The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

DALE MEDICAL CENTER 126 HOSPITAL AVE OZARK, AL 36360 April 16, 2012
VIOLATION: GOVERNING BODY Tag No: A0043
Based on interviews, hospital compliance history and plan of correction the Governing Body has failed to maintain a safe and effective program for Psychiatric services. This has the potential to affect all current and new hospital admissions.

Findings include:

Refer to A 49 for findings related to this condition.
VIOLATION: MEDICAL STAFF - ACCOUNTABILITY Tag No: A0049
Based on review of the facility census for the past three months, review of facility policies and interview it was determined the governing body failed to ensure the facility policy for admission of psychiatric patients to the excluded PPS (prospective payment system) unit and the non-PPS excluded psychiatric unit were in compliance with the identified number of patients at capacity designated by facility policy.

Findings include:

Facility Policy: Criteria for Admission to the Behavioral Health Adult Unit # 1003, revised 8/17/2011 after the complaint survey conducted July 11, 2011.

Purpose: To implement appropriate admission of patients to the (13) bed Non-Prospective Payment System (Non-PPS) Behavioral Adult Unit by identifying inclusionary and exclusionary criteria for admission.

Policy: Patients will be admitted to the Behavioral Health Adult Unit when their behavioral healthcare needs meet diagnostic criteria as defined by the DSM (Diagnostic and Statistical Manual)-IV and are appropriate for diagnosis and treatment in an acute care setting.

***

Facility Policy: Criteria for Admission to the Behavioral Health Geriatric Unit # 1003, revised 8/17/2011.

Purpose: To implement appropriate admission of patients to the (12) bed certified Prospective Payment System (PPS) Behavioral Geriatric Unit by identifying inclusionary and exclusionary criteria for admission.

Policy: Patients will be admitted to the Behavioral Health Geriatric Unit when their behavioral healthcare needs meet diagnostic criteria as defined by the DSM and are appropriate for diagnosis and treatment in an acute care setting.

Refer to A 144 for examples of Geriatric Patients housed in the Intensive Care Unit.

***
Findings:

On the following dates the (Non-PPS) Behavioral Adult Unit had a census of more than the capacity of 13 patients as the facility policy stated.

1/25/12- 14 patients
1/31/12- 14 patients
2/1/12- 14 patients
2/3/12- 14 patients
2/4/12- 14 patients
2/5/12- 14 patients
2/13/12-14 patients
4/2/12- 15 patients
4/4/12- 15 patients
4/6/12- 14 patients.

An interview with Employee Identifier (EI) # 1, the Chief Nursing Officer (CNO) on 4/11/12 at 10:00 AM, who confirmed the number of patients on the Adult unit was more than 13.

The staffing schedule for the Adult Unit 7:00 AM until 7:00 PM is for 1 Registered Nurse (RN) and three Mental Health Technicians (MHT) and a shared RN with the Geriatric unit to administer medications and assist with treatments with new admissions. Even though the census was greater than 13 no additional staff was assigned to provide care to the psychiatric patients who were deemed by the Psychiatrist to be appropriate for treatment in an acute care setting.


On 2/13/12 only one RN and one shared nurse were assigned according to information provided to the surveyor 4/12/12 at 9:30 AM by EI # 2, the Director of the Psychiatric units, although the census was 14.

On 4/4/12 only one RN and one shared nurse plus two MHTs were assigned according to information provided to the surveyor 4/12/12 at 9:30 AM by EI # 2, the Director of the Psychiatric units, even though the census was 15.

On 4/12/12 at 9:30 AM, EI # 1 provided the surveyor with the typical staffing pattern which was the day shift would have 3 nurses and 6 MHTs.

The Evening shift would have 3/2 nurses and 6/4 MHT. (The surveyor understood this to mean it might vary from 3 to 2 or 6 to 4 actually assigned.)

The night shift would have 2 nurses and 5 MHTs.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview with the Chief Nursing Officer and review of medical records it was determined the hospital placed patients in the Intensive Care Unit (ICU) until a bed was available on the Adult Psychiatric unit or the PPS (Prospective Payment System) excluded Geriatric unit. This included patients who were committed through the probate court system.

The hospital failed to protect the safety of all hospital patients in the acute care setting by commingling psychiatric patients in an unlocked and unsecured setting.

This had the potential to affect the safety of all patients served by the hospital and did affect Patient Identifier (PI) # 1, # 2, # 3, # 4, # 5, # 6, # 7, and # 9.


Findings include:

1. PI # 1 was admitted [DATE] to an ICU bed and transported to the adult psychiatric unit on 2/13/12 at 2:25 PM.

The patient had an Axis I diagnosis of [DIAGNOSES REDACTED]

The admitting orders included:
Therapeutic Programs as indicated:
Recreational Therapy- 7 days a week
Nursing education- 7 days a week
Group Therapy- 7 days a week.

The Master Treatment Plan Review Summary was dated 2/13/12 through 2/17/12. The first group therapy note was dated 2/13/12 by the social worker.

The patient remained in the ICU bed from 2/11/12 until 2/13/12 before receiving any therapeutic interventions for the acute illness that required admission to the acute care setting.

An interview on 4/12/12 at 9:50 AM, with Employee Identifier (EI) # 3, the Director of Quality Assurance, who confirmed the first documented group note was 2/13/12 on PI # 1.

2. PI # 2 was admitted [DATE] to an ICU bed and transported to the adult psychiatric unit on 1/14/12 at 6:48 PM.

The patient had an Axis I diagnosis of [DIAGNOSES REDACTED]

The first group therapy note was dated 1/14/12.

The patient remained in the ICU bed from 1/11/12 until 1/14/12 before receiving any therapeutic interventions for the acute illness that required admission to the acute care setting.

The patient was housed in the ICU on 1/12/12 with 3 other psychiatric patients, on 1/13/12 with 3 other psychiatric patients and when transferred out on 1/14/12, 2 psychiatric patients remained in ICU. There was no additional staff assigned to work during the dates with multiple psychiatric patients in the unsecured unit. Two nurses and one tech(technician) worked 7 AM until 3 PM. One nurse and one tech or two nurses and 11 PM until 7 AM. Two nurses on 1/12/12 and 1/13/12.

An interview on 4/12/12 at 9:50 AM, with EI # 3, the Director of Quality Assurance, confirmed the first documented group note was 1/14/12 on PI # 2.

3. PI # 3 was admitted on [DATE] to an ICU bed and transported to the geriatric psychiatric unit on 1/16/12 at 8:09 PM.

The patient had an Axis I diagnosis of [DIAGNOSES REDACTED]

The first group therapy note was dated 1/17/12.

The patient remained in the ICU bed from 1/11/12 until 1/17/12 before receiving any therapeutic interventions for the acute illness that required admission to the acute care setting.

The patient was transported from the nursing home where he resided by his spouse. The nursing home documentation confirmed they were aware no bed was available in the Geriatric Psychiatric unit and the Psychiatrist was also aware no beds were available.

1/11/12 at 10:05 AM, " New order noted from Dr... (psychiatrist) office to send resident to New Day with wife..."

The Treatment Plan was developed and dated 1/16/12.

An interview on 4/12/12 at 9:50 AM, with Employee Identifier (EI) # 3, the Director of Quality Assurance, confirmed the first documented group note was 1/17/12 on PI # 3.

The discharge summary documented the Hospital Course as follows:
" The patient was admitted to New Day and placed on every 15 minute observations. He was admitted to the hospital from the ... Nursing Home as he had been acting more confused, restless, agitated, not responding to the treatment given. Over the past few days he has become restless, agitated, refusing medications and because of this he was admitted for further evaluation and treatment... He did not exhibit any behavioral problems while on the unit. He participated well in group activities..."

The patient was not admitted to New Day and was not on every 15 minutes checks as is the routine on the psychiatric unit.

The patient remained in the ICU bed from 1/11/12 until 1/16/12 before receiving any therapeutic interventions for the acute illness that required admission to the acute care setting.

An interview with EI # 1, the Chief Nursing Officer on 4/11/12 at 8:30 AM, who confirmed with the Chief Financial Officer of the hospital that the entire episode of this patient's care was billed under the PPS excluded unit even though he was in an ICU bed 5 days of his 12 day stay.

4. PI # 4 was admitted to the ICU 1/25/12 and transported to the adult psychiatric unit on 1/26/12 at 12:35 PM.

The patient had an Axis I diagnosis of [DIAGNOSES REDACTED]

The admitting orders included:
Therapeutic Programs as indicated:
Recreational Therapy- 7 days a week
Nursing education- 7 days a week
Group Therapy- 7 days a week.

The Treatment Plan was developed and dated 1/26/12. There were no group notes documented in the medical record until the patient was transferred to the psychiatric unit.

An interview on 4/12/12 at 9:35 AM, with Employee Identifier (EI) # 3, the Director of Quality Assurance, it was confirmed the first documented group note was after the transfer to the psychiatric unit on 1/26/12.

The discharge summary documented the Hospital Course as follows:
" The patient was admitted to New Day and placed on every 15 minute observations. She was admitted to the hospital as she was feeling depressed, not sleeping well, feeling hopeless and helpless. She does have a long history of bipolar disorder, borderline personality, history of alcohol abuse, drug abuse, unpredictability, numerous state hospital admissions..."

The patient was not admitted to New Day and did not have every 15 minutes checks as the psychiatrist implied on his discharge summary.

The patient was housed in the unsecured ICU, which was not a safe place for a patient with her psychiatric history.

5. PI # 5 was admitted on [DATE] and transported to adult psychiatric unit on 1/24/12 at 12:35 PM.

The patient had an Axis I diagnosis of [DIAGNOSES REDACTED]

The patient was discharged home 1/24/12 at 4:12 PM.

The treatment plan was documented 1/22/12 and goals resolved 1/24/12.

The medical record had an individual one on one note from the counselor dated 1/22/12 and recreational assessment documented 1/23/12.

An interview with EI # 3, Director of Quality Assurance on 4/12/12 at 9:38 AM, confirmed the patient did not receive treatment from the therapist to reflect the goals were resolved.


6. PI # 6 was admitted on [DATE] to ICU and transported to the adult psychiatric unit 1/25/12 at 9:20 PM after an altercation with a staff member of the ICU.

The patient had an Axis I diagnosis of [DIAGNOSES REDACTED]

The hand written orders from the psychiatrist documented, " Diagnosis- Autism with aggressive behavior- New Day-( ICU Hold) on 1/23/12 at 6:05 PM." The patient was received from the emergency room at 9:00 PM and placed in ICU bed 5.

The admitting orders included:
Therapeutic Programs as indicated:
Recreational Therapy- 7 days a week
Nursing education- 7 days a week
Group Therapy- 7 days a week.

The Pre-Admission Assessment was completed 1/23/12 at 5:45 PM. The clinical assessment information included, " ... Parents locked their bedroom last night because they were afraid."

The Patient Progress Note documented by the ICU nurse on 1/23/12 at 9:15 PM, " Notified Dr...(psychiatrist) via phone that pt(patient) is continuing to exhibit sexually aggressive behavior toward the staff. Orders received, will continue to closely monitor pt."

The physician ordered Geodon 20 mg (milligrams) IM (intramuscular) every 10 hours PRN ( as needed). There was no documentation the patient received the medication on 1/23/12.

On 1/25/12 the patient remained in the ICU. The Patient Progress Note documented by the ICU nurse on 1/25/12 at 8:10 PM, " Patient started to come out of his room, I walked to the door. He grabbed my right hand and tried to pull it down. When I tried to get loose with my left hand he grabbed it. The other staff in the unit and from 2nd floor came to help. I still could not get loose from him. He pulled my hands up to his face. I was afraid he was going to bite me but he put my hand to his nose....(security) came through the door and when he saw security he turned me loose and went into his room. Employee Identifer (EI) # 4, RN Supervisor, an LPN and ... from X-ray came in. Dr... was downstairs in ND (New Day) so he was notified of the problem. The patients parents came so the dad went in to stay with him."

Dr... came to the ICU at 9:20 PM and transferred PI # 6 to New Day Adult Behavioral Unit.

The receiving nurse on the adult unit documented, "...Patient anxious at this time. Report received from ICU staff nurse that the patient has been medicated." There was no documentation of the patient receiving any medications after the incident.

The patient was discharged [DATE] to his parents. The patient had three documented group notes in the medical record from the adult unit dated 1/25/12, 1/25/12 and 1/26/12, " patient did not attend."

The discharge summary documented the Hospital Course as follows:
" The patient was admitted to New Day and placed on every 15 minute observations. This patient is autistic and was admitted to the hospital as he had become aggressive, out of control and escalating. He had been seen in Birmingham by psychiatry..."

The patient was not admitted to the New Day unit initially and had not been followed by a psychiatrist prior to this admission according to documentation from the Social Worker. The patient had been under the care of Glenwood Center in Birmingham for the treatment of Autistic Spectrum Disorder, under the care of a Pediatrician.

The patient's treatment plan was opened 1/24/12 with the first group note dated 1/25/12 and the two problems listed were impulse control and aggressive behavior and were marked as unresolved but improved on 1/26/12 discharge .


An interview on 4/12/12 at 9:45 AM, with EI # 3, the Director of Quality Assurance, confirmed the first documented group note was 1/25/12 on PI # 6 and no additional medication was administered to the patient before he was transferred.

7. PI # 7 was admitted on [DATE], transferred to room 215 A on the med-surg (medical- surgical) floor 1/15/12 at 9:30 PM and transferred to New Day on 1/17/12 at 3:50 PM.

The patient had an Axis I diagnosis of [DIAGNOSES REDACTED]
The patient was housed in the unsecured ICU and transferred to room 215 which was on a medical surgical floor, which was not a safe place for a patient with her history of suicidal ideations.


The admitting orders dated 1/11/12 included:
Therapeutic Programs as indicated:
Recreational Therapy- 5 days a week
Nursing education- 7 days a week
Group Therapy- 5 days a week.

The medical record contained an order dated 1/16/12, admit to New Day.

There was no order to move the patient and no documentation as to why the patient was moved to the med-surg floor before being admitted to New Day on 1/17/12. There were no group notes for the time from 1/11/12 until 1/17/12 and no documentation of the treatment team establishing a plan prior to 1/17/12.

The discharge summary documented the Hospital Course as follows:
" The patient was admitted to New Day and placed on every 15 minute observations. This patient was admitted to the hospital from the nursing home as she has been depressed, cannot take it any longer, discouraged and verbalizing suicidal ideations."
The patient was not admitted to New Day until 1/17/12 and did not have every 15 minutes checks as the psychiatrist implied on his discharge summary.

An interview on 4/12/12 at 9:45 AM with EI # 3, Director of Quality Assurance, confirmed no one recalled why the patient was moved to the med-surg floor.

An interview with EI # 1, CNO, on 4/11/12 at 10:00 AM, confirmed there were no group notes before 1/17/12. EI # 1 confirmed with the Chief Financial Officer that all of PI # 7's care was billed under the PPS excluded unit even though he was in an ICU bed 4 days and med surg bed 1 day of his 13 day stay.

8. PI # 9 was admitted on [DATE] and transported to the adult psychiatric unit on 1/26/12 at 5:40 PM.

The patient had an Axis I diagnosis of [DIAGNOSES REDACTED]

The admitting orders included:
Therapeutic Programs as indicated:
Recreational Therapy- 7 days a week
Nursing education- 7 days a week
Group Therapy- 7 days a week.

The patient had two individual group notes documented 1/25/12, one from the recreational therapist and the other from the counselor.

The discharge summary documented the Hospital Course as follows:
" The patient was admitted to New Day and placed on every 15 minute observations. He was admitted from... hospital emergency room where he was taken as he had been agitated, out of control and escalating."

The patient was not admitted to New Day and did not have every 15 minutes checks as the psychiatrist implied on his discharge summary.

The above rule violation is a repeat deficiency from the July 22, 2011, complaint investigation survey.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on review of staffing schedules for the adult psychiatric unit, staffing in the PPS (Prospective Payment System) excluded Geriatric unit and the intensive care unit from January 2012 through April 12, 2012 and interview with staff it was determined the facility failed to ensure adequate numbers of staff and appropriately trained staff were available to meet the needs of the patients housed in the intensive care unit and the psychiatric units.

This had the potential to affect all patients served by the psychiatric units of the hospital and did affect Patient Identifier (PI) # 2, # 3, # 4, # 5, # 6, # 7, and # 9.

Findings include:

As a result of a complaint investigation completed 7/22/2011 regarding the housing of patients in the intensive care unit (ICU) while waiting on psychiatric beds to come available the hospital provided a plan of correction stating the following would be completed beginning the week of August 15, 2011:

"The Nurse Managers of the New Day Behavioral Unit will in-service the emergency (ER) department nurses and the intensive care nurses on safety of the psychiatric patient in the ER or ICU. This training will include but not be limited to techniques for de-escalation and room set-up. This in-service will be mandatory for nursing staff. Chief Nursing Officer, Nurse Managers and Nursing Supervisors will assure attendance by staff. Nurse Managers and Supervisors will provide in-service to staff that are unable to attend."

A review of personnel records for staff working in the ICU revealed the following staff reviewed a video of the S.E.C.U.R.E (Safe Emergency Control Understand and Redirect or Elderly population) training. This course prepares the staff to identify major behavioral problems experienced by some elderly persons, as well as causes of those problems and appropriate interventions for managing the problems.

An LPN (Licensed Practical Nurse) whose date of hire was 01/18/1996 watched the video on 10/2/2011.

An LPN whose date of hire was 02/24/2001 watched the video on 10/6/2011.

A RN (Registered Nurse) whose date of hire was 09/09/2002 watched the video on 10/19/2011.

A RN whose date of hire was 08/15/1996 watched the video on 10/4/2011.

A RN whose date of hire was 08/12/2011 watched the video on 9/27/2011.

A RN whose date of hire was 06/03/2010 watched the video on 11/29/2011.

The staff were required to take a post test however, the back section of the test requires the instructors initials to indicate that the student successfully performed the following techniques during testing:

Guarded Body Stance
Bite Release
Strike Block
Kick Block
Hair Pull Release
One Hand Wrist Grab Release
Two Hand Wrist Grab Release
Front Choke Release
Back Choke Release
Double Basket Control Hold
Three Person Carry.

These were not marked as completed since the staff watched the video which had been recorded during one of the first in-services. In an interview on 4/11/12 at 7:00 AM, with Employee Identifier (EI) # 6, the RN who works 7:00 PM until 7:00 AM in the Intensive Care Unit (ICU), EI # 6 stated that she had not attended any classes on restraint except during the annual training but she did have a certificate for completion of S.E.C.U.R.E. training dated 11/29/11. This date was after the instructor who was certified to teach the class was no longer employed at the hospital. EI # 6 had reviewed the video. The surveyor asked if she had been using the form developed for safety of the patient in the ICU rooms. EI # 6 stated, " No, they make the room safe but she had not seen the form in ICU."

The bottom section of the form titled - Psychiatric Room Set Up had these instructions in bold print:
"For use by Nursing Supervisor when admitting a patient for psychiatric observation in ER or ICU. Initial items to verify completion, prior to releasing bed for patient admission. Forward completed forms to CNO (Chief Nursing Officer) office."

In an interview on 4/11/12 at 7:15 AM, with EI # 7, the RN who works 7:00 AM until 7:00 PM, in the ICU, EI # 7 stated that she used to work on the Psychiatric unit last year and had training but went on to say she had never seen the Psychiatric Room Set up form.

In an interview on 4/10/12 with EI # 8, an LPN working 7:00 AM until 7:00 PM, in ICU, EI # 8 confirmed they had inservices all the time and sometimes it is hard to get to them. She stated that she did not know if any of the nurses working in ICU had gone to any psychiatric inservices. EI # 8 reviewed the video on 10/2/11.

In an interview on 4/10/12 at 3:50 PM, EI # 4, the evening shift supervisor confirmed he was not aware of any special training for staff regarding Psychiatric patients going into the ICU and he was not aware of the Psychiatric Room Set Up form. When EI # 4 was asked if additional staff were put in the ICU when Psychiatric patients were placed there, EI # 4 confirmed that the staffing usually stays the same.

The hospital failed to train staff and ensure adequate numbers of staff were available to provide care to medically ill patients in the ICU as well as patients housed there with psychiatric problems.

In an interview 4/10/12 with EI # 4, the 3:00 PM until 11:00 PM, House Supervisor, stated that the only people they put in ICU now are suicidal or homicidal .EI # 4 stated, " Basically 1:1 on camera within eyesight, we put them in room 3 and 4 across from the nurses station." EI # 4 confirmed usually the same staff worked days when more than 2 patients were in the unit.


On the following dates the (Non-PPS) Behavioral Adult Unit had a census of more than 13 patients (total capacity) as the facility policy stated.

1/25/12-14 patients
1/31/12-14 patients
2/1/12-14 patients
2/3/12-14 patients
2/4/12-14 patients
2/5/12-14 patients
2/13/12-14 patients
4/2/12-15 patients
4/4/12-15 patients
4/6/12-14 patients.

The staffing pattern for this unit remained at 1 nurse and 3 techs with a split nurse to administer medications and do treatments between the Geriatric Psych patients and the adult psych patients on the 7:00 AM until 7:00 PM shift to care for up to 15 patients.

The staffing pattern for the 7:00 PM until 7:00 AM shift was for 1 nurse and 2 techs to care for 13 up to 15 patients.

An interview with Employee Identifier (EI) # 1, the Chief Nursing Officer (CNO) on 4/11/12 at 10:00 AM, confirmed the number of patients on the Adult unit was more than 13.

In an interview on 4/11/12 at 3:20 PM with EI # 9, the Medical Director for both Psychiatric units he confirmed safety was very important and he realized how sick the patients being admitted to ICU were. At one time he states he an Autistic patient, a Schizophrenic and a Dementia patient in the ICU.

In an interview with EI # 1, the CNO on 4/12/12 at 9:30 AM she was asked for the patients coming through the emergency room (ER) for admission to a psychiatric bed,was there any attempt made to transfer the patient to another hospital when Dale Medical Center has no available psychiatric beds. EI # 1 stated if they come through the ER and there is no bed available on the Psychiatric unit, they call EI # 1 and this should be documented on the ER record where they have tried to locate another hospital to transfer the patient to. If it is a direct admit they come in and the house supervisor assigns them a room.

In a telephone interview 4/13/12 with EI # 1 she was provided a list of 7 names of psychiatric patients housed in the ICU and asked to see if they had any documentation of attempts to locate another hospital to admit the patient.

On 4/16/12 at 9:40 AM the surveyor received a telephone call from EI # 1. EI # 1 stated that only 2 of the 7 patients came through the ER and there was no documentation on the records of PI # 5 and # 6 regarding any attempts to transfer the patients. This affected Patient Identifier # 2, # 3, # 4, # 5, # 6, # 7, and # 9.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on interview with Employee Identifier (EI) # 1, the Chief Nursing Officer (CNO), a review of a document dated 3/6/12 for wounds which was used as part of the wound care chart audits and medical record reviews it was determined in 1 of 2 patient records reviewed that:
1. The orders were not followed as written
2. The wound was not measured every 7 days
3. The wound care orders were not documented by the physical therapist for three days and
4. The physical therapist failed to put in writing a wound care order for the physician signature or for nursing staff to know what wound care was to be provided. This affected Patient Identifier (PI) # 10 and had the potential to affect all patients served.

Findings include:

Document: Wounds 3/6/12
Admission:
A complete assessment and complete documentation of wounds
Wound Measurement
Photos (photographs)
MD ( medical doctor) orders for wound care or order to have Physical Therapy evaluate

Every 12 hours:
A complete assessment and complete documentation
Documentation of wound care when it's performed.( should match exactly what the MD order states)

Every 7 Days:
Photos retaken
Wounds re-measured.

1. PI # 10 was admitted to the PPS (Prospective Payment System) excluded Geriatric Psychiatric unit on 3/27/12 with a Spinal Cerebrovascular Accident with increasing confusion and dementia.

On 3/27/12 at 7:15 PM a wound on the right buttock measured 1.9 x 1.3 color pink, no drainage and no odor. A second wound on the right buttock measured 2.2 x 2.0 color pink, no odor and no drainage. The nurse went on to document in the narrative section of the note, " 2 open areas to right buttock. Patient has purplish discoloration to left upper back, measures 4.0 x 4.0. Patient has dark purplish area to right abdomen measures 6.0 x 1.0. Patient has light purplish area to left abdomen measures 4.0 x 1.0. Patient has red area right lateral thigh, dark purple area left inner heel. Red area right anterior leg. Red area to right posterior lower arm. Purple area to right anterior hand."

There were no orders for wound care on admission.

On 3/28/12 at 4:15 AM the nurse documented, " Two open area to right buttocks. Color pink. No drainage, no depth, no odor."

On 3/30/12 at 8:39 AM the nurse documented, " Pt has two open areas to right buttocks. Color pink. No drainage, no odor or other signs/ symptoms of infection noted."

On 3/31/12 at 8:53 PM the nurse documented, " Broken skin area below coccyx, stage 2, 3 x 5 cm area cleaned with saline. Patted dry and covered with Duoderm. Pt tolerated well."

There was no order for the wound care provided to PI # 10 on 3/31/12.

The nurses entry for 4/1/12, 4/3/12 and 4/4/12 states, " Pt has duoderm intact to coccyx area."

An order from the physician dated 4/6/12 at 10:15 AM, " Clean decubitus ulcer on sacrum with Betadine daily, physical therapy to assess regarding decubitus ulcer."

The nurses note for 4/6/12 at 1:35 PM documented, " Lantiseptic cream applied to buttocks and duoderm applied to stage II to coccyx." There was no order for this wound care.

The physical therapist (PT) evaluated the decubitus on 4/7/12 in AM, " ...appearance: no full thickness breakdown at center of sacrum with increased redness, signs of pressure changes to dermal layer. All tissue pink, red with no yellow or non-viable tissue at central skin fold...Then area cleansed with CaraKlenz (Duoderm is removed pre-PT) and Duoderm reapplied to sacrum. Nursing advised to increase pressure relief to sacrum with positioning. No skilled PT needed. Pt deferred back to nursing for QD ( every day) wound cleansing/ duoderm."

The patient was discharged home 4/10/12. The nurses continued to document from 4/7/12 on each shift that duoderm was intact. No one assessed the wound visually after it was covered with Duoderm by the physical therapist prior to discharge.

The Physical Therapist wrote a late entry after the surveyor reviewed this record on 4/10/12 at 12:30 PM, " Clarification Order: (late entry) PT wound care eval( evaluation) completed 4/7/12 and sacral pressure care deferred to nursing service with cleansing around sacral area of pressure, duoderm changed PRN (as needed) as indicated and once per week from 4/7/12, also pressure relief off sacrum emphasis."

The physical therapist failed to document any measurement of the wound on 4/7/12.

The wound was only measured on admission 3/27/12.

In an interview with EI # 1, the Chief Nursing Officer, on 4/12/12 at 9:30 AM, EI # 1 confirmed the therapist failed to document a measurement of the decubitus and an order for deferring back to the nurses for wound care.



The above rule violation is a repeat deficiency from the July 22, 2011, complaint investigation survey.
VIOLATION: FORM AND RETENTION OF RECORDS Tag No: A0438
Based on observation, interview and review of medical records it was determined the hospital failed to have admission and discharge records of the prospective payment(PPS) excluded psychiatric unit separately identified from the general hospital records where the patients had been housed in the acute care beds in the intensive care unit. Refer to CFR (Code of Federal Regulations) 412.25(a)(2).

Findings include:

CFR 412.25 (a)(2) Have admission and discharge records that are separately identified from those of the hospital in which it is located and are readily available.

The surveyor reviewed Patient Identifer (PI) # 3 and # 7. Both of these patients had been housed in the intensive care unit of the acute hospital and transferred at some point in their stay to the PPS excluded psychiatric bed. The entire admission was billed under the PPS exclusion according to the Chief Financial Office as reported to the surveyor by Employee Identifier (EI) # 1, the Chief Nursing Officer on 4/11/12 at 9:30 AM. The patients only had one medical record which contained both the documentation from their ICU, medical floor and PPS excluded psychiatric unit for geriatrics.

In an interview on 4/12/12 at 11:00 AM, with EI # 2, the Director of the PPS excluded unit she confirmed that they are supposed to discharge from the acute hospital and re-admit to the PPS excluded unit and have two separate charts.
VIOLATION: CONTENT OF RECORD - OTHER INFORMATION Tag No: A0467
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, review of hospital policies, interview with the Chief Nursing Officer and review of medical records it was determined the hospital housed patients in the Intensive Care Unit until a bed was available on the Adult Psychiatric unit or the PPS (Prospective Payment System) excluded Geriatric unit.
The patients failed to receive:
1. Therapeutic interventions to stabilize their psychiatric condition which required hospitalization in an acute care setting
2. Group therapy
3. Activity therapy
4. Individual therapy from counselors or social workers
5. Psychiatric evaluation and treatment.

This included patients who were committed through the probate court system.

This had the potential to affect the safety of all patients served by the hospital and did affect Patient Identifier (PI) # 8.

Hospital Policy: Admission Criteria for Psychiatric Patients when Psychiatric Units are at Capacity. Effective date: August 1, 2011

Purpose: To provide criteria for admission of psychiatric patients when the psychiatric units are at capacity.

Policy:
When the New Day Behavioral Geriatric and Adult psychiatric units are at capacity, and a patient presents for admission, the patient's admitting, attending or emergency department physician will assess the patient and make the decision regarding the most appropriate disposition of the patient. If the patient is deemed to be in an emergency situation, i.e., at risk for harm to self or others, the physician in charge of the patient's care will make the decision regarding placement. The options available to the physician may include but not limited to observation in the emergency department until a room on the psychiatric unit is available, admission to the intensive care unit for observation until a room on the psychiatric unit is available , or transfer the patient to a facility with the capacity to care for the patient.

If the patient is observed in the emergency department or the intensive care unit, the patient will remain in that unit until the time that an appropriate bed assignment can be made to the psychiatric unit. If the patient is observed in the emergency department or the intensive care unit, one-on-one counseling may be provided to the patient as appropriate. If the psychiatric unit is contacted by the probate court system regarding a patient who is committed for psychiatric treatment, and the unit is at capacity, the probate court system will be notified of same and re-notified upon bed availability.

Patient findings:

1. PI # 8 was admitted to the hospital 3/2/12 at 6:15 PM with diagnoses of [DIAGNOSES REDACTED]

The patient was to continue to self administer Zosyn 3.75 mg intravenously every 6 hours through his PICC (peripherally inserted central catheter) line. The history on the patient included surgery 2/24/12 on his right foot.

An order was present in the medical record date 3/3/12 at 10:30 AM, " Consult Psych notified New Day."

An order was present in the medical record dated 3/4/12 12:20 PM, " Home today please have psych see today to address his medications post discharge."

A physician's progress note dated 3/3/12 at 10:20 AM, " Patient frustrated for there is no adjustment with his psych meds yet, awaiting psych otherwise medically stable."

A physician's progress note dated 3/4/12 at 12:20 PM, " Pt. was to be admitted to the BMU (behavioral management unit). It seems that a nursing decision was made to have him placed on the floor. His whole purpose of being here was to have his psych meds adjusted. This has not been done... due to his work situation he needs to be discharged today so he can be at work in the AM. We will ask psych to see him to adjust his meds... he is extremely frustrated with the fact that he has not had psych meds adjusted which is the whole purpose of his hospital stay."

A history and physical dated 3/3/12 as dictated by the Psychiatrist documented an Axis I diagnosis of [DIAGNOSES REDACTED]

A progress note from the Psychiatrist was dated 3/2/12 as having seen the patient and noted history and physical was dictated, there is no time on the entry.

The patient was not aware he had been evaluated by a psychiatrist, no medication adjustments were ordered, no counseling was documented and the patient went home frustrated because of used hospital days and no care rendered as needed.

In an interview on 4/12/12 with EI # 3, Quality Assurance Director, confirmed the nurse assessing the patient thought he would be better suited for admission to the med-surg floor. When asked if the Psychiatrist would routinely identify themselves to a patient when doing an evaluation EI # 2, the Director of the New Day programs stated that she did not know if the Psychiatrist told the patient who he was and that nurses don't always know a doctor has seen a patient.

The patients failed to receive:
1. Therapeutic interventions to stabilize their psychiatric condition which required hospitalization in an acute care setting
2. Group therapy
3. Activity therapy
4. Individual therapy from counselors or social workers


Refer to A 144 for Patient Identifier examples #1, # 2, # 3, # 4, # 5, # 6, # 7 and # 9.

The above rule violation is a repeat deficiency from the July 22, 2011, complaint investigation survey.