ml per hour) on 7/7/14 at 0700 hours, at 0800 hours, and at 0900 hours.

Multiple observations of Patient 17 were conducted on 7/7/14, accompanied by RN D. The following was identified and was confirmed by the RN:

* At 0905 hours, Patient 17 was lying on his bed with his eyes closed. Propofol was infusing at 40 mcg per kg per minute or 24 ml per hour.

* At 1355 hours, Patient 17 lying on the bed with his eyes closed. Propofol was infusing at 40 mcg per kg per minute or 24 ml per hour. RN D used a lancet (a device, same as a needle, used to stick into the patient's finger) to check his blood sugar. The patient did not open his eyes and no grimace of pain was observed on his face. The patient did not respond when the RN stuck his finger with the lancet.

* At 1405 hours, RN D called Patient 17's name, touched and shook the patient's hands, and pushed on the patient's chest by using her hand. The patient did not open his eyes and no grimace of pain was observed on his face. The patient did not respond to the physical stimulation from the RN. The RN decreased the rate of propofol to 35 mcg per kg per minute.

* At 1409 hour, RN D called Patient 17's name, shook the patient's hands, and suctioned the patient's mouth. The patient did not respond, open his eyes and no grimace of pain was observed on his face. The RN again decreased the rate of propofol this time to 30 mcg per kg per minute.

* At 1413 hours, the RN called the patient and shook the patient's hand. The patient did not respond or open his eyes and no grimace of pain was observed on his face. The RN again decreased the rate of propofol to 20 mcg per kg per minute.

* At 1445 hours, the RN called the patient's name. The patient opened his eyes. Propofol was infusing at 20 mcg per kg per minute.

According to the above observations from 1355 to 1413 hours, and the hospital's P&P, Patient 17 was sedated with RASS score of minus five as the patient was unarousable and did not respond to voice or physical stimulation.

A follow-up medical record review was conducted with the Director of ICU on 7/8/14 at 1020 hours. The Director confirmed Patient 17's RASS score of minus two on 7/7/14 at 0800 hours did not accurately reflect the patient's condition. In addition, the Director confirmed the patient received the same dose of propofol, 40 mcg per kg per minute, until 7/7/14 at 1400 hours.

2. Review of Patient 19's medical record was initiated on 7/7/14. The patient was admitted to the ICU on 7/5/14 at 1554 hours, and transferred to the telemetry unit on 7/6/14 at 1925 hours.

Review of the physician's order dated 7/6/14 at 1325 hours, showed morphine sulfate (narcotic pain medication) 30 mg three times a day was scheduled at 0900 hours, 1300 hours, and 1700 hours.

Review of the MAR showed morphine 30 mg was not administered to Patient 19 on 7/6/14 at 1700 hours as scheduled.

Further review failed to show the reason why morphine 30 mg was not given to the patient as ordered on 7/6/14 at 1700 hours.

During an interview and concurrent medical record review with the Director of ICU on 7/7/14 at 1510 hours, the Director confirmed the finding.

3. Review of Patient 23's medical record was initiated on 7/8/14. The patient was admitted to the hospital on 7/7/14.

Review of the Patient 23's physician's Admission Orders dated 7/8/14 at 0100 hours, showed to give aspirin 81 mg orally daily.

According to Lexicomp Online (a professional drug resource), adverse reactions from aspirin included stomach ulcer, epigastric (the upper central region of abdomen) discomfort, heartburn, nausea, stomach pain and vomiting. Aspirin should be administered with food or a full glass of water to minimize gastrointestinal distress.

Review of the Patient 23's Past Medical History dated 7/8/14 at 0151 hours, showed a history of a gastrointestinal problem or ulcer.

Review of the MAR showed aspirin 81 mg was scheduled to be given to Patient 23 at 0900 hours.

During an observation on 7/8/14 at 0850 hours, RN E prepared to administer an 81 mg chewable aspirin tablet to Patient 23. The patient complained of nausea and requested medication for nausea. The breakfast meal was on the bedside table and uneaten by the patient. The patient stated she had not eaten anything since Sunday and did not eat her breakfast meal. The RN administered the 81 mg chewable aspirin tablet to the patient. The patient swallowed the 81 mg chewable aspirin tablet with sips of water.

When asked, the RN confirmed an aspirin 81 mg chewable tablet was administered to the patient on an empty stomach.

Based on interview and record review, the hospital failed to ensure nursing staff reported a suspected ADR for one of 38 sampled patients (Patient 16) when nursing staff concurrently administered Dextrose 50% and insulin to Patient 16. This failure could lead to poor health outcome for that patient.

Findings:

Review of the hospital's P&P titled Adverse Drug Responses, Suspected reviewed on 9/13, showed the following:

* A significant ADR is any unexpected, unintended, undesired, or excessive response to the drug that requires discontinuing the drug, requires modifying the dose; necessitates supportive treatment.

* The healthcare professional reporting the suspected ADR notified the prescribing physician.

* Adverse Drug Reaction form is filled in the QM module by the initiator in Meditech (a computer system) and sent to the Pharmacy for investigation by a pharmacist. In addition, a pharmacist may be contacted directly to investigate the occurrence.

Review of Patient 16's medical record was initiated on 7/7/14. The patient was admitted to the ICU of the hospital on 7/6/14.

Review of the physician's Admission Order dated 7/6/14 at 0725 hours, showed Patient 16 had acute DKA (diabetic ketoacidosis, a potentially life-threatening complication in the patient with diabetic, one of the specific signs of diabetic ketoacidosis is high blood sugar level).

Review of the nurses' notes recorded 7/6/14 at 1128 hours, showed Patient 16 was admitted from the ED on 7/6/14 at 0840 hours. Regular insulin was infusing via IV drip at 6 units per hour. The blood sugar levels would be checked every hour.

Review of the physician's order dated 7/6/14 at 0840 hours, showed to start regular insulin at 9 ml per hour and adjust the insulin dose with each blood sugar check as follows:

* If the blood sugar is less than 80 mg per dl, decrease the drip by 2 units per hour, and inject one ampule of a Dextrose 50% IVP times one and repeat the blood sugar in 30 minutes;

* If the blood sugar is between 80 mg per dl and 110 mg per dl, decrease the drip by 1 unit per hour;

* If the blood sugar is between 111 mg per dl and 160 mg per dl, continues the same rate;

* If the blood sugar is between 161 mg per dl and 200 mg per dl, increase the drip by 1 unit per hour;

* If the blood sugar is between 201 mg per dl and 250 mg per dl, increase the drip by 1 unit per hour and give 2 units regular insulin IVP once;

* If the blood sugar is between 251 mg per dl and 300 mg per dl, increase the drip by 2 unit per hour and give 2 units of regular insulin IVP once;

* If the blood sugar is between 301 mg per dl and 350 mg per dl, increase the drip by 3 unit per hours and give 2 units of regular insulin IVP once;

* If the blood sugar is greater than 350 mg per dl, call the physician.

Review of the physician's order dated 7/6/14 at 1000 hours, showed to check the patient's blood sugar every one hour.

Review of the physician's order dated 7/6/14 at 1616 hours, showed to check the patient's blood sugar every two hours, starting at 1800 hours.

Review of the Patient 16's Insulin Drip Monitoring Form showed the following:

* On 7/6/14 at 1730 hours, Patient 16's blood sugar was 82 mg per dl. The patient was receiving 14 units of regular insulin per hour.

* On 7/6/14 at 1830 hours, the patient was receiving 8 units regular insulin per hour as per the physician's order.

* On 7/6/14 at 1950 hours, the patient's blood sugar was 23 mg per dl. One ampule (same as 50 ml) Dextrose 50% was administered to the patient. The rate of the regular insulin infusion was decreased to 6 units per hour.

* On 7/6/14 at 2150 hours, the patient's blood sugar was 27 mg per dl. One ampule (same as 50 ml) Dextrose 50% was administered to the patient. The rate of regular insulin was decreased to 4 units per hour.

* On 7/7/14 at 0000 hours, the patient's blood sugar was 28 mg per dl. One ampule (same as 50 ml) Dextrose 50% was administered to the patient. The rate of regular insulin was decreased to 2 units per hour.

* On 7/7/14 at 0200 hours, the patient's blood sugar was 53 mg per dl. One ampule (same as 50 ml) Dextrose 50% was administered to the patient. The insulin drip was now off.

* On 7/7/14 at 0230 hours, the patient's blood sugar was 166. The insulin drip was restarted at 1 unit per hour.

* On 7/7/14 at 0900 hours, the insulin drip was discontinued by the physician.

An interview and concurrent medical record review was conducted with the Director of ICU on 7/8/14 at 1100 hours. When asked, the Director was unable to find documented evidence to show nursing staff notified the physician when the patient required rescue doses of Dextrose 50% for low blood sugar while insulin was infusing as shown above.

During an interview and medical record review with the Director of Pharmacy and the Director of ICU on 7/9/14 at 0855 hours, the Director Pharmacy confirmed a suspected ADR should be reported when Patient 16 concurrently received insulin and required Dextrose 50%.

However, the Director of Pharmacy and the Director of ICU confirmed nursing staff did not report a suspected ADR for Patient 16. The Director of Pharmacy stated no investigations were conducted recently by the pharmacy regarding the use of insulin drips.

Based on observation, interview, and record review, the hospital failed to ensure the medical records were complete and accurate for 16 of the 16 patients on the BHU and three additional patients of the 38 total sampled patients (Patients 2, 5, 7, 8, 9, 10, 11, 12, 13, 14, 17, 31, 32, 33, 34, 35, 36, 37, and 38). This has the potential for lack of integrity of the medical records.

Findings:

Review of the hospital's P&P titled General Documentation Guidelines dated 2/14, showed all health records of the Hospital's patients shall be documented in an accurate, complete and consistent manner to facilitate patient care and foster continuity of care among providers.

Entries should be consistent on each form, only approved abbreviations will be used to foster clarify of the documentation.

All entries are to be made in a timely manner. The authors are encouraged to document information as soon as possible following events.

Once documentation is placed in the records it should not be removed. If additional information is added, addendums may be documented identifying any additional information that should be noted in the record.

The Medical Staff Rules and Regulations (undated, page 15), read in part, "Entries should be made as soon as possible after clinical events occur, to ensure accuracy and to provide information relevant to the patient's continuing care."

1. Review of documentation of patients' conditions on the Interdisciplinary Treatment Plan Update was not accurate for 16 of the 16 patients (Patients 7, 8, 9, 10, 11, 12, 13, 14, 31, 32, 33, 34, 35, 36, 37, and 38) in the BHU. For example:

The Interdisciplinary Treatment Plan Updates for Patient 8 were reviewed on 7/9/14. Update forms included a handwritten list of patient goals for the issues, "Alteration in mood" and "altered thought process" and how the patient was progressing towards those goals as of each treatment meeting date.

Interdisciplinary Treatment Plan Update forms dated 6/23, 6/30, 7/7, and 7/14/14, were reviewed. The Interdisciplinary Treatment Plan Update form dated 7/14/14, for Patient 8, reviewed on 7/9/14 (five days prior to the date on the Update form), indicated: "Alteration in mood: Improving, minimal interaction with peers. Helpless-hopeless. Altered thought process: less paranoia verbalized, continues to improve." The documentation did not reflect an accurate assessment of the patient's condition on 7/14/14, as it was created in advance of that date.

During an interview with the RN D on 7/8/14 at 1000 hours, the RN stated she filled out the forms prior to the Interdisciplinary meeting.

2. Review of Patient 12's medical record was initiated on 7/7/14. The patient was admitted to the hospital on 5/30/14.

On 7/7/14 at 1030 hours review of the Interdisciplinary Treatment Plan Update forms showed the following:

The IDT Plan dated 7/1/14, was signed by the physician and nursing.

The IDT Plan dated 6/24/14, was signed by the physician, nursing, and case manager.

The IDT Plan dated 6/17/14, was signed by the physician.

The IDT Plan dated 6/10/14, was signed by the physician, nursing, case manager, and

The IDT Plan dated 6/3/14, was signed by the physician, nursing, case manager, and psych rehab.

Further review showed no signature of the Director of Psychiatric Services. Copies of the forms were requested at the time of the record review.

A follow-up review of Patient 12's medical record was conducted the next day 7/8/14. The same above forms now showed the signature of the Nursing Director of Psychiatric Services showing he had attended the IDT meetings.

Review of the Hospital Multiple-Disciplinary Treatment Team Meeting attendance forms for Patients 12 and 31 dated from 5/26/14 to 7/6/14, showed no signature of the Nursing Director of Psychiatric Services.

3. Review of Patient 31's medical record was initiated on 7/7/14. The patient was admitted to the hospital on 6/11/14.

On 7/7/14 at 1100 hours, review of Patient 31's Interdisciplinary Treatment Plan Update forms showed the following:

The IDT Plan dated 6/30/14, was signed by the physician, nursing, case manager, and psych rehab.

The IDT Plan dated 6/23/14, was signed by the physician, case manager, and psych rehab.

The IDT Plan dated 6/16/14, was signed by the physician, nursing, case manager, and psych rehab.

Further review showed no signature of the Nursing Director of Psychiatric Services. Copies of the forms were requested at the time of the record review.

A follow-up review of Patient 31's medical record was conducted on the next day, 7/8/14. The same above forms now showed the signature of the Nursing Director of Psychiatric Services showing he had attended the IDT meetings.

Review of the Hospital Multiple-Disciplinary Treatment Team Meeting attendance forms for Patient 31 dated from 5/26/14 to 7/6/14, showed no signature of the Nursing Director of Psychiatric Services.



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4. Review of Patient 16's medical record was initiated on 7/7/14. The patient was admitted to the hospital on 7/6/14.

Review of Patient 16's physician's order dated 7/6/14 at 1450 hours, showed an order for hemodialysis (method that is used to remove the waste products) for Patient 16 on 7/7/14 at 1000 hours.

Review of a physician's telephone order dated 7/7/14 at 1732 hours, showed to discontinue the above order.

Further review failed to show documentation of the reason for discontinuation of the physician's order.

During an interview with RN I on 7/8/14 at 1520 hours, the RN stated a dialysis nurse came and called the physician for an order for dialysis, and the physician canceled hemodialysis.

During an interview and medical record review with the Director ICU on 7/8/14 at 1530 hours, the Director was unable to find documented evidence to show the reason why a physician's telephone order was obtained to cancel hemodialysis for Patient 16 on 7/7/14.

5. Review of the hospital's P&P titled Propofol Infusion Guidelines for Ventilator Patients revised 9/13, the RN must document the patient's response or RASS scale(Richmond Agitation Sedation Scale, used to assess the patient's sedation level).

Review of Patient 17's medical record was initiated on 7/8/14. The patient was admitted to the hospital on 7/3/14. The patient was intubated, and was admitted to the ICU.

Multiple observations were conducted on 7/7/14, accompanied by RN D.

However, there was no documented evidence to show the above observations of the patient as unresponsive were documented in the patient's medical record and there was no documented evidence to show the physician was notified as per hospital's P&P. There was no documented evidence to show the patient was assessed for changes in condition including neurological assessment on 7/7/14 at 1400 hours.

An interview and medical record review was conducted with the Director ICU on 7/8/14 at 1020 hours. The Director confirmed about the above findings. Cross reference to A- 0395, example #1b.



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6. Review of the hospital's P&P Central Line Bundle last review date 5/13, showed daily review of central line necessity by physician was required. The policy showed this review prevents unnecessary delays in removal of lines that are no longer necessary as the risk of infection increases over time as the line remains in place.

The medical record for Patient 5 was reviewed with the Director of Medical Surgical on 7/7/14 at 1320 hours. The patient was admitted to the hospital on 6/17/14, with infections on the bilateral lower extremities.

A PICC line (peripherally inserted central catheter) was inserted in the patient's right upper arm on 6/20/14.

Review of the physician's orders showed pre-printed stamped boxes on order forms dated 6/22/14 through 7/7/14, (there was no stamp for 6/26/14) for documentation of 7/7/14, and the date (6/20/14) the central line was inserted. The physician was to check off a reason to show the central line was still necessary and date and time their signature.

There was no documentation to show the physician for Patient 5 reviewed the necessity of the central line remaining in the patient since the line was inserted on 6/20/14. For four of the dates, documentation on the box showed the PICC was inserted on 6/23/14, not 6/20/14.

7. The medical record for Patient 2 was reviewed with the Director of the ED on 7/7/14 at 0955 hours. The patient was admitted to the hospital on 7/3/14, with a pressure ulcer and a urinary drainage catheter in place. Patient 2 was placed on contact isolation for MRSA of the nares identified on admission.

a. Review of the hospital's P&P Urinary Catheter last review date 5/13, showed physician's must document daily that a catheter is still necessary. The renewal stickers will be on the order sheet for the patients with urinary catheters.

Review of the physician's orders for Patient 2 showed pre-printed stamped boxes on order forms dated 7/4, 7/5, and 7/6/14, (there was no stamp for 7/7/14) for documentation of 7/7/14, and the date (7/3/14) the catheter was inserted. The physician was to check off a reason to show the catheter was still necessary and date and time their signature. None of the boxes showed documentation by the physician.

RN B was interviewed on 7/7/14 at 1100 hours. The RN stated the night shift stamped the physician's order sheets for documentation to continue a catheter or a central line. RN B stated the Infection Control RN was to follow-up to ensure completion.

b. Review of the hospital's P&P MRSA Active Surveillance Screening last review date 2/13, showed any patient whose surveillance culture returns as positive for MRSA, the physician will notify the patient or the patient's representative immediately, or as soon as practically possible. An MRSA Patient Notification Form will be placed on the chart.

During an interview with the Infection Control RN on 7/7/14 at 1110 hours, she was unable to locate documentation in Patient 2's record to show the physician informed the patient or representative of the positive culture for MRSA or provided educational materials.

c. Further review of Patient 2's medical record showed two photographs dated 7/5/14, taken by the WCN of the patient's pressure ulcer and skin tear. There was an area each form for the physician to mark a box showing the wound was acute, acute/chronic, or chronic and to sign the wound assessment was reviewed. There was no physician's signature on either form.



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8. The electronic medical record of Patient 9 was reviewed with the Director of ED on 7/7/14. Review of the record did not show documentation of notes by MD 1, the psychiatrist, for some dates.

The record contained an initial psychiatric evaluation for Patient 9 dated 6/18/14, showed at the bottom of the page a date and time indicating it was dictated on 6/19/14 at 1217.

Progress notes dated at the top of the pages for the dates of 6/20, 6/21, 6/22, 6/22, 6/23, 6/24, 6/25, 6/26, 6/27, 6/28, 6/30, 7/1, 7/2, 7/3, 7/4, and 7/5/14, all had a dictation date at the bottom of the pages for 7/6/14 between 0841 and 0912 hours. There was no psychiatrist's notes in the record for 7/6/14. There was a note dated 6/9/14, prior to the patient's hospital stay, dictated on 7/6/14.

The internal medicine physician's (MD C) notes for Patient 9 were also reviewed. The progress notes dated 6/30 and 7/1/14, were both dictated on 7/2/14 at 0910 and 0912 hours, respectively.

During an interview with the Director of ED on 7/7/14 at 1335 hours, she stated progress notes for MD 1 were missing from the electronic health record. There must be handwritten notes in the medical record.

The paper record for Patient 9 was reviewed on 7/7/14. The record did not contain handwritten progress notes.

During an interview with RN G on 7/7/14 at 1410 hours, she stated the psychiatrists did not place handwritten progress notes in the patients' records. RN G reviewed the progress notes for Patient 9 and stated she was unable to comment on why the notes for 16 previous days were dictated on 7/6/14, by the psychiatrist.

9. Patient 7's medical record was reviewed on 7/8/14.

a. The patient had a psychiatric evaluation dated 6/26/14, which was dictated on 6/27/14. Psychiatric progress notes for 6/27 and 6/28/14, were dictated on 6/29/14. Psychiatric progress notes for 6/29, 6/30, 7/1, 7/2, 7/3, 7/4 and 7/5/14, were all dictated by MD A on 7/6/14 between 1154 and 1216 hours.

The internal medicine consultant's progress notes from 6/30 and 7/1/14 were dictated by MD C on 7/2/14 at 0915 and 0917 hours, respectively. No handwritten progress notes were found in the medical record.

b. Review of the Abnormal Involuntary Movement Scale and AIMS Scale RN/Physician form for Patient 7 showed the form contained sections to indicate facial and oral movement, extremity movements, trunk movements and global judgments, along with columns to indicate the degree present at admission and at discharge. However, the forms were left blank.

c. Nursing notes for Patient 7 on 7/1/14 at 0332 hours, read, "Pt also noted with fine tremors upper extremities. I think the meds (medications) I am taking are wrong." "On 7/1/14 at 0517 hours, the notes read, "Tremors more pronounced and upsetting when spills fluids." On 7/2/14 at 1406 hours, the notes read, "Tremors more pronounced." Reference to the presence or absence of a tremor was not seen on subsequent notes.


10. Patient 8's medical record was reviewed on 7/8/14. The patient had a psychiatric evaluation dated 6/16/14, which was dictated on 6/17/14.

a. Patient 8's electronic medical record showed progress notes dated daily for 6/18, 6/19, 6/20, 6/21, 6/22, 6/23, 6/24, 6/25, 6/26, 6/27 and 6/28/14. All of the notes were dictated by MD A on 6/29/14 between 1115 and 1530 hours.

There were also psychiatric progress notes for 6/29, 6/30, 7/1, 7/2, 7/3, 7/4, and 7/5. All were dictated on 7/6/14 between 1016 and 1027 hours.

The internal medicine consultant's progress notes from 6/30 and 7/1/14, were dictated by MD C on 7/2/14 at 0906 and 0908 hours, respectively. No handwritten progress notes were found in the medical record.

During an interview with the Nursing Director of Psychiatric Services on 7/8/14 at 1450 hours, he stated physicians were to place their treatment notes in the medical records promptly. The Director stated he was surprised they had not done so.

During an interview with the Chief Medical Officer on 7/8/14 at 0920 hours, he stated there needed to be a psychiatrist's note in the medical record daily for all patients in the Behavioral Health Unit. If the notes were being entered late it was a problem.

b. Review of the Abnormal Involuntary Movement Scale and AIMS Scale RN/Physician form for Patient 8 showed the form contained sections to indicate facial and oral movement, extremity movements, trunk movements and global judgments, along with columns to indicate the degree present at admission and at discharge. However, the forms were left blank.

11. The Medical Staff Bylaws (undated, page 30), read in part, "Every patient receives a history and physical within twenty-four hours of admission, unless a previous history and physical was performed within thirty days of admission is on the record, in which case that history and physical will be updated and patient examined within twenty-four hours of admission."

a. Review of the medical record for Patient 9 on 7/7/14, showed the patient was admitted on 6/18/14. The H&P for Patient 9 was dictated on 6/20/14 at 0010 hours, more than 24 hours after admission.

b. Review of the medical record for Patient 8 on 7/8/14, showed the patient was admitted on 6/16/14. The H&P was dictated on 6/18/14 at 2233 hours, more than 24 hours after admission.

During an interview with the Director of ED on 7/8/14 at 0940 hours, she concurred the history and physical exams for Patients 8 and 9 appeared to have been completed more than 24 hours after admission.

12. The hospital's P&P Plan for Assessment/Reassessment of Patients revised on 7/14, read in part, "The patient's status and response to treatment is reassessed and documented by the physician daily in the progress notes." "H&P, Psychiatric Evaluations, Physician Orders, Consults and Progress Notes serve as mechanisms for the medical staff to communicate the patient's care, treatment needs and response to treatment, patient instructions, discharge plans and continued care requirements as appropriate."

The medical records for Patients 7, 8, and 9 showed the notes contained internal inconsistencies and did not reflect the condition of the patient, treatment provided to the patient, and the patient's response to treatment. The notes contained two or three lines containing new observations at the top, followed by several pages of review of systems, physical exam, assessment and plan that appeared to be reprinted from the initial history and physical examination, along with tables containing vital signs and medications.

a. The medical record for Patient 8 was reviewed on 7/8/14. The patient was admitted on 6/16/14, with depression. The 6/19/14, internal medicine progress note showed "Exacerbation of the asthma, rule out pneumonia. We will monitor the patient's pulmonary status closely. We will start the patient on Zosyn at this time. We may also add the azithromycin treatment.(Zosyn and azithromycin are antibiotics.) We will continue with the nebulizer treatment as well as the chest PT (physiotherapy) and cough syrup. If the patient's symptoms does not improve, we will obtain a pulmonary consultation for further evaluation and workup." The same plan was repeated on the internal medicine progress notes on 6/20, 6/21, 6/22, 6/23, 6/24, and 6/25/14.

Other medical problems identified on the history and physical for Patient 8 were sinusitis and rhinitis, reflux disease, osteoarthritis, hypertension, constipation, and chronic back and lower leg pain.

On admission on 6/16/14, a red rash was seen in abdominal, breast, and groin folds. According to the progress notes, the plan for treatment of sinusitis and rhinitis included "Continue with the spray and decongestant." For the reflux disease the plan included "Continue with the Protonix." For the arthritis the plan included "Continue with the NSAIDS (non-steroidal pain medication) PRN (as needed)." For constipation the plan included to "Continue with the MiraLax and the stool softeners." The same plan was repeated on the internal medicine progress notes on 6/20, 6/21, 6/22, 6/23, 6/24, and 6/25/14.

Patient 8's medication orders were reviewed. An Advair discus and Ventolin inhaler (both devices that give lung medication without nebulization), not nebulized medications, were ordered. No antibiotics, chest physiotherapy or cough syrup were ordered, even though they were in the physician's plan. No decongestant or nasal spray was ordered for sinus and nasal symptoms and no medicine was ordered for reflux.

Amitzia, not Miralax, was ordered for constipation. No medication was ordered for pain until Tylenol was ordered on 6/24/14. The assessment and plan repeated in the progress notes from 6/20-6/25/14, did not reflect the patient's treatment or response to the treatment actually provided.

On 6/22/14, documentation showed Patient 8 complained of frequent urination. Laboratory testing was undertaken and Detrol LA was ordered for her symptom. There was no change made in the documented plan by the physician to reflect the treatment and labs that were initiated. The documented review of systems for Patient 8 persisted as "Genitourinary No symptoms reported."

b. Patient 7's medical record was reviewed on 7/8/14. The patient was admitted on 6/26/14 with schizophrenia, anorexia, sore throat, chronic obstructive pulmonary disease, weight loss, anemia, hepatitis C, and constipation, among other concerns.

The physician's plan included hydration, energy drinks, antibiotics, iron supplementation and stool softeners. However, no orders for iron supplementation were placed. Other medications and tests were ordered for the patient, but these were not reflected in the plan. The same review of systems, physical exam and plan were reprinted on the patients' progress notes on 6/26 and 6/27/14, the last day he was seen by that physician and did not reflect the treatments provided or response to treatments provided.

c. Patient 9's medical record was reviewed on 7/7/14. The patient was admitted on 6/18/14, with schizophrenia, cellulitis, high blood pressure, and a history of asthma, among other concerns.

The physician's review of systems, physical exam, assessment and plan from the history and physical dated 6/20/14, was reprinted on the patient's progress notes dated 6/21, 6/22, 6/23, 6/24, 6/25 and 6/26/14.

These treatments included whirlpool, nebulizer therapy and leg elevation. The medical record did not show the patient received whirlpool or nebulizer therapy, only that he was unable to cooperate with leg elevation. The physician's progress notes did not reflect treatments provided or the patient's response to the treatments provided.

The Nursing Director of Psychiatric Services was asked to review the medical record for Patient 8 on 7/8/14 at 1450 hours. The Director concurred the plan in the internal medicine physician's progress notes did not reflect the treatment provided to the patient.

Based on interview and record review the hospital failed to ensure the Verification of the Necessity of Continued Admission form was completed for two of 38 sampled patients (Patients 7 and 8).

Findings:

1. During a review of the medical record of Patient 8 on 7/9/14, the record contained a Medicare Certification and Re-Certification form that contained sections for verification of necessity on four dates. Each section had a check box and signature lines for the psychiatrist and staff members to sign indicating that the patient met criteria for continued admission, and spaces to fill in for the date and the number of days in the hospital.

The form was completed and signed by the staff member, but not the psychiatrist on 6/16/14, the date of admission. An additional three dates were handwritten for 6/28/14 (day 12), 7/4/14 (day 18), and 7/16/14 (day 30). For each of those dates, the box was checked to indicate the necessity of continued admission was certified, but the signature lines were left blank.

2. On 7/9/14, during a review of the medical record of Patient 7 who was admitted 6/26/14, the record contained a Medicare Certification and Re-Certification form that contained sections for verification of necessity on four dates.

Each section had a check box and signature lines for the psychiatrist and staff members to sign indicating the patient met criteria for continued admission, and spaces to fill in the date and the number of days in the hospital. The form was completed and signed by the staff member, but not the psychiatrist on 7/6/14.

Based on interview and record review, the hospital failed to ensure a laboratory test was obtained as ordered for one of 38 sampled patients (Patient 18) when laboratory personal canceled Patient 18's laboratory test without any acknowledge from the physician and nursing staff. This failure could lead to delay in treatment and poor outcome for that patient.

Findings:

Review of the hospital's P&P titled Test Request-Cancellation last reviewed on 12/13, showed the medical record must include documentation of the authorization for cancellation any time a test is canceled.

Review of Patient 18's medical record was initiated on 7/7/14. The patient admitted to the hospital on 6/30/14.

Review of a physician's order dated 7/6/14 at 1114 hours, showed troponin I levels were ordered drawn every eight hours for three times, starting on 7/6/14 at 1113 hours.

According to the physician's order, the troponin I level should be obtained for Patient 18 on 7/6/14 at 1114 hours, and at 1914 hours, and on 7/7/14 at 0314 hours.

Review of the laboratory reports showed the patient's troponin level was only drawn two times on 7/6/14 at 0600 hours, and on 7/7/14 at 0500 hours.

Further medical record review failed to show Patient 18's troponin level was drawn for the third time as ordered.

During an interview and medical record review with the Director of Medical/Surgical/Telemetry on 7/8/14 at 1630 hours, the Director stated laboratory personnel canceled Patient 18's troponin level as a mistake.

During an interview with the DON on 7/9/14 at 1410 hours, the DON stated the physician and the RN should be notified when laboratory personnel canceled a blood test for a patient; however, this did not occur for Patient 18.

Based on observation, record review, and interview, the hospital failed to serve the therapeutic diet consistency as prescribed by the physician for one of 38 sampled patients (Patient 13) who was served four fried bacon slices on 7/8/14, during breakfast. Patient 13 did not have dentures and was on a mechanical soft diet. This has the potential for that patient to choke.

Findings:

Review of the hospital's P&P titled Mechanical or Dental Diet (undated) showed this diet is used for patients who have difficulty chewing or swallowing. The mechanical soft diet consists of foods which are soft in texture to minimize the amount of chewing. Foods are chopped, ground, or pureed according to the individual needs.

Review of Patient 13's medical record was initiated on 7/7/14. Patient 13 was admitted to the facility on 6/27/14, due to increased agitation and refusal to eat and had a diagnosis of severe dementia.

On 7/7/14 at 0945 hours, Patient 13 was observed in front of the nursing station, up in a wheelchair. The patient appeared very thin and disheveled. It was difficult to understand her speech pattern due to the fact she had no teeth and was hard of hearing; however, the patient was pleasant and cooperative.

Review of a physician's order dated 6/30/14, showed an order for mechanical soft diet.

On 7/8/14 at 0845 hours, Patient 13 was observed in the dining room during breakfast. Patient 13 was served eggs with five slices of dry fried bacon.

The diet tray card showed mechanical soft diet; however, the diet consistency did not match the physician's order.

During an interview with the Nursing Director of Psychiatric Services on 7/7/14 at 0850 hours, he confirmed Patient 13 should not be served fried bacon.

Based on observation, interview, and record review, the hospital failed to ensure the condition of the physical plant on the BHU was maintained to provide safety and well-being of patients as evidenced by:

1. An oxygen (medicinal gas) outlet was found protruding from the wall in two rooms resulting in the risk for injury for the patients.

2. Patient public phones were out of order.

3. The seclusion room was not clean and the air conditioning was out of order.

Findings:

The hospital's policy titled Patient's Rights (undated) showed the patients have the right to receive care in a safe setting...."

During an initial tour of the BHU on 7/7/14 starting at 0835 hours, accompanied by the Nursing Director of Psychiatric Services, the following was observed:

1. On the wall above the beds in Patients 13 and 31's rooms were observed with the oxygen piping outlets protruding approximately eight inches from the wall.

During an interview with the Nursing Director of Psychiatric Services on 7/7/14 at 0850 hours, he confirmed the oxygen piping outlets were no longer in use and should be removed. He stated the fixtures in the unit should be concealed on the BHU.

2. Patients were observed trying to use the phones located on the hallways. Inspection and test of the two public phones for patient use showed they were out of order. The Nursing Director of Psychiatric Services stated the hospital had ordered new telephones, but they had not yet received them.

3. Inspection of the seclusion room (a room used for an involuntary confinement of a patient in a room) was conducted. When the Nursing Director of Psychiatric Services unlocked the double doors of room a warm air with a strong smell of stale urine came out of the room.

The room had a wood bed frame with a vinyl plastic mattress covered with fitted linen. The bed linen had multiple brown stains. The floor of the room was badly soiled and stained with multiple debris of white foam. Brown marks were observed on the wall next to the bed.

The Director stated the marks were fecal matter. The Director stated the air conditioning unit for the room had not been working since last week.

During an interview with the Charge Nurse of the BHU on 7/7/14 at 0855 hours, she stated she had completed the morning environmental rounds through the unit.

Review of the Safety Rounds form dated 7/7/14, showed the Charge Nurse found no problem with the environment or damage in the unit. The seclusion room was described as being clean, lights working and toilet sanitized.

During an interview with a Housekeeping Staff on 7/7/14 at 0930 hours, she stated she was responsible for cleaning and keeping the hospital odor free. The Housekeeper stated her staff cleaned the seclusion room almost every day, sometimes they were asked to clean it three times a day.

On 7/8/14 at 1100 hours, an interview was conducted with the Maintenance Manager. The Manager stated his department had not received any work orders to repair the air conditioning of the seclusion room 7/7/14, in the morning.

Based on interview and record review, the hospital failed to ensure completion of the process requiring daily physician documentation of the necessity for continuing a urinary catheter and for continuing a central catheter for two of 38 sampled patients (Patients 2 and 5).

A urinary catheter is inserted in to the bladder through the urethra to drain urine into a drainage bag and is often left in place for may days or weeks of the hospital stay.

A central catheter is a tube placed into a patient's large vein, usually in the neck, chest, arm, or groin. The catheter is often used to draw blood or give fluids or medications. It may be left in place for several weeks.

There is an increase for the potential for infections in patients for whom the urinary and central catheters were possibly no longer necessary.

Findings:

1. Review of the hospital's P&P Central Line Bundle last review date 5/13, showed the central line bundle is a group of evidence-based interventions for patients with intravascular central line catheters that, when implemented together, result in better outcomes than when implemented individually.

Included in the five components of the bundle listed in the P&P was daily review of central line necessity by physician. The policy showed this review prevents unnecessary delays in removal of lines that are no longer necessary as the risk of infection increases over time as the line remains in place.

The medical record for Patient 5 was reviewed with the Director of Medical Surgical on 7/7/14 at 1320 hours. The patient was admitted to the hospital on 6/17/14, with infections on the bilateral lower extremities.

A PICC line (peripherally inserted central catheter) was inserted in the patient's right upper arm on 6/20/14.

Review of the physician's orders showed pre-printed stamped boxes on order forms dated 6/22/14 through 7/7/14, (there was no stamp for 6/26/14) for documentation of 7/7/14, and the date (6/20/14) the central line was inserted. The physician was to check off a reason to show the central line was still necessary and date and time their signature.

There was no documentation to show the physician for Patient 5 reviewed the necessity of the central line remaining in the patient since the line was inserted on 6/20/14. For four of the dates, documentation on the box showed the PICC was inserted on 6/23/14, not 6/20/14.

2. Review of the hospital's P&P Urinary Catheter last review date 5/13, showed one of the purposes of the policy was to prevent and reduce the incidence of catheter-associated urinary tract infections. Urinary catheters should be inserted only when necessary and left in place only for as long as necessary.

Physician must document daily that a catheter is still necessary. The renewal stickers will be on the order sheet for the patients with urinary catheters.

The medical record for Patient 2 was reviewed with the Director of the ED on 7/7/14 at 0955 hours. The patient was admitted to the hospital on 7/3/14, with a urinary drainage catheter in place.

Review of the physician's orders showed pre-printed stamped boxes on order forms dated 7/4, 7/5, and 7/6/14, (there was no stamp for 7/7/14) for documentation of 7/7/14, and the date (7/3/14) the catheter was inserted. The physician was to check off a reason to show the catheter was still necessary and date and time their signature. None of the boxes showed documentation by the physician.

RN B was interviewed on 7/7/14 at 1100 hours. The RN stated the night shift stamped the physician's order sheets for documentation to continue a catheter or a central line. RN B stated the Infection Control RN was to follow up to ensure completion.

The Infection Control RN was interviewed on 7/7/14 at 1110 hours. The RN stated the Charge Nurse of each nursing unit was to follow-up daily to ensure physicians documented the daily necessity of central lines and catheters.

Based on observation, interview, and record review, the hospital failed to ensure staff engaged patient participation in the discharge planning process for one of the 16 patients reviewed in the BHU (Patient 12). This has the potential for readmission for that patient.

Findings:

Review of the hospital's P&P titled Case Management/Social Service Manual last reviewed date 3/13, showed Social Service means assisting patients and their families to understand and cope with emotional and social problems which affect their health status, with appropriately organized staff. When the patients receive social services, appropriate entries and progress notes shall be included in the patient's medical record.

Review of Patient 12's medical record was initiated on 7/8/14, and showed the patient was admitted to the hospital on 5/30/14, (38 days in the hospital) with diagnoses including paranoid schizophrenia (a mental illness that involves false beliefs of being persecuted or plotted against).

During the observation and interview with Patient 12 on 7/8/14 at 0835 hours, he was sitting at a table by himself eating breakfast. Patient 12 stated he was waiting to be discharged and wanted his parents to be called. Patient 12 stated he did not attend group therapy.

Review of the Interdisciplinary Master Plan dated 5/30/14, showed the preliminary discharge plan for Patient 12 was to go home. Patient 12's legal status was temporary conservatorship.

During an interview on 7/7/14 at 1000 hours with ASW 1, she was asked about Patient 12's discharge plan. ASW 1 stated they asked for possible placement for many places. The ASW produced faxed pages with Patient 12's Admission information dated 6/18, 6/26, 6/30, and 7/2/14; however, there was no social services' progress notes to show coordination of care or Patient 12 participation in his discharge planning.

Review of the Interdisciplinary Treatment Plan Update from 5/30 to 7/8/14, showed a problem was developed to address potential discharge placement. The intervention listed included "provide 1:1 (one to one) meeting with patient to discuss and plan discharge/aftercare." The long-term goal was to obtain appropriate placement and follow up.

During an interview with AT 1 on 7/8/14 at 1005 hours, she stated due to the unit workload, she did not have time to document everything in the patient's chart.

During the Interdisciplinary Treatment Plan meeting on 7/8/14 at 1230 hours, MD F (psychiatrist) asked the team members about Patient 12's discharge planning. ASW 1 stated Patient 12 was going to be discharged to a nursing care facility. ASW 1 further stated "we are waiting for the follow-up; we faxed the papers this morning." The physician stated "Okay, so we got a plan for him."