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 Feb. 23, 2017
VIOLATION: GOVERNING BODY Tag No: A0043
Based on review of facility policies, medical records, employee files, Patient Safety Organization - Submission Management reports, Patient Safety Work Product reports, MHT (Mental Health Technician) Observation documentation sheets, Psych Department/ Daily Staffing Grid, Supervisor's staffing sheet, Employee Time sheets, Dale Medical Center's corrective action plan, observations and interviews, it was determined the facility failed to ensure:

1. An investigation was conducted of caregiver reported concerns with the care being provided, which resulted in the family contacting local authorities, including police and Department of Human Resources (DHR). Refer to A119.

2. The facility provided a safe patient care environment. Refer to A144.

3. Investigate and report to authorities/ regulatory agency suspected abuse by a family member. Refer to A145.

4. Patient's right to be free of restraint was not violated by placing a patient in a geri-chair after the patient experienced a fall in the shower room. Refer to A154.

5. Incident reports were completed on a patient who experienced unexplained injuries. Refer to A286.

6. There was a qualified director of psychiatric nursing services in place for the PPS (Prospective Payment System) Psychiatric unit during the complaint survey. Refer to A386.

7. The staffing grid was followed to ensure the Psychiatric Units were staffed. Refer to A392.

8. The Registered Nurse (RN) made shift assignments for unlicensed nursing personnel in the adult and geriatric psychiatric units. Refer to A397.

9. The RN made shift assignments to unlicensed nursing personnel who had completed orientation. Refer to A397.

10. Staff completed accurate documentation every 15 minutes without falsification of the medical record. Refer to A450.

11. The shower area in the isolation room was maintained in a safe manner, locked and unaccessible to patients when not in use. Refer to A701.

12. The common bathroom used on the geri-psych unit was cleaned between patients to prevent potential transfer of infectious body fluids or microorganisms between patients. Refer to A747.

These deficient practices affected 10 of 25 records reviewed, including Patient Identifier (PI) # 1, PI # 8, PI # 9, PI # 10, PI # 11, PI # 12, PI # 13, PI # 14, PI # 15, PI # 16 and has the potential to negatively affect all patients admitted to the psychiatric unit of this facility.

Findings include:

Refer to A057, A119, A144, A145, A154, A286, A392, A397, A450, A701 and A747 for findings.
VIOLATION: PATIENT RIGHTS: REVIEW OF GRIEVANCES Tag No: A0119
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility policies, medical record and interview with facility staff, it was determined the facility failed to investigate caregiver reported concerns with the care being provided to Patient Identifier (PI) # 1 in the Geri-Psychiatric Unit (New Day Behavioral), which resulted in the family contacting local authorities, including police and Department of Human Resources (DHR). This has the potential to negatively affect all patients admitted to the facility.

Findings include:

Facility Policy:

Complaint and Grievance Resolution,Patient
Reference # 2016
Date Reviewed: 9/7/2012

Purpose:

New Day Behavioral, in providing care to its patients, ensures that the care given is of the highest quality and value for its customers. When the patient and/or family member perceives the care received to be less than expected, every effort is made to rectify the situation to the patient's satisfaction.

Policy:

...Issues that arise will be promptly responded to through the appropriate staff. It is every employee's responsibility to address concerns promptly to the best of their ability and then refer on as needed.

Definitions:

... Any patient/family member is encouraged to bring forth any complaint or concern regarding care or treatment. All patients and/or family members who wish to express a concern regarding services or care will be assisted in having their concerns addressed and resolved to their satisfaction...

Procedure:

New Day Behavioral follows the policy and procedure for patient complaint and grievance resolution of Dale Medical Center hospital..


Facility Policy: Complaints/Grievance, Patient/Family
Date Revised: 10/07

Policy:
It is the policy of Dale Medical Center to receive and respond as quickly as possible to all patient and/or family complaints/grievances concerning the quality of care/service they receive... and to document the complaint and resolution.

Definitions:
1. A Complaint is oral or written communication expressing dissatisfaction concerning care or services at Dale Medical Center... Complaints may be related to the following...
g. Care

2. A "patient grievance", according to Medicare guidelines, "is a written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by staff present) by a patient, or the patient's representative, regarding the patient's care, abuse or neglect,.."

Procedure:

1...The person receiving the complaint should complete the patients concerns on a complaint form...

3. If the complaint cannot be resolved by informal means, the administrator (or his/her designee) will respond.

4. Response to any complaints/grievances should be within 7 days. If unable to follow-up within 7 days, a letter should be sent to the patient or patient's representative stating that the hospital is still working on follow-up and resolution.

6. The complaint form, including any written correspondence, is to be submitted to Quality Management Department for trending of complaints in order to improve services/processes at Dale Medical Center.


1. PI # 1 was admitted to the facility on [DATE] with diagnoses including Schizoaffective disorder bipolar type, Diabetes and Arterial Hypertension.

Review of the Social Worker (SW) / Case Manager (CM) Progress Note dated 1/13/17 at 8:50 AM revealed the SW received a call from the patient's son-in-law who voiced concerns that PI # 1 had been complaining of back pain since 1/9/17 and was unsure if the patient had been medicated for pain. He stated the patient's daughter visited the patient the evening of 1/12/17 and the patient "could barely move." ... daughter observed a circular bruise on the patient's right wrist. The SW documented the patient's son-in-law was concerned that several injuries had occurred since the patient had been hospitalized ; however nothing had been documented of them. The SW documented he was not accusing anyone of wrong doing in regards to the patient; however, his first thought was there had been an attempt to cover up incidents since there had been no charting on any of them. The patient's son-in-law had spoken with the local Sheriff's department and was prepared to file a report if none of his concerns were addressed and discussed with him on that day (1/13/17). The SW documented he (son-in-law) would speak with the hospital board. The SW documented she relayed the information to Employee Identifier (EI) # 2, Program Director, New Day Behavioral.

Review of the SW/CM Progress Note dated 1/13/17 at 4:00 PM, the SW documented having met with the patient's daughter and son-in-law along with a police officer from the local police department. The patient's son-in-law had just spoken with EI # 2 and he was to pick up a copy of the patient's Computerized Tomography (CT) scan. The patient's family and the police officer asked to visit with the patient, which was discussed with EI # 2 and the patient was allowed to visit off the unit. The SW documented while they were visiting with the patient, she met with a representative from the local Department of Human Resources (DHR), who informed her the department had received a report regarding the patient's injuries that had occurred while on the New Day Behavioral unit and she would need to also interview the patient. All of this information was provided to representatives from the hospital's administration, who recommended the patient be made a level 1 (1:1 observation) at least throughout the weekend as the patient was currently a level 2 (observations every 15 minutes). This information was relayed to the "nursing supervisor".

Review of the Physician Order dated 1/13/17 at 5:00 PM revealed orders for Level 1 (1:1 observation) at which time the patient was placed on 1:1 observation until discharge on 1/24/17.

An interview was conducted on 1/26/17 at 11:00 AM with EI # 5, Nurse Manager, New Day Behavioral unit. During this interview, the surveyors asked when she found out about PI # 1. EI # 5 stated she found out on Monday 1/16/17 that the family had concerns and that EI # 2, Program Director, New Day Behavioral unit had started an investigation the week prior. She stated the patient's son-in-law called the hospital on [DATE], notified DHR and EI # 2. EI # 5 again stated she found out about the concerns on 1/16/17.

When questioned about how EI # 5 had been involved with the process/investigation, she stated on 1/13/17, EI # 6, DON (Director of Nursing) asked EI # 5 to review the chart and document the incidents and give it to EI # 2, which EI # 5 did. The following week, after EI # 5 found out about the family's concerns, she and EI # 2 interviewed staff. She stated she talked with a couple of the Mental Health Technicians (MHT) and nurses. After that, EI # 1, Director of Quality/Risk Manager initiated an investigation.

On 1/26/17 at 12:00 PM an interview was conducted with EI # 1, Director of Quality/Risk Manager. During this interview, EI # 1 stated on Monday 1/16/17, EI # 1 found out the police had been at the facility on 1/13/17 and she needed to talk with the SW. EI # 1 stated she talked with EI # 2 to find out what happened. EI # 1 said that EI # 2 told her the police and DHR had been here because the patient's son-in-law and daughter were concerned about where the bruise (above left eye) came from and if he didn't have answers by Friday (1/13/17), he would file a report.

She stated she spoke with both SWs about the situation. EI # 7, Social Worker (SW) stated the family was concerned because the chest x-ray showed a fracture of the vertebra. The hospital performed a CT (Computed Tomography) and MRI (Magnetic Resonance Imaging) and the reports came back after the report was filed with the police. EI # 1 stated on 1/16/17, she began investigating the family's concerns about the patient, which was still in progress the date of this interview (1/26/17).

An interview was conducted on 1/27/17 at 8:00 AM with EI # 2, Program Director, New Day Behavioral. During this interview, the surveyors asked EI # 2, when he found out there were concerns about the care being provided to PI # 1. EI # 2 stated that he could not recall the exact date, but that it was the week of 1/13/17, either Tuesday (1/10/17) or Wednesday (1/11/17) was when he received the first call. He stated the patient's son-in-law was voicing concerns. Then on 1/13/17 he (son-in-law) called again voicing concerns about all the places "popping" up on PI # 1. EI # 2 stated he saw all the bruises, started investigating and asking "What was going on?" When EI # 2 saw the patient, the bruise was still present over the patient's eye, it was kind of yellowish. He started looking at the medical record, then EI # 1, Director of Quality/Risk Manager started her investigation. We talked a little about it, but I didn't get involved in it.

When the surveyor questioned if he had talked with anyone? He stated he, EI # 1 and EI # 5 talked with some of the staff to find out what happened to the patient. He stated the only thing he saw in the medical record was that the patient's daughter stated that a mop handle hit the patient in the eye.

The surveyor asked when he notified EI # 1 and EI # 5. He stated he thought it was either Tuesday or Wednesday during the week of 1/13/17. He stated the patient's son-in-law talked with the Social Worker and she reported the same thing.

EI # 2 stated on 1/13/17, he spoke with the patient's son-in-law about the CT and the son-in-law was angry. EI # 2 stated he told the son-in-law the patient was going to have a MRI on 1/13/17. EI # 2 stated he had to leave after that and did not return to the facility.

When questioned if he documented the above concerns and investigation, he stated he did not, just a few notes.

Summary: PI # 1's family notified EI # 2, Program Director of their concerns early in the week of 1/13/17. There was no documentation by EI # 2 of this, his investigation or response to the family's concerns. Therefore, PI # 1's family contacted the local police department and DHR. According to documentation by the SW, both the police and DHR entered the facility on 1/13/17 at 4:00 PM and the SW notified hospital administration. EI # 1, Director of Quality/Risk Manager was notified on 1/16/17 about PI # 1's concerns, police and DHR involvement and initiated a formal investigation into the family's concerns about the patient's injuries.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility policy, medical records, Patient Safety Organization - Submission Management reports, Patient Safety Work Product reports, Incident reports and interviews with facility staff, it was determined the facility failed to provide a safe environment for 5 of 25 records reviewed. This affected Patient Identifier (PI) # 1, PI # 8, PI # 10, PI # 11, PI # 13 and has the potential to negatively affect all patients admitted to the facility.

Findings include:

Policy: Fall Precaution Prevention Plan Protocol
Date: November 7, 2007

Purpose:
To promote patient safety by identifying inpatients who are at high risk for falls, provide intervention to the patient at risk, communicate to appropriate staff patients at high risk...

Procedure:

1. The Fall Risk Assessment should be done during admission interview, reassessed each shift or change in caregiver, change in patient status or following a fall. A Falls Risk Assessment should be performed at least every 12 hours.

2. Based on the Morse Falls Risk Assessment, the patient's fall risk is identified as:
a. Standard Risk 0-24 total score
b. Moderate Risk 25-44 total score
c. High Risk 45 or greater score

A. Standard Interventions for Patient/Caregivers include but are not limited to:
... 2) Create a safe patient room environment by:
a. Place call light within patient reach.
b. Place telephone and personal items within patient reach
c. Clear any clutter from tables, chairs and floor.
d. Position furniture, equipment, and assistive devices so they are accessible on the patient's dominant side.
e. Place any cords, excess furniture, and unnecessary equipment out of the way.
3) Maintain bed in low position with wheels locked...
4) Encourage the use of non-slip footwear.
5) Provide adequate lighting...

B. Moderate Interventions for Patient/Caregivers include but are not limited to:
1) All Standard interventions.
2) Initiate fall risk communication system:
a. Post Red "Stop Sign" on patient's door and above patient's bed.
b. Place "Fall's Precautions" on MEDACT. (Medical Activities)
c. Place "Risk for Injury" on patient's "Plan of Care" list.
d. Re-orient confused patients, if possible.
e. Consider taking patient off specialty bed if confused, disoriented, or agitated...
f. Assess patient's bowel and bladder elimination needs frequently:
1. Supervise elimination and provide assistance as needed.
2. Establish an individualized toileting plan as needed.
3. Provide a bedside commode, as appropriate.
g. Supervise and assist with personal hygiene, and consider the use of a shower chair.
h. Encourage the use of assistive devices and mobility aids.

C. High Interventions for Patients/Caregivers include but are not limited to:
1) All Standard and Moderate fall interventions.
2) Apply Falls Risk Orange Bracelet.
3) Observe patient hourly or as indicated.
4) Remain with patient while toileting.
5) Consider moving patient to a room with best visual access from the nurse's station.
6) Consider a physical therapy consult...

D. Post Fall Management
1) Assess for injury and notify physician and nursing supervisor.
2) Determine level of injury...
5) Use Morse Falls Risk Assessment to assess for change in patient's risk of falls.
6) Document any circumstances related to the incident in the patient's record.
7) Assess all factors contributing to the fall:
a. Equipment
b. Medication factors
c. Interventions in place at the time of the fall...
9) Consider interventions to be placed to prevent a repeat fall...

Morse Fall Risk Assessment...

Risk Factor/ Scale/ Score:

History of falls: Yes = 20, No= 0

Secondary diagnosis: Yes = 15, No = 0

Ambulatory Aid:
Furniture = 30
Crutches/Cane/Walker = 15
None/Bed rest/Wheelchair = 0

IV (Intravenous)/Heparin lock: Yes = 20, No = 0

Gait/Transferring: Impaired = 20, Weak = 10, Normal/Bedrest/Immobile = 0

Mental Status: Forgets Limitations = 15, Oriented to own ability = 0

When assessing a patient for fall risk, the items in the scale are scored as follows:

History of falling: This is scored as a 25 if the patient has fallen during a recent hospital admission or if there was an immediate history of physiological falls, such as from seizures or impaired gait prior to the admission. If the patient has not fallen, this is scored zero. If the patient has a fall after admission, while hospitalized , the patient is reassessed and a score of 25 is given at that point.

Secondary diagnosis: This is scored as 15 if more than one medical diagnosis is listed in the patient's medical record. If the patient is admitted with only one diagnosis, this is scored as zero.

Ambulatory aids: This is scored as a 30 if the patient walks clutching to furniture for support; patient is scored a 15 if the patient uses crutches, cane or walker patient is scored a zero if they walk without a walking aid (even if assisted by nurse), uses a wheelchair, or is on bedrest and does not get out of bed at all.

Gait: The characteristics of the three types of gait are evident regardless of the type of physical disability or underlying cause:

A normal gait is characterized by the patient walking with head erect, arm swinging freely at the side, and striding without hesitation, this is scored a zero.

A weak gait (score 10) is seen with the patient stooping but able to lift head while walking without losing balance. The patient may barely touch furniture, for reassurance, not support. Steps may be short or shuffling.

An impaired gait (score 20) is characterized by the patient having difficulty rising from a chair and/or bouncing to rise from a chair. The patient's head is down and they watch the ground while walking. Because balance is poor, the patient may grasp furniture for support or must have some other support system to ambulate. The patient usually takes short shuffling steps with this gait as well...

Mental status: When using this scale, mental status is measured by checking the patient's own self-assessment of their ability to ambulate. Ask the patient "are you able to go to the bathroom alone or do you require assistance of any kind"? If the patient reply judging on their ability is consistent with the mobility witnessed, then the patient is rated "normal" and scored zero. If the patient response is not consistent with family responses or witnessed ambulation effort, the patient is considered to overestimate their own abilities and to be forgetful of limitations and scored 15...

Policy: Observation Levels
Reference # 8002
Revised: 9/8/2012

Purpose:
To ensure patients are observed at the appropriate level for optimum safety.

Procedure:
All patients will be assessed by nursing staff for level of observation required at a minimum of every shift.

All patients on the Behavior Health Unit shall be observed at a minimum of every 15 minutes.

15 minutes observation: Level II
This is restrictive toward the patient and involves continuous monitoring every 15 minutes and documentation on the Observation Documentation Record indicating the patient's location.

1-to-1 observation at all times: Level I

This is the most restrictive toward the patient and involves continuous monitoring and physical proximity to the patient at all times. Staff shall be within arm's reach at all times, including toileting and showering. Nursing personnel shall document on the Observation Documentation Record indicating the patient's location every 15 minutes. Patients on this level are considered highest risk...

Policy: Observation Rounds, Patient
Reference # 3023
Revised 9/8/12

Purpose:
To ensure patient safety and accountability.

Policy:
An accurate record of the whereabouts of all patients on the Behavioral Health Unit will be maintained during each shift.

Every patient should be seen by a staff member every 15 minutes and checked off on the Observation Sheet as to their location.

1. PI # 1 was admitted to the facility on [DATE] with diagnoses including Schizoaffective disorder bipolar type, Diabetes and Arterial Hypertension.

Review of the Behavioral Health Unit Morse Fall Risk assessment dated [DATE] at 3:27 PM revealed the patient's fall risk score was 25 - History of Falls (0), Secondary diagnosis (15), Ambulatory Aid (0), IV (Intravenous) / Heparin Lock (0), Gait/Transferring (10) Weak, Mental Status (0) Oriented to Own Ability.

Further review of the Behavioral Health Unit Morse Fall Risk assessment dated [DATE] at 3:27 PM, revealed the patient's fall risk score was of Moderate Risk (Level III Observation) Score 25-44 and interventions included but were not limited to: "... All Standard Precautions indicated plus... Risk for Injury to Master Treatment Plan, Frequently remind patient to request assistance when getting out of bed/chair, Offer toileting opportunities frequently... Standby or hands on assist with all ambulation and ADL's (Activities of Daily Living), Consider Physical Therapy consult, Face to face observation every 15 minutes..."

Review of the Initial Physical assessment dated [DATE] at 3:55 PM, revealed the nurse documented the patient was oriented to person and place, was experiencing auditory and visual hallucinations, had disorganized thoughts, poor insight and fair judgement. On 12/19/16 at 5:24 PM, the nurse documented the patient's fall risk assessment was 25, with documentation the patient was oriented to own ability for mental status. Fall Interventions were documented "Standard 0-24 Protocol initiated...", even though the patient's fall risk was greater than 24.

There was no documentation the fall risk protocols were initiated.

Review of the Nursing Patient Progress Notes revealed the following:

12/19/16 at 7:09 PM, revealed the nurse documented the patient's fall risk score remained 25 with "0" scored for Mental status (0 score - Oriented to own ability), even though the nurse documented the patient had poor concentration, poor insight and poor judgement.

12/20/16 at 10:32 AM, revealed the nurse documented the patient's fall risk score remained 25 with "0" scored for Mental status (0 score - Oriented to own ability), even though the nurse documented the patient was lethargic, had poor concentration, poor attention span, disorganized thoughts, poor insight and poor judgement.

12/20/16 at 6:53 PM, revealed the nurse documented the patient's fall risk score remained 25 with "0" scored for Mental status (0 score - Oriented to own ability), even though the nurse documented the patient had poor concentration, poor insight and poor judgement.

12/21/16 at 7:36 AM, revealed the nurse documented the patient's fall risk score remained 25 with "0" scored for Mental status (0 score - Oriented to own ability), even though the nurse documented the patient had poor insight and fair judgement.

12/21/16 at 7:05 PM, revealed the nurse documented the patient's fall risk score was "0". The nurse documented the patient had poor insight and poor judgement.

12/22/16 at 9:54 AM, revealed the nurse documented the patient's fall risk score remained 15 with "0" scored for Gait/Transferring (0 score - Normal/Bedrest/Immobile) and "0" scored for Mental status (0 score - Oriented to own ability), even though the nurse documented the patient had poor insight and poor judgement.

12/22/16 at 9:00 PM, revealed the nurse documented the patient's fall risk score remained 15 with "0" scored for Gait/Transferring (0 score - Normal/Bedrest/Immobile) and "0" scored for Mental status (0 score - Oriented to own ability), even though the nurse documented the patient had poor insight and fair judgement.

12/23/16 at 9:21 AM and 12/23/16 at 7:20 PM, revealed the nurses documented the patient's fall risk score remained 15 with "0" scored for Mental status (0 score - Oriented to own ability), even though the nurse documented the patient had poor insight and poor judgement.

12/24/16 at 12:00 PM, revealed the nurse documented the patient's fall risk score remained 15 with "0" scored for Mental status (0 score - Oriented to own ability), even though the nurse documented the patient had poor insight and fair judgement.

12/24/16 at 7:00 PM, revealed the nurse documented the patient's fall risk score remained 15 with "0" scored for Mental status (0 score - Oriented to own ability), even though the nurse documented the patient had poor insight and poor judgement.

12/25/16 at 9:27 AM and 7:30 PM, revealed the nurses documented the patient's fall risk score remained 15 with "0" scored for Mental status (0 score - Oriented to own ability), even though the nurse documented the patient had poor insight and poor judgement.

12/26/16 at 8:34 AM and 7:26 PM, revealed the nurses documented the patient's fall risk score remained 15 with "0" scored for Mental status (0 score - Oriented to own ability), even though the nurse documented the patient had poor insight and poor judgement.

12/27/16 at 7:23 AM, the nurse documented, "... Patient wandering in the hallways. Stands facing the wall and holds a washcloth in (his/her) hand. Doesn't make eye contact with nurse..."

12/27/16 at 7:26 AM, revealed the nurse documented the patient's fall risk score remained 15 with "0" scored for Mental status (0 score - Oriented to own ability), even though the nurse documented the patient had poor insight and poor judgement.

12/27/16 at 1:56 PM, the nurse documented, "... Patient sitting in the dayroom staring at the floor..."

12/27/17 at 5:10 PM and amended at 5:11 PM revealed the nurse documented the patient was quiet, withdrawn, oriented to self and was so confused the Techs were having to feed the patient.

12/27/16 at 8:15 PM, revealed the nurse documented the patient's fall risk score remained 15 with "0" scored for Mental status (0 score - Oriented to own ability), even though the nurse documented the patient's affect was constricted or blunted, had poverty of speech, poor insight and poor judgement.

12/28/16 at 8:34 AM, revealed the nurse documented the patient's fall risk score remained 25 with "0" scored for Mental status (0 score - Oriented to own ability), even though the nurse documented the patient was confused, disoriented, had disorganized thoughts, poor insight and poor judgement.

The patient's fall risk interventions were documented moderate risk (25-44 score) and the nurse documented, "All standard interventions initiated, re-oriented patient. Elimination needs assessed frequently, Personal Hygiene needs met... Toileting offered every 2 hours..."

12/28/16 at 1:02 PM, revealed the nurse documented the patient continued to be confused. On 12/28/16 at 6:24 PM, the nurse documented the patient was in the Group room with head hanging down.

12/28/16 at 7:30 PM and amended at 8:02 PM, the nurse documented the patient's fall risk score remained 15 with "0" scored for Mental status (0 score - Oriented to own ability), even though the nurse documented the patient had disorganized thoughts, poor insight and poor judgement. Standard fall risk 0-24 protocol interventions were initiated. There was no documentation of the specific interventions initiated for the patient's fall risk.

12/29/16 at 8:20 AM, the nurse documented the patient's fall risk score remained 15 with "0" scored for Mental status (0 score - Oriented to own ability), even though the nurse documented the patient had disorganized thoughts, fair insight and fair judgement.

12/29/16 at 8:05 PM, the nurse documented the patient's fall risk score remained 15 with "0" scored for Mental status (0 score - Oriented to own ability), even though the nurse documented the patient had disorganized thoughts, poor insight and fair judgement.

12/30/16 at 7:20 AM, the nurse documented the patient's fall risk score remained 15 with "0" scored for Mental status (0 score - Oriented to own ability), even though the nurse documented the patient had poor concentration, attention span, insight and judgement.

12/30/16 at 4:58 PM, the nurse documented the patient was sitting in the day room with head hanging down, attempting to eat ice cream with the lid still on the container.

12/30/16 at 8:25 PM, the nurse documented the patient's fall risk score remained 15 with "0" scored for Gait/Transferring (0 score - Normal/Bedrest/Immobile) and "0" scored for Mental status (0 score - Oriented to own ability), even though the nurse documented the patient's psychomotor behavior was slowed (Psychomotor - of or relating to movement or muscular activity associated with mental processes. Relating to the combination of psychic and motor events, including disturbances. www.dictionary.com) and the patient had poor insight and judgement.

12/31/16 at 8:32 AM, the nurse documented the patient was confused, disoriented and used inappropriate words. The nurse documented the patient was confused, delusional and did not know who the individuals taking care of (him/her) at that time.

12/31/16 at 8:32 AM, the nurse documented the patient's fall risk score remained 15 with "0" scored for Mental status (0 score - Oriented to own ability), even though the nurse documented the patient was confused, disoriented, his/her affect was flat, constricted or blunted, had poor insight and poor judgement.

12/31/16 at 10:25 AM, the nurse documented the patient was ambulating in the hall with Physical Therapy.

Review of the Physical Therapy Inpatient Evaluation dated 12/31/16 revealed the Physical Therapist (PT) documented the patient's current measures of daily function included the following deficits:
Sit to Stand Balance - minimal assistance of 1
Dynamic Gait/Balance - moderate assistance of 1
Grooming self - moderate assistance
Bathing self and Toileting - moderate to maximum assistance

The PT documented the patient's posture was impaired with head forward, stooped posture and kyphotic (Kyphotic relating to or suffering from kyphosis, which is an exaggeration or angulation of the posterior curve of the thoracic spine. medical-dictionary.thefreedictionary.com). The PT documented the patient had ataxia. (An inability to coordinate muscle activity during voluntary movement; most often results from disorders of the cerebellum or the posterior columns of the spinal cord; may involve the limbs, head, or trunk. medical-dictionary.thefreedictionary.com)

The PT documented the patient required frequent cues to not cross midline, head up and to increase step length during the Gait Analysis. The treatment provided by the PT and response to treatment revealed, "... Pt (patient) demonstrates generalized weakness and lethargy affecting safe/independent ambulation and transfers. Pt will benefit from PT (Physical Therapy) for gait/balance training, transfer training..." The Treatment plan included, "... New Day staff to assist with ambulation outside of PT visits..."

12/31/16 at 8:17 PM, the nurse documented the patient's fall risk score remained 15 with "0" scored for Gait/Transferring (0 score - Normal/Bedrest/Immobile) and "0" scored for Mental status (0 score - Oriented to own ability), even though the nurse documented the patient had generalized weakness, flat affect, poor concentration, poor attention span, poor insight and poor judgement.

1/1/17 at 8:45 AM, the nurse documented the patient's fall risk score was 40 with "10" or Gait/Transferring (10 = weak) and Mental status "15" (15 = forgets limitations). The patient's fall risk assessment score was of moderate risk (25-44 score). The nurse documented, "All Standard Interventions initiated..." The nurse further documented the patient had poor concentration, attention span, insight and judgement.

1/1/17 at 8:45 AM and amended at 9:35 AM, the nurse documented the patient needed assistance ambulating from his/her room to the day room, confused and hung his/her head instead of looking up while walking.

1/1/17 at 12:42 PM, the nurse documented the patient was confused, staring at the floor with his/her head hanging. On 1/1/17 at 5:11 PM, the nurse documented the patient was very confused, holds head down, had an unsteady gait and needed assistance with ambulation.

1/1/17 at 6:19 PM and amended at 6:20 PM, the nurse documented the patient had bruising with swelling noted above the left eye and the patient had been in the day room with the mental health technicians (MHT) since breakfast. There was no documentation the nurse notified the physician of the bruising and swelling above the patient's left eye.

There was no documentation a falls risk assessment was completed on 1/1/17 evening shift.

1/1/17 at 7:05 PM, the nurse documented the patient was confused, disoriented and had poor concentration, insight and judgement.

1/2/17 at 8:04 AM, the nurse documented the patient's fall risk score was 15 with "0" scored for Gait/Transferring (0 score - Normal/Bedrest/Immobile) and "0" scored for Mental status (0 score - Oriented to own ability), even though the nurse documented the patient had generalized weakness, poor concentration, poor attention span, poor insight and poor judgement.

1/2/17 at 6:03 PM, the nurse documented the patient continued to be confused.

1/2/17 at 7:03 PM, the nurse documented the patient's fall risk score was 15 with "0" scored for Gait/Transferring (0 score - Normal/Bedrest/Immobile) and "0" scored for Mental status (0 score - Oriented to own ability), even though the nurse documented the patient was oriented to person (self), had poor concentration, poor insight and poor judgement. The nurse documented all standard interventions for standard risk (0-24) protocol were initiated and "Moderate Risk Interventions 25-44 score... All standard interventions initiated"

1/3/17 at 5:24 AM, the nurse documented the patient's fall risk score was 15 with "0" scored for Gait/Transferring (0 score - Normal/Bedrest/Immobile) and "0" scored for Mental status (0 score - Oriented to own ability).

1/3/17 at 8:00 AM and amended at 8:21 AM, the nurse documented the patient had poor concentration, poor insight and poor judgement. On 1/3/17 at 1:30 PM, the nurse documented the patient was ambulating in the hallway with the MHT. There was no documentation a fall risk assessment was completed during the day shift (7 AM to 7 PM) on 1/3/17.

1/3/17 at 7:37 PM, the nurse documented the patient's fall risk score was 15 with "0" scored for Gait/Transferring (0 score - Normal/Bedrest/Immobile) and "0" scored for Mental status (0 score - Oriented to own ability), even though the nurse documented the patient had poor concentration, poor insight and poor judgement.

1/3/17 at 8:28 PM, the nurse documented, "... Discussion with pts (patient's) daughter revealed information concerning how pt received bruise to left eye area. Pt daughter states, "At my last visit, the mop handle from cleaning cart fell over and hit (patient) in the eye. (Patient) said (he/she) was ok so I didn't think anything about it. Pt eye bruised on lid area. Pt denied pain or problems with vision..."

Review of the CT (Computed Tomography) of the patient's head/brain conducted on 1/3/17 revealed no acute intracranial findings were visualized. This report was transcribed on 1/3/17 and signed by the radiologist on 1/4/17 at 9:05 AM.

Review of the In-Patient Physical Therapy (PT) Session Note dated 1/4/17 revealed the PT documented, "... Patient alert, oriented to name only... Demonstrating improved transfers and gait... requires slightly decreased assist, however continues to gaze down at ... feet during gait training, only looking forward with cuing and only for 3 - 5 seconds, before returning... gaze to the floor..."

1/4/17 at 9:22 AM, the nurse documented the patient had generalized weakness, poor attention span, poor concentration, poor insight and poor judgement. The patient's fall risk score was 25 with "10" scored for Gait/Transferring (10 score - Weak) and "0" scored for Mental status (0 score - Oriented to own ability), even though the nurse documented the patient had poor attention span, poor concentration, poor insight and poor judgement.

1/4/17 at 10:45 AM, the nurse documented the patient was ambulating in the hallway with slow, uneven gait and was assisted by the MHT.

Review of the In-Patient Physical Therapy (PT) Session Note dated 1/4/17 at 2:47 PM revealed the PT documented, "... Patient agreeable to treatment, but demonstrated increased fatigue, increased need for assist with transfers. Patient required mod / max (moderate/maximum) assist for transfers this pm, and though performed multiple times, was unable to fully complete transfers and let go of chair..."

1/4/17 at 7:48 PM, the nurse documented the patient had generalized weakness, poor attention span, poor concentration, poor insight and poor judgement. The patient's fall risk score was 25 with "10" scored for Gait/Transferring (10 score - Weak) and "0" scored for Mental status (0 score - Oriented to own ability), even though the nurse documented the patient had poor attention span, poor concentration, poor insight and poor judgement.

1/5/17 at 8:58 AM, the nurse documented the patient's fall risk score was 25 with "10" scored for Gait/Transferring (10 score - weak) and "0" scored for Mental status (0 score - Oriented to own ability), even though the nurse documented the patient was oriented to person, had poverty of speech, poor attention span, poor insight and poor judgement.

1/5/17 at 9:34 AM, the nurse documented, "Techs point out to nurse that patient has an open area behind (his/her) left ear. Tech states that open area was noted and reported yesterday..."

Review of the In-Patient Physical Therapy (PT) Session Note dated 1/5/17 at 2:47 PM revealed the PT documented, "... Continues to gaze downward 90%..."

1/5/17 5:37 PM, the nurse documented, "... Patient irritable with staff when attempting to get patient to ambulate to the dayroom to eat (his/her) evening meal..."

1/5/17 ay 8:35 PM, the nurse documented the patient's psychomotor behavior was slowed, had generalized weakness, poverty of speech, poor insight and poor judgement. There was no documentation of a fall risk assessment for 1/5/17 evening shift (7 PM to 7 AM).

1/6/17 at 7:43 AM, the nurse documented the patient's fall risk score was 25 with "10" scored for Gait/Transferring (10 = weak) and "0" scored for Mental status (0 score - Oriented to own ability), even though the nurse documented the patient's psychomotor behavior was slowed, had poor concentration, poor attention span, disorganized thoughts, poor insight and poor judgement.

Review of the In-Patient Physical Therapy (PT) Session Note dated 1/6/17 at 3:30 PM revealed the PT documented, "... Patient with limited treatment this date due to fatigue..."

1/6/17 at 7:13 PM, the nurse documented the patient's fall risk score was 15 with "0" scored for Gait/Transferring (0 score - Normal/Bedrest/Immobile) and "0" scored for Mental status (0 score - Oriented to own ability), even though the nurse documented the patient had limited movement of extremities, disorganized thoughts, poor insight and poor judgement.

1/7/17 at 10:07 AM, the nurse documented the patient was confused and bruising was noted to the left eye.

1/7/17 at 10:07 AM and amended at 10:09 AM, the nurse documented the patient's fall risk score was 40 with "10" for Gait/Transferring (10 = weak) and Mental status "15" (15 = forgets limitations). The patient's fall risk assessment score was moderate risk (25-44 score). The nurse documented, "All Standard Interventions initiated..." The nurse documented the patient's psychomotor behavior was slowed, had disorganized thoughts, poor insight and poor judgement.

1/7/17 at 2:45 PM, the nurse documented the patient was confused and was ambulating in the hallway with nurse. On 1/7/17 at 5:25 PM, the nurse documented the patient continued to be confused, needs assistance with ambulation and with meals.

1/7/17 at 11:08 PM, the nurse documented the patient's fall risk score was 40 with "10" for Gait/Transferring (10 = weak) and Mental status "15" (15 = forgets limitations). The patient's fall risk assessment score was moderate risk (25-44 score). The nurse documented the patient's psychomotor behavior was slowed, had poor concentration, poor insight and poor judgement.

1/8/17 at 9:30 AM, the nurse documented the patient's fall risk score was 40 with "10" for Gait/Transferring (10 = weak) and Mental status "15" (15 = forgets limitations). The patient's fall risk assessment score was moderate risk (25-44 score). The nurse documented the patient's psychomotor behavior was slowed, had generalized weakness, poor insight and judgement. The nurse further documented the patient required assistance with all ADLs (Activities of Daily Living), ambulates slowly with assistance and his/her head was hanging down.

1/8/17 at 6:53 PM, the nurse documented the patient's fall risk score was 40 with "10" for Gait/Transferring (10 = weak) and Mental status "15" (15 = forgets limitations). Fall risk assessment score - moderate risk (25-44 score). The nurse documented the patient's psychomotor behavior was slowed, had generalized weakness, poor insight and poor judgement.

1/9/17 at 8:55 AM, the nurse documented the patient's fall risk score was 40 with "10" for Gait/Transferring (10 = weak) and Mental status "15" (15 = forgets limitations). Fall risk assessment score - moderate risk (25-44 score). The nurse documented the patient had generalized weakness, poor concentration, attention span, insight and poor judgement.

Review of the In-Patient PT Session Note dated 1/9/17 at 3:18 PM, the PT documented, "... Patient demonstrated decreased attention to task and participation this date... Patient unable to perform out of bed activity this date..."

1/9/17 at 7:00 PM, the nurse documented the patient's fall risk score was 40 with "10" for Gait/Transferring (10 = weak) and Mental status "15" (15 = forgets limitations). Fall risk assessment score - moderate risk (25-44 score). The nurse documented the patient had disorganized thoughts, poor insight and poor judgement.

1/10/17 at 8:46 AM, the nurse documented the patient's fall risk score was 40 with "10" for Gait/Transferring (10 = weak) and Mental status "15" (15 = forgets limitations). Fall risk assessment score - moderate risk (25-44 score). The nurse documented the patient walks occasionally, had slightly limited mobility, had disorganized thoughts, poor insight and poor judgement.

1/10/17 at 9:33 PM, the nurse documented the patient's fall risk score was 40 with "10" for Gait/Transferring (10 = weak) and Mental status "15" (15 = forgets limitations). Fall risk assessment score - moderate risk (25-44 score). The nurse documented the patient was confused, disoriented, walked occasionally, had slightly limited mobility, disorganized thoughts, poor insight and poor judgement.

Review of the In-Patient Physical Therapy Session Note dated 1/11/17 at 2:47 PM, the Licensed Physical Therapy Assistant (LPTA) documented, " (Patient) stated... back hurt after ambulation 100 feet with (aide) x (times) 1..."

1/11/17 at 7:30 AM and 7:43 PM, the nurses documented the patient's fall risk score was 40 with "10" for Gait/Transferring (10 = weak) and Mental status "15" (15 = forgets limitations). Fall risk assessment score - moderate risk (25-44 score). The nurse documented the patient was confused, disoriented, walked occasionally, had slightly limited mobility, disorganized thoughts, poor insight and poor judgement.

Review of the Chest x-ray report dated 1/11/17 revealed severe osteoporosis and kyphosis, development of an interval compression fracture at L1 (lumbar spine) which was 90% compressed. This was not present in October 2016, but the radiologist was unable to determine when it occurred and recommended a CT (Computed Tomography) scan. This report was transcribed on 1/11/17 and signed by the radiologist on 1/12/17 at 9:59 AM.

1/12/17 7:30 AM, the nurse documented the patient's fall risk score was 40 with "10" for Gait/Transferring (10 = weak) and Mental status "15" (15 = forgets limitations). Fall risk assessment score - moderate risk (25-44 score). The nurse documented the patient was confused, disoriented, walked occasionally, had slightly limited mobility, disorganized thoughts, poor insight and poor judgement.

Review of the {Employee Identifier (EI) # 7} Social Worker (SW) /Case Manager (CM) Progress Notes revealed on 1/12/17 at 3:30 PM, a phone call was made to inform the patient's daughter of the results of the chest x-ray and CT (Computerized Tomography) of the head. The facility was trying to have a CT scan of the patient's back, as the chest x-ray revealed compression fractures since last chest x-ray (10/10/16) was completed.
VIOLATION: PATIENT SAFETY Tag No: A0286
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility policy, medical record, Submission Management - Patient Safety Organization reports and interviews with facility staff, it was determined the facility failed to ensure incident reports were completed for 2 of 25 records reviewed and failed to update the policy related to the incident reporting system. This affected Patient Identifier (PI) # 1, a patient who experienced unexplained injuries and PI # 12, a patient who sustained a skin tear to the right upper arm on 2/2/16 and an incident report was not completed until 2/6/17 when family concerns were brought to the attention of Employee Identifier (EI) # 7, Social Worker. This also has the potential to negatively affect all patients admitted to this facility.

Findings include:

Policy: Quality Assurance Report Report of Occurrence
Revised: May 16, 2016

Purpose:
Quality Assurance (QA) Occurrence Reporting contributes to the maintenance of a safe environment. Documented occurrences are reviewed and analyzed for development of loss prevention measures and process improvement action under the aspects of QA Laws within the State of Alabama...

Objectives:

1. To document all occurrences involving patients...
2. To assist Quality/Risk Management in the identification of occurrence-prone areas or possible performance improvement opportunities.
4. To comply with regulatory standards.

Policy/Procedure:

1. The report must be completed as soon after the occurrence as possible, but no later than the end of the shift in which the occurrence happened or was discovered.

3. The QA Director/... CNO (Chief Nursing Officer), or Administrator should be notified immediately of all incidents having potential liability.

Patient Occurrence and Unsafe Conditions:

5. Examples: Any occurrence tied to a patient account number... Fall, Patient Injury... Skin Tear/Laceration...

For occurrences involving patients:

1. The attending physician and the appropriate supervisor must be notified of the occurrence when applicable.


1. PI # 1 was admitted to the facility on [DATE] with diagnoses including Schizoaffective disorder bipolar type, Diabetes and Arterial Hypertension.

Review of the Nursing Patient Progress Note dated 1/1/17 at 6:19 PM and amended at 6:20 PM revealed the nurse documented the patient had bruising with swelling noted above the left eye and the patient had been in the day room with the mental health technicians (MHT) since breakfast. There was no documentation the nurse notified the physician of the bruising and swelling above the patient's left eye.

Review of the Nursing Patient Progress Note dated 1/3/17 at 8:28 PM revealed the nurse documented, "... Discussion with pts (patient's) daughter revealed information concerning how pt received bruise to left eye area. Pt daughter states, "At my last visit, the mop handle from cleaning cart fell over and hit (patient) in the eye. (Patient) said (he/she) was ok so I didn't think anything about it. Pt eye bruised on lid area. Pt denied pain or problems with vision..."

Review of the Nursing Patient Progress Note dated 1/5/17 at 9:34 AM revealed the nurse documented, "... Techs point out to nurse that patient has an open area behind (his/her) left ear. Tech states that open area was noted and reported yesterday..."

During an interview conducted on 1/25/17 ay 7:15 AM with Employee Identifier (EI) # 8, MHT, it was determined PI # 1 was in the presence of EI # 8 taking a shower. After the shower was completed, EI # 8 turned her back and called out to the nurse for ointment for the patient's bottom and she heard the patient moan. When she turned around, the patient was sitting on the floor. EI # 8 alleges EI # 9, Registered Nurse (RN) assisted her to stand the patient back up. EI # 8 stated this unwitnessed fall occurred on 1/3/17.

An interview was conducted on 1/25/17 at 2:10 PM with EI # 9, RN. The surveyor asked what she recalled about the incident when the patient fell in the shower. EI # 9 stated she was not made aware of the patient falling in the shower on 1/3/17. EI # 9 stated EI # 8, MHT asked EI # 9 to bring the patient's ointment for the patient's bottom, which she took down to the shower room for EI # 8. EI # 9 stated when she entered the shower room, she observed the patient was standing up holding onto the grab bar. The patient was agitated and babbling. The shower room was lined with towels and blankets to cover the floor and were not in disarray. EI # 9 stated both she and EI # 8 assisted the patient to turn and sit in the wheelchair. EI # 9 stated if she had known the patient fell , she would have completed an incident report.

An interview was conducted on 1/26/17 at 12:00 PM with EI # 1, Director of Quality/Risk Manager. The surveyor asked EI # 1 if incident reports had been completed for PI # 1. EI # 1 stated she had completed 2 incident reports after finding out none had been completed. She stated 1 report had been completed for the patient's fall and the second report was completed for unsafe environment, both of which were completed on 1/26/17.

EI # 1 explained the process for submitting, investigating and resolution of incidents as follows: Incident reports are filed electronically and department heads can pull them and see what has occurred. Then they are discussed in weekly nurse managers meeting. The nurse managers complete the investigation and report back to either EI # 1 or EI # 6, Director of Nursing (DON) and we decide what needs to be done, implement it and report to Quality Assurance committee.

When questioned about the incident reporting system, EI # 1 stated in October 2016 they implemented a new computer system for incident reporting. She stated the reporting system does not send an alert to each department. "It's up to everyone to go in daily and check the reports".

EI # 1 verified the policy for incident reporting, investigation and resolution has not been updated to reflect the new system.

An interview was conducted on 1/27/17 at 1:05 PM with EI # 10, MHT who stated EI # 8 took the patient to the shower room. He stated he was with another patient at the time. He denied seeing the patient fall, but heard the patient yell out with a loud moan. He stated he went to investigate and when he arrived, the patient was standing up. EI # 10 stated no one else was in the room except the patient and EI # 8.

Review of the Submission Management - Patient Safety Organization reports dated 12/22/16 to 1/19/17 revealed no documentation incident reports were completed for PI # 1.

2. PI # 12 was admitted to the facility on [DATE] with diagnoses including Alzheimer's dementia with behavioral disturbance and Neurocognitive disorder due to Alzheimer's dementia.

Review of the History and Physical dated 1/25/17 revealed the patient's present illness included, "... (patient) has become very aggressive... has spit at (spouse) over the last few days... also demanded to have a shower despite being in a wheelchair... is unable to do so... refuses assistance with (his/her) care and because of that... has actually fallen on one occasion and EMTs (Emergency Medical Technicians) had to be called to evaluate (him/her)..."

The patient was placed on 1:1 observations at the time of admission.

Review of the Patient Progress Notes dated 2/2/17 at 7:55 PM and amended on 2/3/17 at 12:36 AM, 12:40 AM and at 12:50 AM, revealed the nurse documented, "... bruising to bilateral upper and bilateral lower extremities, skin tear to right upper arm while bathing patient, cleaned with soap and water, steri strips applied, wrapped with gauze. Pictures taken and wound chart opened. Supervisor notified. Pictures taken of right lower extremity bruising. Line noted that appears to be area that could possibly split open..."

Review of the Patient Safety Organization - Patient Safety Work Product - Event Submission Report dated 2/6/17, which was completed by Employee Identifier (EI) # 7, Social Worker revealed the incident report was of a skin tear to the right upper arm while the patient was getting a bath. The date of the event was, "unknown" and there was no documentation of who reported the event.

Review of the documentation related to the above incident revealed the patient's son voiced a complaint to EI # 2, Program Director New Day Behavioral on 2/6/17 at 10:30 AM who had concerns about the patient having received a skin tear with bruising that the family was not aware of and wanted an investigation. This was reported to Quality and an investigation was initiated. Interviews were conducted with staff present on 2/2/17. Through those interviews, it was determined the patient sustained the skin tear while being transferred from chair to bed. The MHTs notified the nurse, care was implemented, Nursing Supervisor and Certified Registered Nurse Practitioner were contacted. The family was not notified.

These findings were discussed with the patient's daughter and attempts were made to contact the patient's son and the facility ultimately was able to talk with him.

On 2/22/17 at 12:20 PM an interview was conducted with EI # 7, Social Worker who stated the day she completed the incident report, the family had visited the patient and they were upset about the patient's bruising and skin tear. She stated the incident occurred a couple of days prior when the patient fell in the shower. EI # 7 verified she reported all of this to EI # 2.
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
Based on review of medical records, facility policy, employee files and interviews with employees in the New Day Behavioral Health unit, it was determined the Registered Nurse (RN) failed to make the shift assignments for unlicensed nursing personnel in the adult and geriatric area. The RN failed to ensure assignments were made to employees who had completed orientation.

This affected the adult and geriatric units for the psychiatric program and had the potential to negatively affect all patients served by the facility. This affected 1 of 25 records reviewed, including Patient Identifier (PI) # 8.

Findings include:

Policy: Observation Rounds, Patient
Revised Date: 9/8/12

Purpose:
To ensure patient safety and accountability.

Procedure:
The charge nurse will make patient assignments every shift.

Orientation Policy:
Purpose: Employees must be able to demonstrate the knowledge and skills necessary to provide care appropriate to the age of the patients on his or her assigned unit. The individual must demonstrate knowledge of the principles of growth and development over the life span... The skills and knowledge needed to provide such care will be gained through education, training and experience and will be evaluated at the time of the staff member's orientation to his or her position...

Policy:
1. Staff members will receive general orientation prior to department specific orientation in assigned areas.

2. Length of departmental-specific orientation will be determined by Managers after consulting with preceptor and new employee...


During the onsite survey to investigate a patient care complaint regarding nursing services the survey team conducted confidential employee interviews with nurses and MHT (Mental Health Technicians).

In an interview on 1/26/17 at 7:40 AM Employee Identifier (EI) # 12, MHT was asked to describe how shift assignments are determined. EI # 12 stated, "the MHT's completing the shift pass their boards on to the on coming MHT."

In an interview on 1/26/17 at 8:45 AM EI # 13, LPN (Licensed Practical Nurse) was asked to describe how shift assignments are determined. EI # 13 stated, "sometimes the nurse does, but the techs (MHT) will all tell the nurses who they are going to take."

In an interview on 1/26/17 at 11:00 AM EI # 5, Nurse Manager was asked to describe how shift assignments are determined. EI # 5 stated "We have shift assignment sheets and the Registered Nurse (RN) and Licensed Practical Nurse (LPN) do the assignments for the MHTs."

In an interview on 1/27/17 at 8:00 AM EI # 2, Program Director, New Day Behavioral was asked to describe how shift assignments are determined on each unit within the New Day Behavioral areas. EI # 2 stated, "The RN's or the nurses are suppose to assign patients during report."





Employee Identifier (EI) # 18, Mental Health Technician (MHT) was hired 1/31/17 to work on the Geriatric Psych Unit.

A review of the Observation Documentation form used by the MHT to document every 15 minute observations and 1:1 observations were conducted 2/21/17 for Patient Identifier (PI) # 8.

PI # 8 was admitted to the Geriatric Psych Unit 2/6/17 at 7:30 PM with diagnoses of Vascular Dementia with Behavioral Disturbances.

EI # 18 documented on the patient from 7:15 PM through 11:30 PM on 2/7/17, then resumed documentation and 1:1 care on 2/8/17 at 12:00 Midnight through 2/8/17 at 7:15 AM, except for the time of 2:15 AM until 2:30 AM.

There was no documentation EI # 18 was with an assigned preceptor, no co-signing of the documentation or any indication EI # 18 was not responsible for PI # 8 during the hours covered.

In an interview 2/22/17 at 9:40 AM with EI # 18 the orientation process was discussed. He stated that he was suppose to shadow another employee for about a week and then he started being responsible for some patients. He went on to say that he would be out of orientation Friday 2/24/17. This would complete 4 weeks of orientation. EI # 18 was assigned to provide care for PI # 8 on 2/7/17, a patient who had just fallen in the shower and was placed in a geri-chair on 1:1 observation for the remainder of EI # 18's shift.

A review of the personnel file for EI # 18 included a New Employee Orientation completed 2/13/17, 7 pages of education and observation of demonstration to verify skills for new employees. The form included a self evaluation section that EI # 18 completed in the section by initialing Can Perform Safely/ Demo/ Verbalize. EI # 18 failed to mark Demo or Verbalize.

The peer reviewer section was initialed by a nurse under the section Discussed or Demonstrated but the reviewer failed to mark whether EI # 18 discussed or demonstrated.

In an interview 2/22/17 at 2:30 PM with EI # 1, Director of Quality the above information was confirmed and was not completed appropriately.
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
Based on review of the MHT (Mental Health Technician) documentation form, facility policies, employee time sheets and interviews with the staff, it was determined the facility failed to ensure the staff completed accurate documentation every 15 minutes without falsification of the medical record. This affected 8 of 8 Observation documentation sheets and did affect PI (Patient Identifier) # 1, PI # 19, PI # 20, PI # 21, PI # 22, PI # 23, PI # 24, PI # 25 and had the potential to negatively affect all patients served by the facility.

Findings include:

Policy: Staffing-Nursing Levels of Observation
Revised: 9/16/2012

Observations and Precautions, New Day Behavioral Health

Purpose:
To outline the levels of observation and types of precautions used on behavioral health services based on assessed risk to assure patient safety.

Policy:
The safety of patients is a priority during hospitalization . The behavioral health inpatient program ensures the safety of the patients through a level of monitoring and observation matched to the patient's need and based on assessed risk...

Setting Levels of Observation:
Assessment and Determination of Need:

G. The Charge RN (Registered Nurse) is responsible for assuring that all patient observations are completed and documented by a member of the nursing staff.
a. A patient check is visual identification of the patient with his/her location and observable behavior.
b. Patient checks are assigned to specific staff members for specific time periods on each shift. The staff person assigned to these checks is responsible for circulation continuously on the unit for the assigned time period.
c. The assigned staff records the patient's location and behavior on the patient check sheet at the time the patient check is done.

Review of the Observation documentation sheets dated 12/30/16 revealed the following PI's were documented as having been observed every 15 minutes by the MHT: PI # 19, PI #20, PI # 21 and PI # 22. Further review revealed Employee Identifier (EI) # 14, MHT documented he/she observed the above patients on 12/30/16 at 4:45 PM and 5:00 PM

Review of the time sheet for EI # 14 dated 12/30/16 revealed EI # 14 clocked out at 4:39 PM and clocked back in to work at 5:08 PM.

Review of the Observation documentation sheets dated 1/3/17 revealed the following PI's were documented as having been observed every 15 minutes by the MHT: PI # 1, PI # 23, PI # 24 and PI # 25. Further review revealed Employee Identifier (EI) # 14, MHT documented she observed the above patients on 1/3/17 at 11:45 AM, 12:00 PM and 12:15 PM.

Review of the time sheet dated 1/3/17 revealed EI # 14 clocked out at 11:32 AM and clocked back in at 12:16 PM.

Further review of the time sheets and the Observation documentation sheets dated 12/30/16 and 1/3/17 revealed EI # 14 was not on the time clock at the documented times listed above and was unable to observe any of the above patients on the New Day Behavioral Unit.

An interview was conducted on 1/25/17 at 12:45 PM with EI # 14 during the investigation of the complaint by the surveyors. EI # 14 was asked to tell the surveyors the reason he/she clocked out at 4:39 PM and back in at 5:08 PM on 12/30/16. EI # 14 responded by saying, "I had to go home because the water pipe in the bathroom burst. I clocked out in the morning it was early like 8:00 or 9:00 AM or something. I don't know why I clocked out at 4:39 PM and back in at 5:08 PM. I left early in the morning."

The surveyors asked EI # 14, what was the reason she clocked out at 11:32 AM and back in at 12:16 PM on 1/3/17? EI # 14 stated she probably went to lunch. She stated she called the supervisor to let them know and the nurses and MHT's knew. She stated she could not recall the reason she clocked out on 1/3/17.

The Observation documentation sheets were shown to EI # 14, who verified the signature as hers. The surveyor asked EI # 14, "How can you do 15 minute observations if you were not here?" EI # 14 responded, "I don't know. I don't know. I just don't know, I don't know what happened. Maybe my board wasn't caught up I don't know. When I clock out they put someone in my place so I don't know."

Review of the staffing sheet dated 12/30/16 revealed EI # 15, RN worked on the day shift in New Day Behavioral Unit.

A confidential interview was conducted on 1/26/17 at 9:40 AM with EI #15. During the interview, EI # 15 was asked the question: on 12/30/16 do you recall any one leaving the unit? EI # 15 responded "I don't remember. If they leave the building they have to clock out and in and if it's a MHT; then the other MHT's cover for the one leaving."

Review of the staffing sheet dated 1/3/17 revealed EI # 16, RN worked the morning shift on the Geri-Psychiatric side of the New Day Behavioral Unit.

An interview was conducted on 1/26/17 at 8:10 AM with EI # 16 and the surveyor asked the question: What do the MHT's do if they leave the building for lunch? EI # 16 replied "They tell the supervisor and have the other techs watch their patients while they are gone". The surveyor then asked if she recalled someone telling her they were leaving the floor for lunch on 1/3/17? EI # 16 responded "I do not remember"

On 1/26/17 at 8:20 AM, an interview was conducted with EI # 17, RN Nursing Supervisor. The surveyor asked EI # 17 the question: Do you remember anyone telling you they were leaving the building on 12/30/16. EI # 17 responded, "I do not recall that. It happens only occasionally, not that often. We do not document it anywhere. They have to tell their charge nurse and if they are doing 1 to 1 they have to have another MHT cover their patient. I think there may have 3 times this year that occurred but I do not know what days. I couldn't begin to guess what days."

An interview was conducted on 1/26/17 at 11:00 AM with EI # 5, Nurse Manager of the New Day Behavioral Unit. During the interview EI # 5 was asked if a MHT leaves the unit for any reason what occurs? EI # 5 responded by saying, "when a tech (MHT) leaves the unit, that tech has another tech watch their patients and the tech that takes over is the one that does the documentation on the MHT documentation form during that time."
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
Based on observations, review of Dale Medical Center's corrective action plan submitted to the surveyors and interviews with facility staff, it was determined the facility failed to ensure the shower area in the isolation room was maintained in a safe manner, locked and unaccessible to patients when not in use. This has the potential to negatively affect all patients admitted to New Day Behavioral Health unit.

Findings include:

A tour of the Geriatric Psych Unit of New Day Behavioral Health unit was conducted 2/21/17 at 12:30 PM by the surveyors. During the tour Employee Identifier (EI) # 2, Program Director and EI # 3, RN (Registered Nurse) Supervisor accompanied the surveyors. A review of the restraint/seclusion room revealed in the ante room a handicapped bathroom was available for staff to bring patients to bathe on the handicapped bench seat for safety. The door to this room was not locked and the door did not have a lock on it for use by the staff for safety to prevent patients from wandering into the bath area.

The bathroom had an elevated area where the bench was placed and a long curled hose to enable staff to spray and wash the patients. This bathroom was the documented area of several falls. The long curled hose presented a hanging risk for depressed or suicidal patients.

An interview was conducted on 1/25/17 at 7:15 AM with Employee Identifier (EI) # 8, Mental Health Technician (MHT). EI # 8 stated on 1/3/17 she took Patient Identifier (PI) # 1 to get a shower in the shower room. She stated she went to the door to ask the nurse for the patient's ointment for his/her bottom. EI # 8 stated she heard the patient moan and when she turned around, she saw the patient sitting on the floor. EI # 8 stated that EI # 9, Registered Nurse (RN) helped her get the patient up off the floor.

An interview was conducted on 1/25/17 at 2:10 PM with EI # 9, RN. When questioned what she recalled about the patient falling in the shower, EI # 9 stated she was not made aware the patient had fallen. She stated EI # 8 was in the shower room and requested for her to bring the patient's ointment. EI # 9 stated she went to the nurses station, obtained ointment and went to the shower room. She stated the patient was agitated and babbling something EI # 9 could not understand. EI # 9 stated the patient was standing up holding onto the rail. EI # 8 was explaining to the patient that he/she was holding onto the rail. EI # 9 stated she and EI # 8 assisted the patient to turn and sit in the wheelchair. EI # 9 stated she was not made aware the patient had fallen.

An interview was conducted on 1/27/17 at 1:05 PM with EI # 10, MHT. EI # 10 verified he was with another patient on 1/3/17. EI # 10 stated he heard the patient yell out with a loud moan. He stated when he heard the patient, he went to assist. EI # 10 stated once he arrived in the shower room, he observed that the patient was standing up. When questioned who was in the shower room, EI # 10 stated PI # 1 and EI # 8. He stated that when he was going down the hall, EI # 9, RN was coming down the hall with the patient's ointment for the patient's bottom. He stated when they entered, EI # 8 had the patient standing up.

In an interview with EI # 8, Mental Health Technician (MHT) on 2/22/17 at 7:20 AM, it was revealed that at times the patients might bathe in their rooms, but generally they either give them a bed bath or take them to the shower. EI # 8 confirmed she was with Patient Identifier (PI) # 8 on 2/7/17 when he/she fell . EI # 8 stated that he/she fell backward trying to get up over the lip into the shower, they had given him/her a walker to use and he/she was not familiar with it.

In an interview with EI # 19, RN on 2/22/17 at 7:45 AM, it was revealed that it is rare for a patient to bathe in the bathroom in their room, they usually go down to the shower room with the bench. EI # 19 confirmed patients are left alone in the shower room and that they are not always observed.

On 2/23/17 at 9:40 AM, the surveyors again toured the Geriatric Psych Unit of New Day Behavioral in the presence of EI # 2, Program Director and EI # 3 RN Supervisor. During this tour, the surveyors observed the shower area located in the ante room of the seclusion room. The surveyors observed the door to the ante room was not locked and did not have a lock in place for the staff to lock the door when not in use. The shower was handicap accessible with a small ramp into the shower. There were open grab bars on the three sides of the shower and a long shower hose approximately 4 feet in length.

During the above tour, both EI # 2 and EI # 3 verified the staff did not have the ability to lock the ante room, but a lock had been ordered for the door.

Review of the plan submitted to the surveyors on 2/24/17 by the Chief Executive Officer (CEO) and Chief Nursing Officer (CNO) revealed the following plan was implemented to address the unlocked, unsafe shower room:

"... 3. The shower room on geri side has a coded key pad placed today but will remain locked and not used for patient care until cleaning policy revised for multiple patient use and staff training completed on ADL (Activities of Daily Living) Patient Care to begin on 2/27/17 and completed no later than 30 days. A Shower Commode Chair had been ordered and will be used for safe transfers and showering of patients at high risk for falls. Non skid strips will be added to the shower floor as an additional safety measure..."
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on review of Psych Department/ Daily Staffing Grid, Supervisor staffing sheet, facility policies, medical records, Dale Medical Center's corrective action plan submitted to the surveyors and interviews with facility staff, it was determined the facility failed to follow the staffing grid to ensure the Psychiatric Units were staffed.

This has the potential to negatively affect all patients admitted to the Psychiatric Units.

Findings include:

Policy: Observation Levels
Reference # 8002
Revised: 9/8/2012

Purpose:
To ensure patients are observed at the appropriate level for optimum safety.

Procedure:
All patients will be assessed by nursing staff for level of observation required at a minimum of every shift.

All patients on the Behavior Health Unit shall be observed at a minimum of every 15 minutes.

15 minutes observation: Level II
This is restrictive toward the patient and involves continuous monitoring every 15 minutes and documentation on the Observation Documentation Record indicating the patient's location.

1 to 1 observation at all times: Level I

This is the most restrictive toward the patient and involves continuous monitoring and physical proximity to the patient at all times. Staff shall be within arm's reach at all times, including toileting and showering. Nursing personnel shall document on the Observation Documentation Record indicating the patient's location every 15 minutes. Patients on this level are considered highest risk...

Policy: Observation Rounds, Patient
Reference # 3023
Revised 9/8/12

Purpose:
To ensure patient safety and accountability.

Policy:
An accurate record of the whereabouts of all patients on the Behavioral Health Unit will be maintained during each shift.

Every patient should be seen by a staff member every 15 minutes and checked off on the Observation Sheet as to their location.

The Adult psychiatric unit has a maximum of 13 patient beds available. The Geri-psychiatric unit has a maximum of 12 patient beds available. The Staffing Grid is designed to increase the total number of staff members, including nurses and MHTs according to the increase in patient census. An RN is required to be assigned to New Day Behavioral units for each shift.

Review of the Staffing Grid for New Day Behavioral Health unit, which was provided to the surveyors revealed the following required staff:

Adult unit: 7 AM to 7 PM Shift: For a Census of 6 Patients - 1- RN (Registered Nurse), 1 - MHT (Mental Health Tech)
Adult unit: 7 PM to 7 AM Shift: For a Census of 6 Patients - 1- Float RN, 1- RN/LPN (Licensed Practical Nurse), 1- MHT

Geri unit: 7 AM to 7 PM Shift: For a Census of 6 Patients - 1- RN, 2 - MHT
Geri unit: 7 PM to 7 AM Shift: For a Census of 6 Patients - 1 RN/LPN and 2 MHT

Adult unit: 7 AM to 7 PM Shift: For a Census of 7 to 12 Patients - 1- RN, 1 - LPN and 2 - MHT
Adult unit: 7 PM to 7 AM Shift: For a Census of 7 to 12 Patients - 1- Float RN, 1- RN/LPN and 2- MHT
Geri unit: 7 AM to 7 PM Shift: For a Census of 7 to 12 Patients - 1- RN, 1 - LPN and 2 - MHT
Geri unit: 7 PM to 7 AM Shift: For a Census of 7 to 12 Patients 1 RN/LPN and 2 MHT

Adult unit: 7 AM to 7 PM Shift: For a Census of 13 Patients - 1- RN, 1 - LPN and 2 - MHT
Adult unit: 7 PM to 7 AM Shift: For a Census of 13 Patients - 1- Float RN, 1- RN/LPN and 2- MHT

Staffing for all 1:1 (one to one). One MHT for each 1:1 patient in unit.

1. Review of the Census for 12/17/16 revealed 9 patients on the Geri unit for both 7 AM to 7 PM (7 AM) and 7 PM to 7 AM (7 PM) shifts. There were (2) 1:1 patients which requires 1 MHT per patient at arms length and 1 level 2 patient which requires the patient to be in constant view of employee.

Review of the Supervisor staffing sheet for the Geri unit dated 12/17/16 revealed 2 LPNs on the 7 AM shift. The staffing grid requires 1 RN and 1 LPN for the 7 AM shift.

Review of the 7 PM shift for the Geri unit revealed 2 MHTs scheduled. The staffing grid requires 2 MHTs for a census of 9 patients and 2 additional MHTs for the (2) 1:1 patients. Staffing requirements for the Geri unit were not met.

2. Review of the census for 12/27/16 revealed 10 patients on the Geri unit for the 7 PM shift with (2) - 1:1 patients and (4) level 2 patients.

Review of the Supervisor staffing sheet dated 12/27/16 for the Geri unit revealed 2 MHTs with one float MHT from the adult unit to the Geri unit for a total of 3 MHTs on the 7 PM shift. The staffing grid requires 2 MHTs for a census of 10 and 2 additional MHTs for the (2) - 1:1 patients. The staffing requirements were not met on the Geri unit.

Review of the census for 12/27/16 for the Adult unit revealed 11 patients on the 7 AM shift and 10 patients on the 7 PM shift.

Review of the Supervisor staffing sheet for the Adult unit dated 12/27/16 revealed 2 LPNs on the 7 AM shift, 1 MHT to float to ICU and 1 MHT on the Adult unit. The staffing grid requires 1 RN, 1 LPN and 2 MHTs for a census of 11.

3. Review of the census for 12/29/16 for the Geri unit revealed 12 patients on both the 7 AM with (2) 1:1 patients and 5 level 2 patients.

Review of the Supervisor staffing sheet dated 12/29/16 for the Geri unit revealed 3 MHTs for the 7 AM shift. The staffing grid requires 2 MHTs for a census of 12 patients and 2 additional MHTs for the (2) 1:1 patients. Staffing requirements for the Geri unit were not met.

4. Review of the census for 12/30/16 for the Geri unit revealed 12 patients on both the 7 AM and the 7 PM shifts with (2) 1:1 patients and 5 level 2 patients on both shifts.

Review of the Supervisor staffing sheet dated 12/30/16 for the Geri unit revealed 3 MHTs scheduled for the Geri unit on the 7 AM shift. The staffing grid requires 2 MHT's for a census of 12 patients and 2 additional MHTs for the (2) 1:1 patients.

Review of the 7 PM Supervisor staffing sheet for the Geri unit revealed 3 MHTs were scheduled, one of which floated to the Geri unit from the Medical/Surgical unit and was a PCA (Patient Care Assistant). The staffing grid requires 2 MHTs for 12 patients and 2 additional MHTs for the (2) 1:1 patients. Staffing requirements were not met for either shift on the Geri unit.

5. Review of the census for 12/31/16 for the Geri unit revealed 11 patients for the 7 PM shift with (2) 1:1 patients and 5 level 2 patients.

Review of the Supervisor staffing sheet dated 12/31/16 for the Geri unit revealed 3 MHTs to work the 7 PM shift.

The staffing grid requires 2 MHTs for a census of 11 patients and 2 additional MHTs for the (2) 1:1 patients. Staffing requirements were not met for the 7 PM shift on the Geri unit.

Review of the census for 12/31/16 for the Adult unit revealed 12 patients for the 7 AM shift with no 1:1 patients and 3 level 2 patients.

Review of the Supervisor staffing sheet dated 12/31/16 revealed 2 LPNs on the 7 AM shift in the Adult unit. The staffing grid requires 1 RN and 1 LPN on the 7 AM shift. Staffing requirements were not met for the Adult unit on the 7 AM shift.

6. Review of the census for 1/1/17 for the Geri unit revealed 11 patients on the 7 AM shift and 10 patients for the 7 PM shift with (2) 1:1 patients and 5 level 2 patients on both shifts.

Review of the Supervisor staffing for the Geri unit sheet dated 1/1/17 revealed 3 MHTs and 1 MHT from 7:00 AM until 4:00 PM on the 7 AM shift. The staffing grid requires 2 MHTs for the 11 patients and 2 additional MHTs for the entire shift for the (2) 1:1 patients. Staffing requirements were not met for the 7 AM shift.

Review of the Supervisor staffing sheet for the 7 PM shift revealed a PCA from the Medical/Surgical floor floated to the Geri unit for the 7 PM shift.

Review of the census for 1/1/17 for the Adult unit revealed 12 patients for the 7 AM shift with no 1:1 patients and (4) level 2 patients.

Review of the Supervisor staffing sheet for the Geri unit for the 7 AM shift revealed 1 LPN and 2 MHTs one of which was to float to the Geri unit. The staffing grid requires 1 RN, 1 LPN and 2 MHTs. Staffing requirements were not met for the 7 AM shift on the Adult unit.

7. Review of the census for 1/2/17 for the Adult unit revealed 12 patients for the 7 AM shift with no 1:1 patients and (4) level 2 patients.

Review of the Supervisor staffing sheet for the Adult unit dated 1/2/17 for the 7 AM shift revealed 2 LPNs. The staffing grid requires 1 RN and 1 LPN. Staffing requirements were not met for the 7 AM shift on the Adult unit.

8. Review of the census for 1/3/17 for the Geri unit revealed 11 patients on the 7 AM shift and 12 patients for the 7 PM shift with (2) 1:1 patients and 6 level 2 patients on the 7 AM shift and 7 level 2 patients on the 7 PM shift.

Review of the Supervisor staffing sheet for the Geri unit dated 1/3/17 revealed 3 MHTs to work 7 AM to 7 PM and 1 MHT to work 7:00 AM to 3:00 PM. The staffing grid requires 2 MHTs for the 11 patients and 2 additional MHTs for the (2) 1:1 patients for a full shift. The staffing requirements were not met for the 7 AM shift of the Geri unit.

Review of the census for 1/3/17 for the Adult unit revealed 11 patients for the 7 AM shift with no 1:1 patients and (3) level 2 patients.

Review of the Supervisor staffing sheet for the Adult unit for the 7 AM shift revealed 2 LPNs and 2 MHTs one of which "will leave at 11:00 AM ",which then leaves 1 MHT after 11:00 AM. The staffing grid requires 1 RN and 1 LPN and 2 MHTs for 11 patients. Staffing requirements were not met for the 7 AM shift on the Adult unit.

9. Review of the census for 1/4/17 for the Adult unit revealed 9 patients for the 7 AM shift with no 1:1 patients and (2) level 2 patients.

Review of the Supervisor staffing sheet for the Adult unit dated 1/4/17 for the 7 AM shift revealed 2 LPNs and 2 MHTs. The staffing grid requires 1 RN and 1 LPN for 9 patients. Staffing requirements were not met for the 7 AM shift on the Adult unit.

10. Review of the census for 1/5/17 for the Geri unit revealed 11 patients for the 7 PM shift with (1) 1:1 patient and (8) level 2 patients on the 7 PM shift.

Review of the Supervisor staffing sheet for the Geri unit revealed 2 MHTs for the 7 PM shift which does not meet the requirements of the staffing grid of 2 MHTs for 11 patients and 1 additional MHT for the 1:1 patient. Staffing requirements for the Geri unit on the 7 PM shift were not met.

Review of the census for 1/5/17 for the Adult unit revealed 11 patients for the 7 AM shift with no 1:1 patients and 3 level 2 patients.

Review of the Supervisor staffing sheet for the Adult unit dated 1/5/17 for the 7 AM shift revealed 2 LPNs. The staffing grid requires 1 RN and 1 LPN for 11 patients. Staffing requirements were not met for the 7 AM shift on the Adult unit.

11. Review of the census for 2/2/17 for the Geri unit revealed 8 patients on the 7 AM shift and 9 patients on the 7 PM shift with (2) - 1:1 patient on both shifts and 4 level 2 patients on both shifts.

Review of the Supervisor staffing sheet for the Geri unit dated 2/2/17 revealed 3 MHTs for the 7 AM shift with one MHT orientee. The staffing grid requirements for the Geri unit were 2 MHTs for the 8 patients and 2 additional MHTs for the (2)- 1:1 patients for the 7 AM shift. Requirements for staffing on the Geri unit for the 7 AM shift were not met.

Review of the Supervisor staffing sheet for the 7 PM shift of the Geri unit revealed 1 of the staff members was a PCA from the Medical/Surgical unit.

12. Review of the census for 2/3/17 for the Geri unit revealed 9 patients on both the 7 AM shift and the 7 PM shift with (2) 1:1 patient and (4) level 2 patients on both shifts.

Review of the Supervisor staffing sheet for the Geri unit dated 2/3/17 for the 7 AM Geri unit revealed 2 MHTs, 1 MHT orientee and and 1 float monitor tech from the Intensive Care unit.

Review of the Supervisor staffing sheet for the Geri unit revealed on the 7 PM shift there was 1 Medical/Surgical Tech and 1 emergency room Tech which both floated to the Geri unit and 2 scheduled MHT's.

Review of the staffing grid revealed the requirement for a census of 9 patients requires 2 MHTs and 2 additional MHTs for the (2) 1:1 patients. Staffing requirements for the Geri unit were not met on 2/3/17.
Review of the census for 2/3/17 for the Adult unit revealed 13 patients for the 7 AM with no 1:1 patients and (8) level 2 patients.

Review of the Supervisor staffing sheet for the Adult unit dated 2/3/17 for the 7 AM shift revealed 2 LPNs were scheduled.

Review of the staffing grid revealed the requirements for the 7 AM shift for the Adult unit requires 1 RN and 1 LPN for the 13 patients. Staffing requirements were not met for the 7 AM shift on the Adult unit.

13. Review of the census for 2/4/17 for the Geri unit revealed 9 patients on the 7 AM shift and on the 7 PM shift with (2) 1:1 patient on both shifts and 4 level 2 patients on both shifts.

Review of the Supervisor staffing sheet for the Geri unit dated 2/4/17 for the 7 AM shift revealed 3 MHTs until 1:00 PM at which time one MHT left. The staffing grid requires 2 MHTs for the 9 patients and 2 additional MHTs for the (2) 1:1 patients the entire shift. Staffing requirements for the 7 AM shift were not met.

Review of the Supervisor staffing sheet for the 7 PM shift on the Geri unit revealed 2 MHTs from the New Day Behavioral Unit and 1 PCA (Patient Care Assistant) from the Medical/Surgical area and 1 MT (Monitor Tech) from the Intensive Care Unit.

Review of the census for 2/4/17 for the Adult unit revealed 13 patients for the 7 AM shift with no 1:1 patients and (7) level 2 patients.

Review of the Supervisor staffing sheet for the Adult unit dated 2/4/17 for the 7 AM shift revealed 2 LPNs. The staffing grid requires 1 RN and 1 LPN for 13 patients on the 7 AM shift. Staffing requirements were not met for the 7 AM shift on the Adult unit.

14. Review of the census for 2/5/17 for the Geri unit revealed 9 patients on both the 7 AM shift and the 7 PM shift with (2) 1:1 patients on both shifts and 4 level 2 patients on both shifts.

Review of the Supervisor staffing sheet for the Geri unit dated 2/5/17 for the 7 AM shift revealed 2 RNs from 7:00 AM until 3:00 PM and after 3:00 PM there was only 1 RN and 3 MHTs. The staffing grid requires 1 RN and 1 LPN for the entire 12 hour shift and 2 MHTs for the 9 patients with 2 additional MHTs for the (2) 1:1 patients. Staffing requirements for the 7 AM shift of the Geri unit were not met.

Review of the 7 PM Supervisor staffing sheet for the Geri unit revealed 1 RN, no float nurse and 3 MHTs. The requirements from the staffing grid require 2 MHTs for the 9 patients with 2 additional MHTs for the (2) 1:1 patients and 1 float RN. Staffing requirements were not met for the 7 PM shift.

Review of the census for 2/5/17 for the Adult unit revealed 12 patients for both the 7 AM shift and the 7 PM shift with no 1:1 patients and 8 level 2 patients on both the 7 AM shift and the 7 PM shift.

Review of the Supervisor staffing sheet dated 2/5/17 for the 7 AM shift on the Adult unit revealed 2 LPNs. The staffing grid requires 1 RN and 1 LPN for 12 patients.

Review of the Supervisor staffing sheet for the 7 PM shift revealed 1 RN and no RN float nurse. The staffing grid requires 1 float RN. Staffing requirements were not met for both the 7 AM shift and the 7 PM shift on the Adult unit.

15. Review of the census for 2/6/17 for the Geri unit revealed 9 patients on the 7 AM shift and 10 patients for the 7 PM shift with (2) - 1:1 patient on both shifts and 4 level 2 patients on the 7 AM shift and 5 level 2 patients on the 7 PM shift.

Review of the Supervisor staffing sheet for the Geri unit 7 AM shift revealed 3 MHTs and one MHT orientee. The staffing grid requires 2 MHTs for the 9 patients and 2 additional MHTs for the (2) 1:1 patients. Staffing requirements for the 7 AM shift were not met.

Review of the Supervisor staffing sheet for the Geri unit for the 7 PM shift revealed 3 MHTs and 1 PCA float from the Medical Surgical floor.

16. Review of the census for 2/7/17 for the Geri unit revealed 8 patients for the 7 PM shift with (2) 1:1 patient and (3) level 2 patients.

Review of the Supervisor staffing sheet dated 2/7/17 for the 7 PM shift on the Geri unit revealed 1 RN and 1 LPN on the Adult unit and no float RN on either the Geri unit or the Adult unit. Further review revealed 2 MHTs, 1 PCA float from Medical/Surgical floor and 1 MHT orientee. The staffing grid requires 1 RN float nurse, 1 nurse on the Geri unit and 1 nurse on the Adult unit and 2 MHTs for the 10 patients and 2 additional MHTs for the (2) 1:1 patients in the Geri unit. Staffing for the Geri unit on the 7 PM shift were not met.

Review of the census for 2/7/17 for the Adult unit revealed 13 patients for the 7 PM shift with no 1:1 patients and 7 level 2 patients.

Review of the Supervisor staffing sheet for the Adult unit dated 2/7/17 revealed 1 LPN on the 7 PM shift with no float RN. Further review of the staffing sheet revealed 1 RN from the 7 AM shift on the Adult unit was to stay for medication pass for the 7 PM shift. Staffing requirements for the Adult unit on the 7 PM shift were not met.

17. Review of the census for 2/9/17 for the Geri unit revealed 7 patients on the 7 PM shift with (1) 1:1 patient and (4) level 2 patients.

Review of the Supervisor staffing sheet for the Geri unit dated 2/9/17 for the 7 PM shift revealed 1 LPN and no float RN. The staffing grid requires 1 RN float nurse and 1 LPN or other nurse. The staffing requirements for the Geri unit 7 PM shift were not met.

Review of the census for 2/9/17 for the Adult unit revealed 13 patients for the 7 PM shift with no 1:1 patients and (7) level 2 patients.

Review of the Supervisor staffing sheet for the Adult unit dated 2/9/17 for the 7 PM shift revealed 1 RN and no float RN scheduled. Staffing requirements for the Adult unit were not met.

18. Review of the census for 2/11/17 for the Geri unit revealed 7 patients on both the 7 AM shift and the 7 PM shift with (1) 1:1 patient and 5 level 2 patients on both shifts.

Review of the Supervisor staffing sheet dated 2/11/17 for the Geri unit for the 7 AM shift revealed 1 RN and 2 MHTs.

Review of the staffing grid requires the Geri unit to have 1 RN and 1 LPN. Further review of the staffing grid revealed the Geri unit was required to have 2 MHTs for the 7 patients and 1 additional MHT for the (1) 1:1 patient. Staffing requirements for the Geri unit on the 7 AM shift were not met.

Review of the Supervisor staffing sheet for the Geri unit dated 2/11/7 for the 7 PM shift revealed 2 MHTs and 1 PCA ,which floated from the Medical/Surgical unit.

Review of the census for 2/11/17 for the Adult unit revealed 12 patients for the 7 AM shift and 11 patients for the 7 PM shift with no 1:1 patients on the 7 AM shift and (1) 1:1 patient on the 7 PM shift and 6 level 2 patients on the 7 AM shift and 5 level 2 patients for the 7 PM shift.

Review of the Supervisor staffing sheet for the Adult unit dated 2/11/17 for the 7 PM shift revealed 2 MHTs and 1 Monitor Tech from the Intensive Care Unit.

19. Review of the census for 2/12/17 for the Geri unit revealed 7 patients on both the 7 AM shift and the 7 PM shift with (1) 1:1 patient and 2 level 2 patients on both shifts.

Review of the Supervisor staffing sheet dated 2/12/17 for the 7 AM shift for the Geri unit revealed 1 RN and 2 MHTs and 1 PCA from the Medical/Surgical unit until 10:30 AM. Review of the staffing grid revealed the Geri unit is to have 1 RN, 1 LPN, 2 MHTs for the 7 patients and 1 additional MHT for the (1) 1:1 patient. Staffing requirements for the Geri unit on the 7 AM shift were not met.

Review of the Supervisor staffing sheet dated 2/12/17 for the 7 PM shift of the Geri unit revealed 2 MHTs. Review of the staffing grid revealed for a census of 7 patients and (1) 1:1 patient there should have been 2 MHTs for the 7 patients and 1 additional MHT for the (1) 1:1 patient. Staffing requirements on the 7 PM shift for the Geri unit were not met.

20. Review of the census for 2/13/17 for the Geri unit revealed 7 patients on both the 7 AM shift and the 7 PM shift with (1) 1:1 patient and 2 level 2 patients on both shifts.

Review of the Supervisor staffing sheet for the Geri unit dated 2/13/17 for the 7 AM shift revealed 1 MHTs and 1 PCA from the Medical/Surgical unit until 10:30 AM.

Review of the staffing grid revealed the Geri unit was required to have 2 MHTs for the 7 patients and 1 additional MHT for the 1:1 patient for the entire shift. Staffing requirements for the Geri unit on the 7 AM shift were not met.

Review of the 7 PM Supervisor sheet dated 2/13/17 revealed 2 MHTs for the shift. Review of the staffing grid revealed for a census of 7 patients and (1) 1:1 patient there should have been 2 MHTs for the 7 patients and an additional MHT for the (1) 1:1 patient. Staffing requirements on the 7 PM shift for the Geri unit were not met.

Review of the census for 2/13/17 for the Adult unit revealed 12 patients for the 7 AM shift with no 1:1 patients and (5) level 2 patients.

Review of the Supervisor staffing sheet for the Adult unit dated 2/13/17 revealed 1 RN to work from 7:00 AM to 3:00 PM and an LPN to work from 3:00 PM to 7:00 PM. The staffing grid for the Adult unit requires 1 RN and 1 LPN the entire 12 hour shift. The staffing requirements for the 7 AM Adult unit were not met due to no RN scheduled after 3:00 PM.

21. Review of the census for 2/14/17 for the Geri unit revealed 7 patients on the 7 AM shift and 8 patients for the 7 PM shift with (2) 1:1 patients and 1 level 2 patient on the 7 AM shift and (2) 1:1 patients and 2 level 2 patients on the 7 PM shift.

Review of the Supervisor staffing sheet dated 2/14/17 for the 7 AM shift of the Geri unit revealed 3 MHTs from 7 AM to 7 PM and 1 MHT from 4 PM to 7 PM. The staffing grid for the Geri unit requires 2 MHTs for the 7 patients and 2 additional MHTs for the (2) 1:1 patients the entire 12 hour shift. Staffing requirements for the Geri unit on the 7 AM shift were not met.

Review of the 7 PM shift revealed 2 MHTs and 1 PCA from the Medical/Surgical floor. Review of the staffing grid revealed for a census of 7 patients with (2) 1:1 patients there should have been 2 MHTs for the 7 patients and 2 MHTs for the (2) 1:1 patients. Staffing requirements on the 7 PM shift for the Geri unit were not met.

Review of the census for 2/14/17 for the Adult unit revealed 12 patients for the 7 AM shift with no 1:1 patients and (1) level 2 patient.

Review of the Supervisor staffing sheet for the Adult unit dated 2/14/17 revealed 2 LPNs on the 7 AM shift. The staffing grid requires 1 RN and 1 LPN on the 7 AM shift. Staffing requirements for the 7 AM shift of the Adult unit were not met.

22. Review of the census for 2/15/17 for the Geri unit revealed 6 patients for the 7 PM shift with (2) 1:1 patient.

Review of the Supervisor staffing for the Geri unit sheet dated 2/15/17 for the 7 PM shift revealed 1 LPN to work from 11:00 PM to 7:00 AM and no other nurse scheduled to work from 7 PM to 11:00 PM. Review of the staffing grid requires 1 RN float nurse and 1 nurse on the Geri unit. Staffing requirements on the 7 PM shift for the Geri unit were not met.

Review of the census for 2/15/17 for the Adult unit revealed 13 patients for the 7 AM shift and 11 patients for the 7 PM shift with no 1:1 patients on both the 7 AM shift and the 7 PM shift. Further review revealed 2 level 2 patient on the 7 AM shift and no level 2 patients for the 7 PM shift.

Review of the Supervisor staffing sheet for the Adult unit dated 2/15/17 for the 7 AM shift revealed 1 LPN scheduled for the Adult unit. Review of the staffing grid requires 1 RN and 1 LPN. Staffing requirements on the 7 AM shift of the Adult unit were not met.

23. Review of the census for 2/16/17 for the Geri unit revealed 6 patients on the 7 AM shift and 7 patients for the 7 PM shift with (2) 1:1 patient on the 7 AM shift and (1) 1:1 on the 7 PM shift and 2 level 2 patients on the 7 AM shift and 4 level 2 patients on the 7 PM shift.

Review of the 7 AM Supervisor staffing sheet dated 2/16/17 revealed 3 MHTs from 7 AM to 7 PM and 1 MHT from 7 AM to 3 PM. This left the unit without a 4th MHT from 3 PM to 7 PM. The staffing grid requires 2 MHTs for a census of 6 patients and 2 additional MHTs for the (2) 1:1 patients. The staffing requirements for the 7 AM shift of the Geri unit were not met.

Review of the 7 PM Supervisor staffing sheet dated 2/16/17 for the Geri unit revealed 2 MHTs scheduled for this shift.

Review of the staffing grid revealed for a census of 7 patients the requirement is 2 MHTs for the 7 patients and 1 additional MHT for the (1) 1:1 patient. Staffing requirements on the 7 PM shift for the Geri unit were not met.

24. Review of the census for 2/17/17 for the Geri unit revealed 7 patients on both the 7 AM shift and the 7 PM shift with (1) 1:1 patient and 4 level 2 patients on both the 7 AM shift and the 7 PM shift.

Review of the 7 AM and 7 PM Supervisor staffing sheet dated 2/17/17 revealed 2 MHTs scheduled for both shifts. Requirements per the staffing grid were 2 MHTs for the 7 patients and 1 additional MHT for the (1) 1:1 patient. The staffing requirements for the Geri unit were not met.

25. Review of the census for 2/18/17 for the Geri unit revealed 8 patients on the 7 AM shift with (1) 1:1 patient and (5) level 2 patients on each shift.

Review of the Supervisor staffing sheet dated 2/18/17 revealed 2 LPNs scheduled for the 7 AM shift. The staffing grid requires 1 RN and 1 LPN. The staffing requirements for the Geri unit were not met.

Review of the census for 2/18/17 for the Adult unit revealed 13 patients for the 7 AM shift with no 1:1 patients on either shift and (3) level 2 patients.

Review of the Supervisor staffing sheet dated 2/18/17 revealed 1 LPN scheduled and an RN floated from ICU to the Adult unit and 1 MHT scheduled. The staffing grid requires 2 MHTs for a census of 13 patients. The staffing requirements were not met for the 7 AM shift.

26. Review of the census for 2/19/17 for the Geri unit revealed 8 patients on both the 7 AM shift and the 7 PM shift with (1) 1:1 patient on the each shift and 5 level 2 patients on both shifts.

Review of the Supervisor staffing sheet dated 2/19/17 revealed 1 RN floated to the Adult unit from ICU for the 7 AM shift and 1 LPN for the 7 PM shift with no float RN. The staffing grid requires 1 RN float nurse for the 7 PM shift. The staffing requirements for the Geri unit on 7 PM shift were not met.

Review of the census for 2/19/17 for the Adult unit revealed 12 patients for the 7 AM shift and 13 patients for the 7 PM shift with no 1:1 patients. Further review revealed (2) level 2 patients on the 7 AM shift and (3) level 2 patients for the 7 PM shift.

Review of the Supervisor staffing sheet for the Adult unit dated 2/19/17 revealed 1 LPN on the 7 AM shift and no RN. The staffing grid requires 1 RN and 1 LPN for a census of 12 patients.

Review of the 7 PM Supervisor staffing sheet dated 2/19/17 for the Adult unit revealed 1 LPN and no float RN for the unit. The staffing requirements were not met for the Adult unit.

27. Review of the census for 2/20/17 for the Geri unit revealed 8 patients on the 7 AM shift with (1) 1:1 patient and (5) level 2 patients.

Review of the Supervisor staffing sheet dated 2/20/17 revealed 1 LPN scheduled for the 7 AM shift on the Geri unit. The staffing grid requires 1 RN and 1 LPN. The staffing requirements for the Geri unit were not met.

Review of the census for 2/20/17 for the Adult unit revealed 13 patients for the 7 AM shift with no 1:1 patients and (3) level 2 patients.

Review of the Supervisor staffing sheet for the Adult unit dated 2/20/17 revealed 1 LPN scheduled on the 7 AM shift with 1 RN orientee. The staffing grid requires 1 RN and 1 LPN. The staffing requirements were not met for the Adult unit for the 7 AM shift.

28. Review of the census for 2/21/17 for the Geri unit revealed 7 patients on the the 7 PM shift with (1) 1:1 patient and (4) level 2 patients.

Review of the Supervisor staffing sheet for the Geri unit dated 2/21/17 for the 7 PM shift revealed 1 LPN float from Medical/Surgical area on the 7 PM shift with a scheduled RN and 2 MHTs. The staffing grid requires 2 MHTs for the 7 patients and 1 additional MHT for the (1) 1:1 patient. The staffing requirements for the Geri unit were not met.

Summary: After reviewing the staffing grid and Supervisor staffing sheets, it was determined the Adult and Geriatric psychiatric units (New Day Behavioral) were understaffed. On multiple occasions, there was no Registered Nurse on the unit, not enough nurses and Mental Health Technicians (MHTs) to provide prescribed observational care, including 1 staff member for each patient that required 1:1 care. Often times, staff had to "float" to New Day Behavioral from other areas of the hospital. The float staff included Patient Care Technicians, emergency room Techs, Monitor Techs from Intensive Care Unit, LPNs (Licensed Practical Nurse) and Registered Nurses from the Medical/Surgical unit. By not providing the units with enough qualified nursing and unlicensed personnel, this placed these psychiatrically unstable patients at risk for injury, either intentional or accidental.





An interview was conducted on 2/22/17 at 7:20 AM with Employee Identifier (EI) # 27, Mental Health Technician (MHT). The surveyors asked EI # 27 to tell us about a time when there were not enough nurses/ MHTs present to care for patients. EI # 27 responded, "All of the time" When questioned to clarify her response, she stated, "If we have 1:1 who are both women, we put both of them together and one person watches both patients." EI # 27 stated that 1:1 observations are supposed to be done 1 MHT to 1 patient.

An interview was conducted on 2/22/17 at 7:50 AM with EI # 8, MHT. The surveyors asked EI # 8 to tell us about a time when there were not enough nurses/ MHTs present to care for patients. EI # 8 stated that they are always understaffed. EI # 8 stated that when a new Nurse Manager was appointed to New Day Behavioral about 2 years ago, she decided they had too many staff and decided they only needed 2 nurses at night. EI # 8 stated that she was unable to remember when the amount of techs changed, "But, we only have 2 techs on each side."

An interview was conducted on 2/22/17 at 8:30 AM with EI # 28, Patient Care Assistant (PCA). The surveyors asked EI # 28 about training she received for New Day Behavioral. She stated that she felt more comfortable with the geriatric patients. She has had CPI (Crisis Prevention Intervention) training. When questioned if she felt like she had received enough training for the psychiatric unit, she stated, "Not enough."

An interview was conducted on 2/22/17 at 7:50 AM and 8:30 AM with EI # 19, Registered Nurse (RN). The surveyors asked EI # 19 to tell us about a time when there were not enough nurses/ MHTs present to care for patients. EI # 19 stated she was unable to remember exact dates, but there were multiple times there has been a lack of both nurses and MHTs. She stated they are working hard to have enough staff. She stated, "It's really bad when there are 1:1 (patients) and not enough MHTs. 7 PM - 11 PM is the busiest times and when it's bad." At times, they have to pull staff from Med/Surg (Medical/Surgical floor). When questioned about training of the staff from Med/Surg, she stated the techs are quickly oriented to the psych unit, but the nurses are a different story and it makes it difficult.

An interview was conducted on 2/22/17 at 8:42 AM with EI # 29, Licensed Practical Nurse (LPN). The surveyors asked EI # 29 to tell us about a time when there were not enough nurses/ MHTs present to care for patients. EI # 29 stated that occasionally she has had to work short, but was unable to remember dates. EI # 29 stated there was a time when she was the nurse for the Geri-psych unit and had one tech, but was unable to recall the date. The surveyors asked EI # 29, how many nurses were present on this past Sunday, (2/19/17). EI # 29 replied, "There were 2 on Sunday." EI # 29 stated she was on the Geri unit, but, was unable to recall who the nurse was on the Adult unit. When questioned who was the RN charge nurse, she stated she was unsure, but that it was the RN Supervisor, who was in the emergency room (ER).

An interview was conducted on 2/22/17 at 9:02 AM and 9:20 AM with EI # 26, Registered Nurse (RN). The surveyors asked EI # 26 to tell us about a time when there were not enough nurses/ MHTs present to care for patients. EI # 26 stated that some nights "yes" and some
VIOLATION: CHIEF EXECUTIVE OFFICER Tag No: A0057
Based on review of facility policies, medical records, employee files, Patient Safety Organization - Submission Management reports, Patient Safety Work Product reports, MHT (Mental Health Technician) Observation documentation sheets, Employee Time sheets, Dale Medical Center's corrective action plan, observations and interviews, it was determined the Chief Executive Officer failed to ensure:

1. An investigation was conducted of caregiver reported concerns with the care being provided, which resulted in the family contacting local authorities, including police and Department of Human Resources (DHR). This has the potential to negatively affect all patients admitted to the New Day unit. Refer to A119

2. The facility provided a safe patient care environment. Refer to A144.

3. Investigate and report to authorities/ regulatory agency suspected abuse. Refer to A145.

4. Patient's right to be free of restraint was not violated by placing a patient in a geri-chair after the patient experienced a fall in the shower room. Refer to A154.

5. Incident reports were completed for a patient who experienced unexplained injuries. Refer to A286.

6. There was a qualified director of psychiatric nursing services in place at the PPS (Prospective Payment System) Psychiatric unit during the complaint survey. Refer to A386.

7. The staffing grid was followed to ensure the Psychiatric Units were staffed. Refer to A392.

8. The Registered Nurse (RN) made shift assignments for unlicensed nursing personnel in the adult and geriatric psychiatric units. Refer to A397.

9. The RN made shift assignments to unlicensed nursing personnel who had completed orientation. Refer to A397.

10. Staff completed accurate documentation every 15 minutes without falsification of the medical record. Refer to A450.

11. The shower area in the isolation room was maintained in a safe manner, locked and unaccessible to patients when not in use. Refer to A701.

12. The common bathroom used on the geri-psych unit was cleaned between patients to prevent potential transfer of infectious body fluids or microorganisms between patients. Refer to A747.

These deficient practices affected 10 of 25 records reviewed, including Patient Identifier (PI) # 1, PI # 8, PI # 9, PI # 10, PI # 11, PI # 12, PI # 13, PI # 14, PI # 15, PI # 16 and has the potential to negatively affect all patients admitted to the psychiatric unit of this facility.

Findings include:

Refer to A119, A144, A145, A154, A286, A392, A397, A450, A701 and A747 for findings.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical records, facility policy and interview, it was determined the facility failed to investigate and report to authorities/ regulatory agency potential abuse by a family member related to 1 of 25 records reviewed, affecting Patient Identifier (PI) # 9. This has the potential to affect all patients in this facility.

Findings include:

Facility Policy
Policy: Suspected Child, Adult, Disabled Person or Elderly Abuse/ Neglect/ Exploitation revised June 21, 2010

Policy: Patient have the right to be free from mental, physical, sexual and verbal abuse, neglect and exploitation. It is the policy of this hospital to protect patients from real or perceived abuse, neglect or exploitation from anyone, including staff members, students, volunteers, other patients, visitors or family members. Healthcare Workers are required by law to report all known or suspected cases of abuse/neglect/exploitation. This hospital mandates that, under the guidance of applicable laws, any healthcare worker having reasonable cause to believe that any person is in the state of abuse, exploitation or neglect shall report the information to the appropriate regulatory agency...

... Physical Abuse: Physical injury that results in substantial harm to the person, or the genuine threat of substantial harm from physical injury to the person, including an injury that is at variance with the history or explanation given and excluding an accident or reasonable discipline by a parent, guardian or managing possessory conservator that does not expose the person to a substantial risk of harm...

The following criteria may be used to assist in the identification of abuse:

Physical Abuse - Willful infliction of injury, unreasonable confinement or cruel punishment:

Scratches, cuts, bruises or burns...

... Procedure:

Management of Suspected Abuse/Neglect:

Cases of suspected sexual assault, physical abuse or neglect will be given priority and will be investigated thoroughly.

In many instances, the healthcare provider may suspect the possibility of an inflicted injury before the physician. Careful assessment and documentation of physical findings can help provide the data that are believed to confirm diagnosis. History taking and examination of all patients will be done promptly and in privacy.

All cases of suspected abuse/neglect must be reported to authorities. A person (including an employee, volunteer or other person) associated with the hospital, who reasonably believes or knows of information that would reasonably cause a person to believe that the physical or mental health or welfare of a patient of the hospital, who is receiving medical services, has been, is or will be adversely affected by abuse or neglect by any person shall, as soon as possible, report the information supporting the belief to the Department of Human Resources (DHR) or the appropriate healthcare regulatory agency by telephone, in writing or by personal visit. When domestic violence has occurred, always notify law enforcement officials, even if the patient does not want to press charges. A healthcare provider who fails to report shall be referred by the Department of Health to the individual's licensing board for appropriate disciplinary action...

To protect the patient from real or suspected mental, physical, sexual and verbal abuse, neglect and/or exploitation, staff will safeguard the patient from the offending individual(s). This "safeguarding" may be overt or covert, dependent upon the patient's mental and physical sense of wellbeing. If any type of abuse or exploitation is proven legitimate (witnessed and obvious), the offending individual will be restricted from access to the patient. If the abuse is suspected, however unproven, staff shall be present at all times when the patient receives visitors.

1. PI # 9 was admitted to the facility 2/13/17 with diagnoses of Mood Disorder Not Otherwise Specified, Possibly Benzodiazepine Dependence and Osteoarthritis.

The History and Physical dictated by the psychiatrist 2/14/17 included the following under history of present illness:
Apparently the son brought his parents here a year or two ago from (another town)... they have been seeing psychiatrists, I believe and medical doctors and (the patient) has been taking numerous medications for medical and psychiatric problems. Apparently (spouse) has opiate dependence among other things... it is not enough for them to be satisfied with what they are taking so they take all kinds of stimulants including amphetamines, crack cocaine and Benzodiazepines. They live to do that and this has been compounding (the patient's) problems...

Review of the Initial Interview dated 2/13/17 revealed the Registered Nurse (RN) documented the patient currently resided at home with the spouse with the intended destination post discharge: family/so (significant other).

Review of the Initial Physical assessment dated [DATE] at 4:30 PM, revealed the RN documented the patient had bruising to the left buttock and top of left foot. The RN further documented, "... Pt (patient) is manic, hyperverbal and reports, "I just can't get it together. My (spouse) is in New Vision" (Medical Stabilization for drug withdrawal)... Pt has old bruising assessed to left buttock and left foot. Pictures made..."

Review of the Patient Progress Note dated 2/13/17 at 11:30 PM, revealed the RN documented the patient was having hallucinations, believed saw a boy falling from the ceiling and the patient was trying to help him. The patient stated (he/she) went to (his/her) knees and hit the bedside table under the right shoulder with a reddened area noted.

Review of the Patient Progress Note dated 2/13/17 at 11:59 PM, the RN documented she called and spoke with the patient's son regarding the incident with the patient falling and that there were no apparent injuries with the exception of the red area noted to the patient upper right chest under arm area. The RN documented the son stated he is the one that brought the patient to the hospital (2/13/17), The RN further documented the son also stated that he would prefer the nurse not contact (patient's spouse) regarding the incident at that time.

On 2/15/17 at 10:42 AM, the Social Worker (SW) documented, "... The patient is a 66 year old... admitted to New day Behavioral from the ER (emergency room ). Patient reportedly has a history of bipolar disorder... was brought to the ER... states... been hallucinating..."

On 2/15/17 at 10:51 AM, the SW documented, "... Patient's son feels that their recent behaviors could be the result of withdrawal, as he is suspicious that patient has been misusing medications, some that may not even be prescribed to (him/her). The patient was admitted to New Day (Behavioral) for further evaluation and treatment..." The patient was currently living with the spouse. The SW documented the patient was suspicious and worried.

Review of the Patient Progress Note dated 2/18/17 at 8:02 PM revealed the RN documented the patient's spouse was visiting.

Review of the Patient Progress Note dated 2/20/17 at 12:53 PM revealed the Licensed Practical Nurse (LPN) documented, "Discharge instructions reviewed and patient education given on appt (appointment)... Safety plan... Patient escorted off unit and to vehicle also accompanied by spouse..."

Review of the visitor sheet (part of the medical record) revealed the patient's spouse visited with the patient's son on 2/15/17 at 7:38 PM and 2/16/17 at 7:36 PM. The patient's spouse also visited the patient alone on 2/17/17 at 7:44 PM, 2/18/17 at 7:02 PM and 2/19/17 at 7:08 PM.

An interview was conducted on 2/22/17 at 7:50 AM with Employee Identifier (EI) # 19, RN. EI # 19 stated the patient had a bruise to the buttocks, which had the appearance of a hand print. When questioned if she suspected the spouse was abusing the patient, EI # 19 stated, "We talked about it."

An interview was conducted on 2/22/17 at 9:02 AM with EI # 25, RN. She stated she was the float nurse the night (2/13/17) the patient fell . She stated they took pictures of the patient's shoulder and buttocks. EI # 25 stated without prompting the patient defensively stated, "My (spouse) didn't do it."

On 2/22/17 at 10:45 AM, the surveyors reviewed the photos of the bruised area located on the patient's left buttock. The bruised area had the appearance of a palm with faint markings that appeared to be four fingers.

There was no documentation the patient's suspicious brusing to the buttocks area were reported to facility staff/managers, investigated or reported to DHR. There was no documentation the patient had supervised visitation with the spouse on 2/17/17, 2/18/17 and 2/19/17 according to the facility's policy. The patient was also discharged with the spouse.
VIOLATION: ORGANIZATION OF NURSING SERVICES Tag No: A0386
Based on interviews, review of Centers for Medicare and Medicaid (CMS) conditions of participation for Psychiatric Hospitals and Dale Medical Center's corrective action plan submitted to the surveyors on 2/24/17, it was determined the facility failed to have a qualified director of psychiatric nursing services in place at the PPS (Prospective Payment System) Psychiatric unit during the complaint survey.

This had the potential to affect all patients served.

Findings include:

CMS: Conditions of Participation for Psychiatric Hospitals.
482.60 Condition of Participation: Special Provisions Applying to Psychiatric Hospitals.
482.62(d) Standard: Nursing Services

482.62(d) The hospital or unit must have a qualified director of psychiatric nursing services. In addition to the director of nursing, there must be adequate numbers of registered nurses, licensed practical nurses, and mental health workers to provide nursing care necessary under each patient's active treatment program and to maintain progress notes on each patient.

In an interview 2/22/17 at 12:30 PM with Employee Identifier # 3, Registered Nurse (RN) Supervisor who had been appointed to be the Nurse Manager for the PPS Psychiatric Unit it was confirmed that she had no prior psychiatric nursing experience.

Review of the plan submitted to the surveyors by the Chief Executive Officer (CEO) and Chief Nursing Officer (CNO) revealed the following plan was implemented to address not having a qualified director of psychiatric nursing:

"... 5. Employee Identifier (EI) # 25, RN has assumed Interim Nurse Manager of New Day. She has 6 years psychiatric nurse experience. EI # 3 will continue to work closely with EI # 25 in a supervisory role. Also, EI # 6, CNO and EI # 1, Director of Quality will be available and assisting on New Day both of which have extensive Nurse Management experience of New Day previously. Resumes of EI # 25, EI # 6 and EI # 1 are included..."
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on review of facility policies, medical records, Patient Safety Organization - Submission Management reports, Patient Safety Work Product reports and interviews, it was determined the facility failed to:

1. Ensure an investigation was conducted of caregiver reported concerns with the care being provided, which resulted in the family contacting local authorities, including police and Department of Human Resources (DHR). Refer to A119

2. Provide a safe patient care environment. Refer to A144.

3. Investigate and report to authorities/ regulatory agency suspected abuse by a family member Refer to A145.

4. Ensure patient's right to be free of restraint was not violated by placing a patient in a geri-chair after the patient experienced a fall in the shower room 2/7/17. Refer to A154.

These deficient practices affected 6 of 18 records reviewed, including Patient Identifier (PI) # 1, PI # 8, PI # 9, PI # 10, PI # 11 PI # 13 and has the potential to negatively affect all patients admitted to the psychiatric unit of this facility.

Findings include:

Refer to A119, A144, A145 and A154 for findings.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on review of medical records, employee files, facility policies, Psych Department/ Daily Staffing Grid, Supervisor's staffing sheet, Dale Medical Center's corrective action plan submitted to the surveyors on 2/24/17 and interviews with facility staff, it was determined the facility failed to ensure:

1. There was a qualified director of psychiatric nursing services in place at the PPS (Prospective Payment System) Psychiatric unit during the complaint survey. Refer to A386.

2. The facility failed to follow the staffing grid to ensure the Psychiatric Units were staffed. Refer to A392.

3. The Registered Nurse (RN) made shift assignments for unlicensed nursing personnel in the adult and geriatric psychiatric units. Refer to A397.

4. The RN failed to ensure assignments were made to employees who had completed orientation. Refer to A397.


This affected 1 of 25 patients, including Patient Identifier (PI) # 8 and had the potential to negatively affect all patients admitted to the Psychiatric Units.

Findings include:

Refer to A386, A392 and A397 for findings.
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
Based on review of medical records (MR) facility policy and procedure and interview it was determined in 1 of 25 patient records reviewed the patient's right to be free of restraint was violated by placing a patient in a geri-chair for greater than 15 hours after having experienced a fall in the shower room on 2/7/17. This affected Patient Identifier (PI) # 8 and had the potential to affect all patients receiving care in the facility.


Findings include:

Policy and Procedure: Restraints
Effective Date: June 2016

Policy: "All patients have the right to be free from restraints or seclusion of any form that are not medically necessary. The patient shall not be restrained as a means of coercion, discipline, convenience or retaliation by staff. The term "restraint" includes any physical restraint, mechanical device, material, medication, equipment or drug that is being used as a restraint...

Application of Restraints:
The person requiring restraints is usually confused/ disoriented and will need frequent reminders and re-orientation to avoid feelings of isolation and confinement...

D. Protective devices or mechanisms intended to compensate for a specific physical deficit or prevent safety incidents not related to cognitive dysfunction. These include but are not limited to:
Geri-chairs (the patient has the skill/ability to easily remove)..."

Policy: Observation Levels - Revised 9/8/2012, another revision was completed 2/20/2017.

Purpose: "To ensure patients are observed at the appropriate level for optimum safety.

Policy: All patients will be observed at a minimum of every 15 minutes...

Procedure: All patients will be assessed by nursing staff for level of observation at a minimum of every shift.

Level III: Every 15 minutes observation...

Level II: Eye Sight Observation...

Level I: 1 to 1 observation at all times
This is the most restrictive toward the patient and involves continuous monitoring and physical proximity to the patient at all times. Staff shall be within arm's reach at all times, including toileting and showering..."

1. PI # 8 was admitted to the Geriatric Psych Unit 2/6/17 with a primary diagnosis of Vascular Dementia with Behavioral Disturbances.

The Observation Documentation form used by the MHT (Mental Health Technicians) dated 2/7/17 at 7:15 PM documented the patient was in the SH (Shower) at 7:25 PM and at 7:30 PM documented the patient was in the QR/O (Quiet Room/Off unit), this was documented by orientee, Employee Identifier (EI) # 18.

Review of the amended nurses note dated 2/7/17 at 7:50 PM included the following documentation, "Tech, EI # 8, calls nurse into shower room and reports that patient fell . Assisted tech and orientee, EI # 18, MHT Orientee to help patient up. Patient states, 'it hurts' and rubs the top of his/her head. Reddened area noted without bleeding or swelling. Supervisor notified."

7:35 PM patient taken to x-ray for CT (Computerized Tomography) scan.

7:45 PM Patient returns from X-ray. Photo taken of reddened area...

PI # 8 had a physician's order: Patient is a level one observation due to fall risk dated 2/7/17 at 8:20 PM.

8:18 PM patient made a level one observation at this time due to fall history with unsteady gait. Patient doesn't seem to understand to use the walker. Patient uses a cane at home.

8:35 PM While patient is being showered, techs call nurse to note three bruises to the right arm. Right upper arm, lower arm and wrist. Photo taken.

8:43 PM Called patient's daughter and notified her of the fall and the CT results. Daughter notified of a bruise to the top of his/her head reported to patient's daughter that patient is a level one for now...

9:45 PM Patient moved to gerichair in the dayroom after patient, "repeatedly gets up out of bed. Confused."

There was no documentation of interventions tried to prevent the patient's behaviors prior to placing him/her in a gerichair in the day room. There was no order from the physician to place patient in a gerichair.

The Observation Documentation form used by the EI # 18, MHT orientee dated 2/7/17 at 10:45 PM through 2/8/17 at 4:00 AM, has the patient in the gerichair asleep. The patient was toileted on 2/8/17 at 4:00 AM then remained in the gerichair in the dining room asleep until 6:00 AM, when he was washed up then returned to dayroom until 9:30 AM, when treatment team met.

The nurses documentation included the patient resting in the gerichair on 2/8/17 at 4:44 AM.

PI # 8 was on one to one observation and slept in the gerichair in the dayroom with the orientee MHT EI # 18 in attendance through out the night. The physician was not aware the patient was in a gerichair through out the night. There was no documentation the staff tried to return the patient to his/her bed at any time during the night, no documentation the patient was offered liquids, repositioned or toileted until 4:00 AM. PI # 8 was confused and not able to easily remove or get out of the gerichair. The patient was on 1:1 observation also throughout this time.

In an interview 2/22/17 at 9:40 AM with EI # 18, he confirmed PI # 8 was in the gerichair but not as a restraint he/she slept better in the gerichair.

In response to written questions left with EI # 3, RN (Registered Nurse) Supervisor and EI # 1, Director of Quality 2/22/17 the following answers were received 2/23/17 at 8:30 AM:

"... The patient could get out of the gerichair at any time he/she chose. It was simply used so that the patient could rest comfortably..."

The patient remained in a gerichair after the day shift arrived on 2/8/17 until 10:15 AM. Documentation included, "Patient is sitting up in gerichair this morning in the dayroom, he/she has a ready smile and interacts with SN (skilled nurse) during assessment..."

The patient remained in the gerichair on 2/8/17 at 12:02 PM with documentation including, "Patient sitting up in gerichair and he/she observes those around him/her during group therapy. He/she does not participate in the activity but he/she is not disruptive in any way."

On 2/8/17 at 6:30 PM, the patient's daughters arrived at the facility and checked him/her out AMA (Against Medical Advice) saying he/she doesn't fall at home.

The staff maintained the patient in the gerichair after the night shift and throughout the day shift the following day, where they alleged he/she was more comfortable. There was no information regarding why the patient was in a gerichair for greater than 15 hours.
VIOLATION: INFECTION CONTROL Tag No: A0747
Based on observations, review of policy and interviews it was determined the common bathroom used on the Geriatric Psych Unit of New Day Behavioral Health unit was not cleaned between patients to prevent potential transfer of infectious body fluids or microorganisms between patients.

Findings include:

Refer to A 749 for additional findings.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observations, review of policy and interviews it was determined the common bathroom used on the geri-psych unit was not cleaned between patients to prevent potential for transfer of infectious body fluids or microorganisms between patients.

Findings include:

Policy : Infection Control revised 9/8/2012
Department: Behavioral Health

Purpose: To maintain an environment that reduces or prevents the spread of infection.

Policy: The unit participates in the hospital-wide infection control program and maintains the standards of the policies and procedures contained in the Infection Control Manual.

Procedure: Nursing staff will assess patients under their care for indications of possible infectious diseases or conditions...

Nursing staff will adhere to correct aseptic technique and standard precautions, to assist in the prevention of infection and to teach others by example...

A tour of the Geriatric Psych Unit was conducted 2/21/17 at 12:30 PM by the surveyors. During the tour Employee Identifier (EI) # 2, Program Director and EI # 3, RN (Registered Nurse) Supervisor accompanied the surveyors. A review of the restraint/seclusion room revealed in the ante room a handicapped bathroom was available for staff to bring patients to bathe on the handicapped bench seat for safety.

In interviews with Mental Health Technicians (MHT) on 2/22/17, EI # 8, MHT revealed that patients were left alone in the handicapped area to bathe themselves and the MHT would return to help them dress.

In an interview with EI # 8 on 2/22/17 at 7:20 AM it was revealed that at times the patients might bathe in their rooms, but generally they either give them a bed bath or take them to the shower.

In an interview with EI # 19, Registered Nurse (RN) on 2/22/17 at 7:45 AM, it was revealed that it is rare for a patient to bathe in the bathroom in their room, they usually go down to the shower room with the bench. The surveyor asked EI # 19 how the shower was cleaned between patients. EI # 19's response was that it's not cleaned between patients.

An interview was conducted on 2/22/17 at 8:30 AM with EI # 28, Patient Care Assistant (PCA). The surveyors asked EI # 28 if the shower was cleaned between patients. EI # 28 stated she was not sure.

An interview was conducted on 2/22/17 at 9:02 AM with EI # 26, RN. The surveyors asked EI # 26 if the shower was cleaned between patients. EI # 26 stated she was not sure.

An interview was conducted on 2/22/17 at 9:45 AM with EI # 18, MHT (Hire date 1/31/17). The surveyors asked EI # 18 if the shower was cleaned between patients. EI # 18 stated that no one had told him about cleaning the shower.

An interview was conducted on 2/22/17 at 10:25 AM with EI # 36, MHT. The surveyors asked EI # 36 if the shower was cleaned between patients. EI # 36 stated other techs clean, wipe down with disinfectant.

The surveyors returned to the Geriatric Psych Unit of New Day Behavioral on 2/22/17 at 10:30 AM to observe the shower room and interview staff regarding the cleaning of the shower room after each patient's use.

EI # 2, Program Director accompanied the surveyors to the unit. EI # 2 was unable to locate any spray or type cleaner used in the bathroom. The MHT working the floor was asked what the bathroom was cleaned with and she stated that she did not know, baths were done at night.

Two nurses were present in the nurses room an RN and a LPN (Licensed Practical Nurse), they were asked what the bathroom was cleaned with and they thought housekeeping cleaned it. When asked if housekeeping was called between each patients bath, they stated, "no". The RN was trying to locate the antiseptic wipes used to clean equipment on the unit and revealed there were no wipes available. The RN went to another unit and came back with 2 containers of Sani-cloths.

This is an infection control hazard due to the lack of cleaning between patients presenting a potential infection control issue for transferring microorganisms or body fluids.

The facility failed to have a policy for cleaning the shower area, this was confirmed by EI # 3, RN Supervisor 2/22/17 at 3:30 PM.