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.

BULLOCK COUNTY HOSPITAL 102 WEST CONECUH AVENUE UNION SPRINGS, AL 36089 Jan. 7, 2016
VIOLATION: LICENSURE OF HOSPITAL Tag No: A0022
Based on review of personnel files, medical record reviews, patient activity log book, job qualifications for exclusion from prospective payment system (PPS) psychiatric system units (412.25 - A1184), and Alabama Hospital Rules for Licensure and interviews it was determined:

1. The Registered Nurse (RN) Unit Manager failed to meet the qualifications for the Director of Psychiatric Nursing Services.

2. The Therapeutic Activities for PPS excluded Psychiatric units (A 1190) failed to be evaluated and provided to meet the patient's needs.

This affected 10 of 10 medical records reviewed and had the potential to negatively affect all patients admitted to the Psychiatric Unit.

Findings include:

PPS psychiatric system units 412.25 (A1184):

A1184 3(i) The director of psychiatric nursing services must be a registered nurse who has a master's degree in psychiatric and mental health nursing, or its equivalent from a school of nursing accredited by the National League of Nursing, or be qualified by education and experience in the care of the mentally ill. The director must demonstrate competence to participate in interdisciplinary formulation of individual treatment plans; to give skilled nursing care and therapy; and to direct, monitor, and evaluate the nursing care furnished.

Rules of Alabama State Board of Health Chapter 420-5-7 for Hospitals:

420-5-7-2(e) Psychiatric Hospitals:
Nursing services. The hospital shall have a qualified director of psychiatric nursing services. In addition to the director of nursing, there shall 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.

1. The director of psychiatric nursing services shall be a registered nurse with an active, unencumbered Alabama license who has a master's degree in psychiatric or mental health nursing, or its equivalent, from a school of nursing accredited by the Commission on Collegiate Nursing Education, the National League for Nursing, or be qualified by education and experience in the care of the mentally ill. The director shall demonstrate competence to participate in interdisciplinary formulation of individual treatment plans; to give skilled nursing care and therapy; and to direct, monitor, and evaluate the nursing care furnished.

In an interview with Employee Identifier (EI) # 4, Nurse Manager Psychiatric Unit, on 1/7/16 at 11:38 AM, EI # 4 stated she started working on the psychiatric unit in June 2014 and assumed the role of Nurse Manager in October 2014. (Approximately four months.)

EI # 4 stated she had never worked with Psychiatric patients before her employment with Bullock County Hospital and that she had no previous experience in the care of mentally ill patients.

A review of the personnel file for EI # 4 failed to include any Psychiatric nursing experience. EI # 4 does not have a Master's or Bachelor's degree in nursing.

In an interview with EI # 1, Co-Administrator on 1/7/16 at 1:16 PM she confirmed EI # 4 failed to meet the documented requirements for overseeing the Psychiatric Unit. When asked if the hospital Director of Nursing or the Assistant Director of Nursing had any Psychiatric experience the answer was," No." EI # 1 was agreeable to arrange for a consultant to work with EI # 4 to assist with her education and decision making on the unit.


Rules of Alabama State Board of Health Chapter 420-5-7 for Hospitals:

420-5-7-3(h) Psychiatric Hospitals;

(h) Therapeutic activities. The hospital shall provide a therapeutic activities program.
1. The program shall be appropriate to the needs and interests of patients and be directed toward restoring and maintaining optimal levels of physical and psychosocial functioning.
2. The number of qualified therapists, support personnel, and consultants shall be adequate to provide comprehensive therapeutic activities consistent with each patient's active treatment program.


PPS psychiatric system units 412.25 (A1190):
A1190 Therapeutic Activities: The unit must provide a therapeutic activities program.
(i) The program must be appropriate to the needs and interests of inpatients and be directed toward restoring and maintaining optimal levels of physical and psychological functioning.

Ten medical records were reviewed. There was no documentation of an Activity assessment, activity plan and no documentation of participation in therapeutic activities in 10 of 10 medical records reviewed onsite prior to 1/7/16.

A review of the Activities Log book 1/6/16 revealed the current week of January 4-6 forms were present. All prior sheets had been thinned from the book to 9/15/15. A review of the log sheets from 1/6/16 through 6/30/15 consistently showed incomplete assignment of Groups and Topics to be presented during the following dates: 9/15/15, 9/14/15, 9/10/15, 9/9/15, 9/6/15, 9/5/15, 9/1/15, 8/27/15, 8/26/15, 8/24/15, 8/23/15, 8/22/15, 8/18/15, 8/13/15, 8/11/15, 8/9/15, 8/4/15, 8/3/15, 7/30/15, 7/29/15, 7/26/15, 7/25/15, 7/21/15, 7/16/15, 7/11/15, 7/7/15, 7/6/15, 7/2/15 and 6/30/15.

In an interview on 1/6/16 at 10:35 AM with EI # 6, Activities Director, he stated they do not document activities in the charts. If the patients do not participate, they just tell the RN (Registered Nurse).

A Recreation/Activities Assessment & Treatment Plan was developed 1/6/16 and provided to the surveyor 1/7/16 at 9:30 AM by EI # 2, Director of Nursing. EI # 2, states EI # 6, Activities Director will start immediately using the new tool today (1/7/16).
VIOLATION: GOVERNING BODY Tag No: A0043
Based on medical record review, review of the hospital's policies and procedures, review of Hospital Bylaws / Rules and Regulations, observation and interview, it was determined the facility failed to ensure:

a.) The patients on the Gateway Unit were in a safe environment to protect themselves and others from injury. Refer to A 144


b.) Physician's orders for 1:1 observation were obtained and the physician was notified of changes in patient behavior and condition. Refer to A 144

c.) Psychiatric evaluations and follow up care for mental health services were documented in the medical record. Refer to A 449

d.) The physician was notified of no activity assessment and/or no therapeutic activities being conducted and documented. Refer to A 022 and A 449

e.) Ensure an on-going review of each medical staff member's clinical performance. Refer to A 049


f.) Patient care areas did not contain potentially hazardous conditions that could cause harm to the patients or staff. Refer to A 724

g.) The Registered Nurse Unit Manager met the qualifications for the director of psychiatric nursing services. Refer to A 022 and A 386

h.) The Chief Executive Officer who is responsible for managing the hospital ensured the Psychiatric Unit of the facility was managed and functioned with trained staff to meet the needs of psychiatric patients to include:

1. The Registered Nurse Unit Manager met the qualifications for the director of psychiatric nursing services. Refer to A 022 and A 386

2. The Therapeutic Activities for PPS (Prospective Payment System) excluded Psychiatric units were conducted and became a part of the therapeutic activities through the treatment plan. Refer to A 022 and A 057

3. Completion of planned actions related to an involving and incident which occurred 12/16/15 with Patient Identifier (PI) # 2. Refer to A 057


This had the potential to affect all patients and staff served by this facility.
VIOLATION: MEDICAL STAFF - ACCOUNTABILITY Tag No: A0049
Based on review of the Hospital Bylaws/Rules and Regulations and interview, the hospital failed to provide peer review for the psychiatrist.
This deficient practice has the potential to affect all patients receiving psychiatric treatment.

Findings include:

According to the Hospital Bylaws, Article I, The purpose of the Medical Staff shall be:

...2. To provide a high level of professional performance by all individuals exercising clinical privileges through the appropriate delineation of such clinical privileges of each Medical Staff member's clinical and ethical performance on the Hospital.

The Medical Staff Bylaws and Rules and Regulations are not dated.

During an interview on 1/7/16 at 11:30 AM, the Co-Administrator (EI # 1) was informed the psychiatrist's credential and quality files were needed for review. The Co-Administrator said there was no quality file or peer review for the psychiatrist due to the small size of the hospital.
VIOLATION: CHIEF EXECUTIVE OFFICER Tag No: A0057
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical records, policies and procedures, the attestation to continue participation as a PPS (Prospective Payment System) excluded Psychiatric unit submitted 12/20/15, and interview it was determined the chief executive officer who is responsible for managing the hospital failed to ensure the Psychiatric Unit of the facility was managed and functioned with trained staff to meet the needs of Psychiatric patients to include:

1. The Registered Nurse (RN) Unit Manager failed to meet the qualifications for the director of psychiatric nursing services. Refer to A 386 and A 22

2. The Therapeutic Activities for PPS exclude Psychiatric units were conducted and became a part of the therapeutic activities through the treatment plan. Refer to A 022

3. Suicidal ideations/homicidal ideations and ensuring planned actions to prevent a re-occurrence of incidents would not be repeated.

This affected 10 of 10 medical records reviewed and had the potential to negatively affect all patients admitted to the psychiatric unit.

Findings Include:

1. Refer to A 386 for qualifications and staff findings.

2. Ten medical records were reviewed. There was no documentation of an Activity assessment, activity plan and no documentation of participation in therapeutic activities in 10 of 10 medical records reviewed onsite prior to 1/7/16. Refer to A 022 for additional findings.


Medical Record findings:

1. PI (Patient Identifier) # 4 was admitted to the unit 12/15/15 with a diagnosis of Neuro-cognitive Disorder and Alzheimer's Mood Disorder.

A review of PI # 4's treatment plan included the following activities:

The surveyor reviewed the Gateway Unit Schedule and Activities Log for 12/16/15 when Patient Identifier (PI) # 4 was an active patient. The following areas were blank or incomplete on the form where the initials of the person conducting the activity was to be recorded:
8:30-9:00 Community Meeting (Current Events, Weather, Review Daily Schedule/Unit Rules)_________
9:00-9:30 Therapy Group:________
9:30-10:00 Nurse Group-Meds. Topic:_________
1:30-2:00 Nurse Group. Topic:_________
2:30-3:00 Therapy Group__________
9:00-9:30 Community Meeting/Relaxation Time/ Wrap-Up of Day's Activities____________.


A review of the Activities Log book 1/6/16 revealed the current week of January 4-6 forms were present. All prior sheets had been thinned from the book back until 9/15/15. A review of the log sheets from 1/6/16 to June 30,15 consistently showed incomplete assignment of Groups and Topics to be presented during the following days 9/15/15, 9/14/15, 9/10/15, 9/9/15, 9/6/15, 9/5/15, 9/1/15, 8/27/15, 8/26/15, 8/24/15, 8/23/15, 8/22/15, 8/18/15, 8/13/15, 8/11/15, 8/9/15, 8/4/15, 8/3/15, 7/30/15, 7/29/15, 7/26/15, 7/25/15, 7/21/15, 7/16/15, 7/11/15, 7/7/15, 7/6/15, 7/2/15 and 6/30/15.


In an interview on 1/6/16 at 10:35 AM with Employee Identifier (EI) # 6, Activities Director, he stated that they do not document activities in the charts and if the patients do not participate, they just tell the RN (Registered Nurse).


A Recreation/Activities Assessment & Treatment Plan was developed 1/6/16 and provided to the surveyor 1/7/16 at 9:30 AM by EI # 2, Director of Nursing. EI # 2, states EI # 6, Activities Director will start immediately using the new tool today (1/7/16).

***
An incident occurred 12/16/15 in room 206 at which time a current patient on the PPS Psych Unit, PI # 2, committed suicide by hanging himself/herself with bed linen that was placed over the bathroom door. The incident was self reported by EI # 1, Co-Administrator to the Division of Health Care Facilities/ Department of Public Health.

Summary of incident as presented by EI # 1:
Upon arrival on the unit, the patient (PI# 2) was started on continuous fifteen minute observations. During his/her stay, the patient denied suicidal ideations and auditory/visual hallucinations several times; the patient stated he/she was homicidal with no specific target or plan. On 12/16/15, the patient had an individual counseling session with EI # 10, at 9:35 AM. During the session, the patient discussed some of his/her past life events and again denied suicidal ideations and auditory/visual hallucinations. The patient stated he/she had anger issues with no specific target.

At approximately 11:00 AM, PI # 2 participated in treatment team where he/she repeatedly denied suicidal ideations. PI # 2 wanted to leave the facility after being denied his/her request for Klonopin. The psychiatrist informed PI # 2 that he had no immediate plans to discharge him/her.

At approximately 1:28 PM a mental health technician, EI # 8 stated that he rounded on and interacted with PI # 2 in the patient's room. At approximately 1:30 PM a second mental health technician, EI # 11 went into the patient's room to return some freshly laundered clothing and found PI # 2 patient hanging from the bathroom door by a bedsheet. CPR (cardiopulmonary resuscitation) was immediately started and the patient was quickly transported to the Emergency Department.

Additional Planned Actions submitted to Division of Health Care Facilities/ Provider Services on 12/21/15:

- Educate staff on behavioral signs and symptoms exhibited by patients who may be a harm to self or others
- Educate staff not to rely solely on patient self-report of no suicidal ideations
- Ensure a safe physical environment- over-the-door pressure sensor alarms
- Educate staff to avoid over confidence in or over reliance on 15 minute checks
- Equip nurses station with live-feed video surveillance equipment.

The surveyors arrived at the facility 1/5/16 at 9:30 AM and completed a tour of the Psychiatric Unit and conducted interviews with nurses and mental health technicians.

An interview was conducted on 1/5/16 at 3:00 PM with EI # 1, Co-Administrator; EI # 2, Director of Nursing; EI # 3, Assistant Director of Nursing: and EI # 4, Nurse Manager of the Psychiatric Unit to determine what part of the planned actions had been completed.

EI # 2 stated there had not been an official meeting for staff education. Administration had been talking to staff who worked on 12/16/15 (day of patient suicide). She continued to say more technicians (techs) were working now and they plan to began formal education with the staff.

The over the door pressure sensor alarms had not been ordered. Administration was waiting to talk with a representative of the company.

The surveyors expressed concern about there being no way for staff to call for help without running down the hall or shouting. The staff decided to purchase walkie talkies for staff to use immediately.

The video feed, to be viewed at the nursing station, was installed on 12/28/15.

The staff and governing body had not addressed any interventions or documented any interventions put in place since the incident on 12/16/15 except for the live video feed available 12/28/15.

On arrival to the facility on [DATE] walkie talkies were observed in the conference room where survey staff were working. Administrative staff said the devices were available for use and plans to orient staff were to begin on 1/6/16.

Staff education had been started 1/5/16 (night shift) and morning shift of 1/6/16 regarding Suicide/Homicide warning signs. Documentation of staff attendance was provided to the surveyors. All staff education was to be completed by 1/8/16.

EI # 1 stated that as of 12/16/15 the MHTs were rounding at staggered intervals where the patients would not be aware of the specific 15 minutes times between each other to observe the patients closely to increase safety.

A letter was (MDS) dated [DATE] at 12:50 PM confirming the order of door top pressure alarms for the unit. The install date listed on the order is 1/25/16.

Continued education is planned for all staff members of the PPS Psych unit ongoing for evaluation of suicidal and homicidal ideations over the next week.

On 1/7/16 at 10:30 AM, EI # 1 presented the conclusion of the hospital investigation of the incident that occurred on 12/16/15 to the surveyors. The staff concluded the incident was unavoidable.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on medical record review, review of the facility's policies and procedures observation and interview, it was determined the facility failed to ensure:

a.) Participation of the patients in developing their treatment plan, failed to include individualized short term and long term goals and failed to update or change the treatment plan when patient's behaviors and outcomes did not improve. Refer to A 130


b.) Patients were in a safe environmental setting to protect them from self injurious behavior and harm to other patients, staff or the general public.
Refer to A 144

c.) Physician's orders for 1:1 observation were obtained and the physician was notified of changes in patient behavior and condition. Refer to A 144

This had the potential to affect all patients served by this facility.

Findings include:

Refer to A 130 and A 144 for findings.
VIOLATION: PATIENT RIGHTS: PARTICIPATION IN CARE PLANNING Tag No: A0130
Based on review of medical records, policy and procedures and interview it was determined the facility failed to include participation of the patients in developing their treatment plan, failed to include individualized short term and long term goals and failed to update or change the treatment plan when patient's behaviors and outcomes did not improve. This had the potential to affect all patients served by the facility and did affect 8 of 10 patients; Patient Identifier (PI) # 4, # 6, # 7, # 8, # 9, # 10, # 3 and # 5. This had the potential to affect all patients served.


Findings include:


Policy and Procedure:
Title: Multidisciplinary Treatment Plan

Purpose: " To provide individualized care response to the patient's specific need and to ensure the patient's participation in care is provided."

Policy:
A. " Each patient shall have a written individualized treatment plan based on the patient's present problems, physical health, emotional and behavioral status, and strengths and weaknesses. The Multidisciplinary Treatment Plan shall be derived from each discipline's assessment of the patient as well as the patient/family perceptions of the patient's needs. This includes a review of the data available at the time of the information of the plan, to include:
2. Psychiatric evaluation...
4. Nursing Admission Assessment
5. Psychosocial history...
8. Activity Recreation Therapy Assessment...

B. The plan of care is supervised by the attending psychiatrist. The Multidisciplinary Treatment Plan will be completed no later than 3 days following the date of admission. The Multidisciplinary Treatment Plan shall be signed by the attending physician and the treatment team...

E. The Multidisciplinary Treatment Plan process must include active participation by the patient or legal...

H. Short and long term goals for the problems identified shall be formulated. Objectives must be behavioral, measurable, realistic, time limited and must be stated in positive terms. Goals must be patient goals.

I. Interventions must describe how they will assist the patient in meeting the objectives....

M. The Multidisciplinary Treatment Plan shall be reviewed at least weekly by the treatment team.

Procedure:
D. Within twenty-four hours of admission the staff assigned will initiate the Multidisciplinary Treatment Plan, formulate short and long term objectives and interventions for the problems identified on admission..."


Policy and Procedure: 1.20
Title: Interdisciplinary Care /Treatment Plan

Policy: " An Interdisciplinary Care/Treatment Plan will be initiated for each patient by the RN (Registered Nurse). The care plan can be implemented and updated by either the RN or LPN (Licensed Practical Nurse). Care plans will be initiated within 24 hours of admission and will be reviewed every 24 hours and updated with a change in patient behavior/condition. The nurse responsible for the patient's care will notify the attending physician with any significant change in patient behavior or condition...

The Treatment Team (consisting of the Physician, Counselor, Case Manager/Discharge Planner and a RN) will meet at least weekly to review the care plans together to determine effectiveness and make recommendations..."


1. PI # 4 was admitted to the unit 12/15/15 with a diagnosis of Neuro-cognitive Disorder and Alzheimer's Mood Disorder.

The Psychosocial assessment was completed 12/18/15 by Employee Identifier (EI) # 9, Counselor. The initial treatment plan documented by the counselor included:
" Patient is not coping well as evidenced by mood swings, irritability and depressed mood. Goal: Stabilize mood, increase medication compliance and return to higher level of functioning. Intervention: Attend groups daily and work toward 100% treatment (compliance)".

The counseling form Therapy Progress note dated 12/22/15 included, " Pt (patient) stated I just want to go home b/c (because) yesterday a patient attacked him. Counselor assured patient he is safe and taken care of."

In response to questions provided to Administrative staff 1/7/16 at 10:30 AM regarding daily group notes and an incident 12/21/15 the following information was received at 2:30 PM from EI # 3, Assistant Director of Nursing (ADON). " After reviewing chart, documentation of a 12/22 attack by another patient is not found. There is a nurse's note for 12/21 of a patient pushing the patient down. Documentation of notification of the Psychiatrist and/or family members of this incident is not noted in the nurse's documentation. An incident report was not submitted on this incident."

The patient only had two documented counseling notes in the medical record. There was no documentation of an incident of PI # 4 taking PI # 2's clothes. This resulted in a verbal altercation between the two patients. PI # 2 was moved to another room on 12/16/15.

There was no documentation of an Activity assessment, no activity care plan developed and no documentation of participation in therapeutic activities.

During an interview on 1/6/16 at 10:35 AM, EI # 6, Activities Director, stated patient activities are not documented in the medical record. Failure to participate is reported to the RN.

The Interdisciplinary Care Plan was established 12/16/15:

Page 1 of the Treatment plan has signatures of the patient, physician, nurse manager, RN and Medical Social Worker/Counselor.

Page 1 also includes Patient Strengths- nothing is marked or selected.
Short Term Goals-nothing is marked or selected.
Long Term Goals-nothing is marked or selected.
Patient Participation in Treatment Planning- nothing is marked or selected, however the patient did sign the form.

Page 2 includes areas for Diagnosis/ Psychiatric issues interfering with ability to function, expected outcomes and interventions which included Individual Therapy as needed and Family Therapy as needed.

Page 3 includes areas for Diagnosis Safety issues, marked is elopement, all of the expected outcomes are selected and all of the interventions are selected.

Page 10 includes areas for Diagnosis Pain management/comfort, marked is, acute pain, all of the expected outcomes are selected and all of the interventions are selected.

Page 11 includes areas for Diagnosis Acute Stress, marked is, difficulty concentrating and sleep disturbance, all of the expected outcomes are selected and all of the interventions are selected.

Page 12 includes areas for Diagnosis Psychosocial Needs, marked is, return to current residence, all of the expected outcomes are selected and the top two of the interventions are selected.

The next date on each page of the treatment plan was in the resolved column, dated 12/24/15 and staff initials, this was the date of discharge.

The Interdisciplinary Care Plan established 12/16/15 is a pre-printed care plan with generic interventions/ selections and outcomes. The staff failed to individualize the treatment plan to the needs of the patient. When the patient exhibited behavior changes or expressed fear for his/her safety no changes were made to the treatment plan.

The only changes documented for the Psychiatric Unit Careplan Update Sheet from 12/16/15 through 12/23/15 were medication changes, no names or dosage only written is, " Med change symbols".

In an interview on 1/7/16 at 3:00 PM with EI # 1, Director of Nursing confirmed, staff needed to work on the treatment plans.

2. PI # 6 was admitted to the unit 12/30/15 with a diagnosis of Schizophrenia, Chronic, with acute exacerbation.

The Interdisciplinary Care Plan was established 12/30/15:

Page 1 of the Treatment plan has signatures dated 1/6/16 of the patient, physician, nurse manager, RN and Medical Social Worker/Counselor.

Page 1 also includes Patient Strengths- nothing is marked or selected.
Patient Limitations: Lack of insight into illness, Non-compliant with treatment, unemployed/financially insecure and uses drugs and/or alcohol.
Circumstances of admission: Medication/treatment noncompliant, paranoid, bizarre behavior, audio/visual (A/V) hallucinations, disorganized thoughts.
Short Term Goals-nothing is marked or selected.
Long Term Goals-nothing is marked or selected.
Patient Participation in Treatment Planning- nothing is marked or selected, however the patient did sign the form.

Page 2 includes areas for Diagnosis/ Psychiatric issues interfering with ability to function: Hallucinations A/V, Paranoid thinking, Sleep Disturbance and Treatment. Expected outcomes all selected. Interventions all selected except Anger Management, Depression, Anxiety and Bi-polar Disorder, and included Individual Therapy as needed.

Page 3 includes areas for Diagnosis Safety issues, marked is self-injurious behavior and fall risk, all of the expected outcomes are selected and all of the interventions are selected.

Page 6 includes areas for Diagnosis: Non-compliance with treatment due to: Little or no insight. Under Expected outcomes the first item is selected and all of the interventions are selected.

Page 8 includes areas for Diagnosis Impaired ADL's (Activities of Daily Living) unable to perform due to mental illness. All of the expected outcomes are selected and all of the interventions are selected including PT/OT (Physical Therapy/Occupational Therapy) consult if ordered.

No PT or OT therapy was ordered.

Page 10 includes areas for Diagnosis Pain management/comfort, marked is, acute pain, all of the expected outcomes are selected and all of the interventions are selected.

Page 11 includes areas for Diagnosis Acute Stress, marked is, Substance Abuse and sleep disturbance. All of the expected outcomes are selected and the intervention selected is for the Nurse Education regarding diagnosis follow up care and relapse prevention.

Page 12 includes areas for Diagnosis Psychosocial Needs, marked is, return to current residence, all of the expected outcomes are selected and the first and third interventions are selected.

The Interdisciplinary Care Plan established 1/6/16 is a pre-printed care plan with generic interventions/ selections and outcomes. The staff failed to individualize the treatment plan to the needs of the patient.

The only changes documented for the Psychiatric Unit Careplan Update Sheet from 12/31/15 through 1/6/16 were medication changes, no names or dosage only written is, " Med change symbols".

The date resolved column contained no documentation or dates.

In an interview on 1/7/16 at 3:00 PM, the Director of Nursing / EI # 1, confirmed staff needed to work on the treatment plans.

3. PI # 7 was admitted to the unit 12/16/15 with diagnoses of Paranoid Schizophrenia, Aggressive Behavior and Insulin Dependent Diabetes Mellitus.

The Interdisciplinary Care Plan was established 12/16/15:

Considerations: Cannot read

Page 1 of the Treatment plan has signatures dated 12/23/15 of the physician, nurse manager, RN and Medical Social Worker/Counselor.

The patient initially refused to sign but did put his/her mark on the page 12/30/15.

Page 1 also includes Patient Strengths- Compliance with treatment and stable residence was selected.
Patient Limitations:Nothing is selected.
Circumstances of admission: Blank.
Short Term Goals-All are marked including Patient will participate in groups and other therapies 2-3 x (times) per day.
Long Term Goals-All are selected.
Patient Participation in Treatment Planning- nothing is marked or selected, however the patient did sign the form one week after the initial completion of the treatment plan with his/her mark.

Page 2 includes areas for Diagnosis/ Psychiatric issues interfering with ability to function: Paranoid thinking and bipolar were selected.
Expected outcomes all selected. Interventions selected Assess shift & PM (evening), Monitor for: Symptoms of psychosis, thoughts of suicide or injury to self or others, symptoms of mania. Monitor and encourage participation in therapeutic activities, medication as ordered/prescribed and nursing education and included Family Therapy as needed.

Page 3 includes areas for Diagnosis Safety issues, marked is assaultive behavior and fall risk, all of the expected outcomes are selected and all of the interventions are selected.

Page 7 includes areas for Diagnosis Chronic or new onset of acute medical conditions requiring treatment: marked is hypertension and diabetes, all of the expected outcomes are selected and all of the interventions are selected.

The Interdisciplinary Care Plan established 12/23/15 is a pre-printed care plan with generic interventions/ selections and outcomes. The staff failed to individualize the treatment plan to the needs of the patient.

The only changes documented for the Psychiatric Unit Careplan Update Sheet from 12/23/15 through 1/6/16 were medication changes, no names or dosage only written is, " Med change symbols" and twice that pt (patient) refused to sign.

The date resolved column contained no documentation or dates even though the patient has had documented behavior issues requiring 1:1 observation and remains hospitalized after receiving 22 days of care.

The facility failed to document PI # 7 participated in groups and other therapies 2-3 x (times) per day as recommended on the short term goal.

In an interview on 1/7/16 at 3:00 PM the Director of Nursing/ EI # 1, confirmed staff needed to work on the treatment plans.

4. PI # 8 was admitted to the unit 12/29/15 with a diagnosis of Major Depressive Disorder, single, severe with suicide attempt.

The Interdisciplinary Care Plan was established 12/29/15:

Considerations: Needs glasses/contacts to see/ read

Page 1 of the Treatment plan has signatures dated 12/30/15 of the patient, physician and Medical Social Worker/Counselor.

Page 1 also includes Patient Strengths- Support of significant people in life
Patient Limitations: Uses drugs and/or alcohol
Circumstances of admission: Blank.
Short Term Goals- Patient will comply with unit rules as evidenced by participating in groups. Patient will participate in groups and other therapies 2 times per day.
Long Term Goals- Patient agrees to stay compliant on prescribed medications at discharge.
Patient Participation in Treatment Planning- nothing is marked or selected.

Page 2 includes areas for Diagnosis/ Psychiatric issues interfering with ability to function: Depression.
Expected outcomes all selected. Interventions selected Assess shift & PM (evening), Monitor for: Thoughts of suicide or injury to self or others. Included individual Therapy and included Family Therapy as needed.

Page 3 includes areas for Diagnosis Safety issues, marked is self-injurious, assaultive behavior and fall risk, all of the expected outcomes are selected and all of the interventions are selected.

Page 6 includes areas for Diagnosis: Non-compliance with treatment due to: Little or no insight. Expected outcomes the first is selected and all of the interventions are selected.

Page 10 includes areas for Diagnosis Pain management/comfort, marked is, acute pain, the first expected outcome is selected and all of the interventions are selected.

Page 11 includes areas for Diagnosis Acute Stress, marked is, Suicidal thoughts, expected outcomes selected patient will identify major life conflicts from past and present and the intervention selected is the first and last.

Page 12 includes areas for Diagnosis Psychosocial Needs, marked is, return to current residence (jail), first and second expected outcomes are selected and the first and fourth interventions are selected.

Page 13 includes areas for Infection, marked is, Potential Wound, all of the expected outcomes are selected and all the interventions are selected.

The Interdisciplinary Care Plan established 12/29/15 is a pre-printed care plan with generic interventions/ selections and outcomes. The staff failed to individualize the treatment plan to the needs of the patient.

The facility failed to document PI # 8 participated in groups and other therapies times per day as recommended on the short term goal selection.

The only changes documented for the Psychiatric Unit Careplan Update Sheet from 12/30/15 through 1/6/16 were medication changes, no names or dosage only written is, " Med change symbols".

The date resolved column contained no documentation or dates even though the patient has had sutures removed and healed wounds.

In an interview 1/7/16 at 3:00 PM with EI # 1, Director of Nursing confirmed staff needed to work on the treatment plans.

5. PI # 9 was admitted to the unit 12/29/15 with a diagnosis of Chronic Schizoaffective disorder, Bipolar Type.

The Interdisciplinary Care Plan was established 12/29/15:

Considerations: Assessed and none identified.

Page 1 of the Treatment plan has signatures dated 12/30/15 of the patient, physician, the nurse and Medical Social Worker/Counselor.

Page 1 also includes Patient Strengths- no selected strengths
Patient Limitations: Lack of insight into illness. Uses drugs and/or alcohol
Circumstances of admission: Blank.
Short Term Goals-All selected.
Long Term Goals- All selected.
Patient Participation in Treatment Planning- nothing is marked or selected.

Page 2 includes areas for Diagnosis/ Psychiatric issues interfering with ability to function: Mood unstable and Anxiety.
Expected outcomes all selected except 3-7. Interventions selected Symptoms of mania. Medications ordered/prescribed, Social support and resources services, anger management, Bipolar disorder and included individual Therapy and included Family Therapy as needed.

Page 3 includes areas for Diagnosis Safety issues, marked is self-injurious, assaultive behavior and fall risk, all of the expected outcomes are selected and all of the interventions are selected.

Page 6 includes areas for Diagnosis: Non-compliance with treatment due to: Little or no insight. Expected outcomes all are selected and all of the interventions are selected.

Page 11 includes areas for Diagnosis Acute Stress, marked is, Substance abuse, expected outcomes nothing is selected and the intervention nothing is selected.

The Interdisciplinary Care Plan established 12/29/15 is a pre-printed care plan with generic interventions/ selections and outcomes. The staff failed to individualize the treatment plan to the needs of the patient.

The only changes documented for the Psychiatric Unit Careplan Update Sheet from 12/30/15 through 1/6/16 were medication changes, no names or dosage only written is, " Med change symbols" and no changes written in 12/31/15, 1/1/16,and 1/5/16.

The date resolved column contained no documentation or dates.

In an interview 1/7/16 at 3:00 PM with EI # 1, the Director of Nursing confirmed staff needed to work on the treatment plans.

6. PI # 10 was admitted to the unit 1/4/16 with a diagnosis of Schizophrenia, Chronic, with acute exacerbation.

The Interdisciplinary Care Plan was established 1/4/16:

Considerations: Assessed and none identified.

Page 1 of the Treatment plan has signatures dated 1/6/16 of the patient, physician, the nurse and Medical Social Worker/Counselor.

Page 1 also includes Patient Strengths- Insight into illness and support of significant people in life.
Patient Limitations: none
Circumstances of admission: Paranoia, History of Schizophrenia, Court ordered.
Short Term Goals-All selected.
Long Term Goals- All selected.
Patient Participation in Treatment Planning- nothing is marked or selected.

Page 2 includes areas for Diagnosis/ Psychiatric issues interfering with ability to function: Paranoid thinking, other delusional beliefs, anxiety, sleep disturbance.
Expected outcomes all selected. Interventions selected all except anger management, depression and bipolar disorder.

Page 3 includes areas for Diagnosis Safety issues, marked is self-injurious, assaultive behavior and S/H (suicide/homicide) precautions, all of the expected outcomes are selected and all of the interventions are selected.

Page 6 includes areas for Diagnosis: Non-compliance with treatment due to: Little or no insight. Expected outcomes all are selected and all of the interventions are selected.

Page 11 includes areas for Diagnosis Acute Stress, marked is,sleep disturbance, expected outcomes all selected and the interventions all selected.

Page 12 includes areas for Diagnosis Psychosocial Needs, marked is, court ordered,expected outcomes all are selected and interventions all are selected.

The Interdisciplinary Care Plan established 12/29/15 is a pre-printed care plan with generic interventions/ selections and outcomes. The staff failed to individualize the treatment plan to the needs of the patient.

In an interview on 1/7/16 at 3:00 PM with EI # 1, the Director of Nursing confirmed staff needed to work on the treatment plans.

7. PI # 3 was admitted to the unit 12/7/15 with a diagnosis of Bipolar Mood Disorder, mixed with Homicidal Ideations.

The Interdisciplinary Care Plan was established 12/7/15:

Considerations: Assessed and none identified.
Barriers to learning: Educational level inappropriate for age.

Page 1 of the Treatment plan has signatures dated 1/6/16 of the patient, physician, the nurse and Medical Social Worker/Counselor.

Page 1 also includes Patient Strengths- Stable residence, Insurance, Insight and support of significant people in life.
Patient Limitations: Lack of insight into illness, non-complaint with treatment, unemployed/financially insecure, uses drugs and/or alcohol
Circumstances of admission:Medication non-compliance, homicidal ideations and threats toward a step-father.
Short Term Goals-None
Long Term Goals- None.
Patient Participation in Treatment Planning- nothing is marked or selected.

Page 2 includes areas for Diagnosis/ Psychiatric issues interfering with ability to function: Paranoid thinking, mood unstable, treatment.
Expected outcomes all selected. Interventions selected all except Depression, Anxiety, Bipolar Disorder and Schizophrenia.

Page 3 includes areas for Diagnosis Safety issues, marked is self-injurious and assaultive behavior, all of the expected outcomes are selected and all of the interventions are selected.

Page 6 includes areas for Diagnosis: Non-compliance with treatment due to: Little or no insight. Expected outcomes all are selected and all of the interventions are selected.

Page 10 includes areas for Diagnosis Pain management/comfort, marked is, acute pain, all of the expected outcome is selected and all of the interventions are selected.

Page 11 includes areas for Diagnosis Acute Stress, marked is, anger, irritability, substance abuse and hyper vigilance, expected outcomes all selected and the interventions all selected.

Page 12 includes areas for Diagnosis Psychosocial Needs, marked is, court ordered, expected outcomes all are selected and interventions all are selected.

The Interdisciplinary Care Plan established 12/7/15 is a pre-printed care plan with generic interventions/ selections and outcomes. The staff failed to individualize the treatment plan to the needs of the patient.

The only changes documented for the Psychiatric Unit Careplan Update Sheet from 12/9/15 through 12/15/15 were medication changes, no names or dosage only written is, " Med change symbols" and no changes written in six times.

The date resolved column contained the discharge date only.

In an interview 1/7/16 at 3:00 PM with EI # 1, Director of Nursing confirmed staff needed to work on the treatment plans.

8. PI # 5 was admitted to the unit 12/22/15 with a diagnosis of Chronic Schizophrenia with Acute Exacerbation.

The Interdisciplinary Care Plan was established 12/23/15:

Considerations: Assessed and none identified.
Barriers to learning: Educational level inappropriate for age.

Page 1 of the Treatment plan has signatures dated 12/23/15 of the patient, physician, the nurse and Medical Social Worker/Counselor.

Page 1 also includes Patient Strengths: Blank.
Patient Limitations: Blank.
Circumstances of admission: Blank
Short Term Goals-None
Long Term Goals- None.
Patient Participation in Treatment Planning- nothing is marked or selected.

Page 2 includes areas for Diagnosis/ Psychiatric issues interfering with ability to function: Paranoid thinking other delusional beliefs, mood unstable and anxiety. Expected outcomes all selected. Interventions selected monitor and encourage participation in therapeutic activities, medication as ordered/prescribed, nursing education and social support and resources services and individual therapy.

Page 3 includes areas for Diagnosis Safety issues, marked is self-injurious and assaultive behavior, all of the expected outcomes are selected and all of the interventions are selected.

Page 6 includes areas for Diagnosis: Non-compliance with treatment due to: Little or no insight. Expected outcomes all are selected and all of the interventions are selected.

Page 8 includes areas for Diagnosis Impaired ADL's poor hygiene. All of the expected outcomes are selected and all of the interventions are selected except PT/OT consult if ordered.

Page 11 includes areas for Diagnosis Acute Stress, marked is, anger, irritability, difficulty Concentrating, expected outcomes all selected and the interventions all selected.

The Interdisciplinary Care Plan established 12/23/15 is a pre-printed care plan with generic interventions/ selections and outcomes. The staff failed to individualize the treatment plan to the needs of the patient.

The only changes documented for the Psychiatric Unit Careplan Update Sheet from 12/23/15 through 1/5/15 were medication changes, no names or dosage only written is, " Med change symbols" and no changes written in eight times.

The date resolved column contains no documentation.

The review of the 8 medical records failed to identify any family counseling documented although it was a scheduled intervention.

The patient's participation in developing their treatment plan is only documented as a signature. There is no documentation on the treatment plan itself to individualize the care by interventions or individualized goals.

The facility policy includes direction for the patient goals to be "patient goals" and interventions " Must describe how they will assist the patient in meeting the objectives". The preprinted, canned care plans in use fail to address the patients realistic and individualized needs and goals.

In an interview on 1/7/16 at 3:00 PM with EI # 1, the Director of Nursing confirmed staff needed to work on the treatment plans.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical records, policy and procedures, incident report and interview it was determined the facility failed to:

1. Keep patients in a safe environmental setting to protect them from self injurious behavior and harm to other patients, staff or the general public.

2. Obtain orders for 1:1 observation and report changes to the physician requiring a change in the level of care.

3. Place Patient Identifier (PI) # 2 on 1:1 observation after noting he/she was actively homicidal per policy.

4. Recognize the complexity of PI # 2's previous suicide attempts and family history of suicide.

This affected 3 of 10 records reviewed PI # 2, # 7 and # 8 . This had the potential to affect all others receiving care or visiting this facility.


Findings include:

Policy and Procedure: O.10
Title: One-to-One Observation

Policy: " One-to-One supervision is close observation of patients who have been identified as an imminent danger to themselves or others. In addition, patients may be placed on One-to-One Observation if their self-care and/or Medical needs require continuous support/assistance. Although a Physician must order One-to-One Observation, a Registered Nurse may place a patient on One-to-One Observation and contact a physician for the order..."


Policy and Procedure: C.20
Title: Close Observation of Patients on the Gateway Behavioral Health Unit

Policy: " Patients admitted to the psychiatric unit are placed on suicidal/homicidal precautions and will be monitored under close observation. Patients who are actively suicidal or homicidal will be monitored on 1:1 or 1:1 within arms' reach..."

Procedure: "Close Observation:
A. All patients shall be placed on Close Observation for the duration of the hospitalization .
1) Close observation requires that staff monitor the patient by direct visual contact every fifteen minutes which will be documented on an Observation Log sheet."

Policy and Procedure:
Title: Suicide Assessment and Precautions

Policy: " Staff observing potential suicidal statements and behaviors exhibited by patients will report to supervisory staff immediately and take measures to promote safety. Suicide precautions 1:1 or 1:1 within arms' reach shall be initiated when a patient actively demonstrates suicidal ideations or behaviors...

Procedure:
1. Patients are screened prior to admission for suicidal ideation (SI) and potential for self harm by physician and/or nurse reviewers at intake...
5. If the patient is determined to be actively suicidal with the intent to harm themselves and the ability to do so, they will be placed on one-to-one observation or one-to-one observation within arms' reach until the psychiatrist evaluates the patient and discontinues the one-to-one order. Only the psychiatrist may discontinue the one-to-one order.

Given the absence of valid or reliable "evidence based" tools for the prediction of suicide risk, the clinician should focus on determining whether the patient has:
1. Suicidal intent
2. A viable plan and
3. The means to carry out their intent and plan (cognition).

Due to the variety and complexity of factors related to suicide risk, consultation with clinical peers is essential and any doubt should be resolved on the side of protecting the patient...
4. Screening questions may include:
Have you had thoughts of death or killing yourself? If so, what were they?
Are you currently thinking about killing yourself...

History and environmental indicators (may be assessed via record or by patient observation/questioning):
Have you attempted suicide in the past? If so, what did you do?
Has a close friend or anyone in the family committed suicide?


Hospital B Record Review:

1. Patient Identifier (PI ) # 2 received a psychiatric evaluation by a Registered Nurse (RN) at Hospital B's Emergency Department (ED) on 12/15/15 at 8:06 AM:

Onset: 3 weeks.
Associated symptoms: Anger, Depression, Wanting to harm others, Thought Disturbances, Self Mutilation.
History of Drug Overdose: Yes.
Family History of Suicide: Yes.
History of Suicide Attempt(s): Yes.
Details: Shot hole in leg, cut wrists, Soma overdose.
Stressors: "Been in jail, Watched his cousin blow his brains out when he was seven, has seen lots of death and rape in jail, abused as a child."

A review of the ED Nursing Notes on 12/15/15 revealed Patient Identifier (PI) # 2:
- was on suicide precautions beginning at 9:05 AM.
- Received Lorazepam (benzodiazapine) 1 milligram po (by mouth).
- At 10:44, the note revealed PI # 2 remained on suicide precautions and was in line of sight from the nursing station.
- Received Lorazepam 1 milligram IM (intramuscular) at 12:44 PM.
- was transferred to Hospital A (Bullock County Hospital / BCH) at 2:30 PM for psychiatric treatment.


Review of PI # 2's medical record from BCH:

Patient Identifier (PI ) # 2 presented to BCH's Emergency Department (ED) on 12/15/15 at 4:20 PM via EMS (Emergency Medical Services).

Chief Complaint: Hearing voices.
Mental Status: Alert and oriented.
HPI (History of Present Illness): 51 yo presents with...Homicidal thoughts and auditory hallucinations.
Diagnoses: Bipolar Disorder
Auditory Hallucinations
Condition: Fair
Disposition: Admit to Gateway (Behavioral Health Unit - part of BCH)

Medications taken at home Medication Reconciliation -12/15/15 at 5:45 PM include:
Clonazepam 1 milligram for seizures.

Behavioral Health Unit Nursing Note: 12/15/15 at 6:50 PM:
Patient arrived on the unit at 5:15 PM...patient is here because of "Depression and HI (Homicidal Ideation)...states his childhood was "riddled with continuous physical and emotional abuse by his father."
History of Gunshot wound to leg and stab wound to shoulder secondary to abuse by his father. Also reports facial surgery, secondary to his face being "smashed with a ball bat" by his father. Reports seizure disorder, hypertension, migraines and arthritis. "Routine orders" received from psychiatrist.

A review of the routine orders revealed:

- Admit to Gateway
- q (every) 15 minute observations
- SP/HP (Suicide/Homicide Precautions)
- Zyprexa 5 milligrams po (by mouth) q (every) HS (Hour of Sleep)
- Remeron 15 milligrams po q HS

PRN (as needed) Orders include:
- Ativan 1-2 milligrams every 6 hours prn for agitation...
- Vistaril 25 milligrams every 6 hours prn for anxiety.


Nursing Admission Assessment - Gateway Behavioral Unit on 12/15/15 at 7:05 PM:

Admission Legal Status: Voluntary

Chief Complaint: Depression and Homicidal Ideation.

Violence to Self within the past 6 months:" Past suicide attempts, intentional cutting of self, intentional damaging of self."

Describe suicide attempts by family members: Cousin committed suicide.

Violence Risk to Others with the past 6 months: "Thoughts of harm to others, homicidal thoughts."

Psychological Trauma: Physical and emotional abuse, severe childhood neglect, traumatic family loss.

Current/previous psychiatric problems: Depression

Previous legal issues: Prison ('98 -2011).

Emotional/Behavioral/Cognitive Status:

Affect: Flat, blunted.

Mood: Depressed.

Paranoia Present: "Present."

Eye Contact: Fair.

Appetite: Decreased.

Sleep Patterns: Difficulty falling and staying asleep. Reports 3 hours of sleep per week.


Interdisciplinary Patient/Family Education, 12/15/15 at 6:45 PM:

Barriers to Learning: Cannot read, Cannot write.


Nurse's Notes regarding Patient Identifier (PI) # 2:

12/15/15 at 9:33 PM: ..."Rates Depression 10/10." ...Appears anxious, depressed. Flat affect...States he has anger problems to the point he wants to harm others-denies at present. "Preoccupied with home medications; states Klonopin, Soma only things that help his anxiety and pain. "...explained routine orders and encouraged him to discuss with Dr. (name of psychiatrist).

12/16/15 at 6:02 AM: Restless sleep.

12/16/15 at 9:00 AM: Blunted, irritable and anxious. Preoccupied with getting Klonopin. "I take 2-3 tablets three times daily. Explained to patient he doesn't have any Klonopin ordered and that he would be seeing the doctor soon and that he would need to speak with him." ...Patient inquiring about signing himself out and stated, "I came on my own and I can leave whenever I get ready. Explained to patient that discharges where automatically up to the psychiatrist and discuss his concerns with him during treatment team. Patient stated some of his belongings were taken by his roommate "...and since he couldn't have his medications he would rather just leave." Patient was "allowed" to change rooms earlier due to "confrontation" about personal belongings.


12/16/15 at 12:00 PM: Irritable. Continues to request Klonopin or be discharged ...Patient advised MD started him on a different medication to help with detoxing, seizures and anxiety. Patient also reminded of his encounter during treatment team. "Patient advised during treatment team that if he continued to demand to leave an emergency hold would be placed on him. Patient verbalized understanding and abruptly went to his room."

12/16/15 at 2:30: Code Blue. Patient transferred to ER (emergency room at BCH).


Psychiatric History and Physical 12/16/15:

...male with second grade education. Divorced. Lives with ex-wife.

CC (Chief Complaint): Anger. Depression. Homicidal thoughts.

HPI: admitted from Hospital B's emergency room . Presented with anger, severe dysphoria, self mutilation and history of three prior suicide attempts. Homicidal, disorganized and drug seeking behavior. The patient is having mood swings, hopelessness, helplessness, worthlessness.

Past Psychiatric History: Significant for depression and drug abuse.

Urine Drug Screen: Positive for Benzodiazapines (tranquilizer) and THC (Marijuana).

Medical History: Paternal cousin committed suicide by gunshot.

Mental Status Examination: ...Unkempt. Has increased psychomotor activity. Disheveled. Has dysphoric (profound state of uneasiness) and angry mood, congruent affect, drug seeking behavior.

Has been self mutilating and cutting self. Poor insight and impaired judgement.

Impression:
Axis I: Major Depressive Disorder, recurrent, severe with Homicidal Ideation. THC and Benzodiazapine use disorder.
Axis V: GAF (Global Assessment of Functioning): 30. ( A scale from 0 to 100. Higher scores indicate greater levels of functioning. Severe problems fall in the 21 - 30 range.)

Psychiatric History and Physical was not timed or signed by the physician.

A review of PI # 2's Medication Administration Record (MAR) revealed
Phenobarbital 30 milligrams po was not given as ordered at 12:00 PM on
12/16/15.


Observation Log
A review of the log revealed PI # 2's observation status was 15 minute checks. The final entry documentation by the Mental Health Technician revealed PI # 2 was awake and in his room at 1:30 PM on 12/16/15.


Review of PI # 2's ER Record dated 12/16/15:

1:36 PM: Brought in to ER via stretcher unresponsive (from Psychiatric Unit) with ACLS (Advanced Cardiac Life Support) in progress.

HPI (History of Present Illness): ...year old male patient "presents with unresponsive. Pt. (patient) reportedly found in his room on psych (psychiatric) unit hanging from door unresponsive with bedsheet tied around his neck. It is unknown how long he had been there...CPR (Cardiopulmonary Resuscitation) started and patient transported to ER. Patient noted to be in asystole." (absence of heartbeat).

Additional Clinical Notes:
Patient found to be in asystole once transported to ER. CPR / ACLS continued and patient intubated (insertion of a breathing tube into the trachea)...Patient given a total of 3 milligrams of Epi (Epinephrine) before additional resuscitative efforts were discontinued. He was pronounced dead at 1:51 PM.


Interviews

1. During an interview on 1/6/16 at 2:30 PM, the staff RN (Registered Nurse)/Employee Identifier (EI) # 7 (assigned to Patient Identifier (PI # 2) described PI # 2 on the morning of 12/16/15 as "upset because he could not get Klonopin." EI # 7 said she informed the patient he had to be assessed by the physician before medications would be ordered.

EI # 7 stated she was on another unit on 12/16/15 obtaining Phenobarbital for PI # 2 when she heard Code Blue via overhead page. When EI # 7 reached PI # 2's room CPR was in progress. The RN was asked if she completed an incident report and she said, "No."


2. During an interview on 1/7/16 at 9:00 AM, the Mental Health Technician (MHT)/ EI # 8 confirmed he was assigned to PI # 2. The MHT described PI # 2 's behavior earlier in the day as pacing between the dayroom and room 206. PI # 2 was angry after talking with the psychiatrist because he had been told he could not go home. According to the MHT, the last time he saw PI # 2 alive, the patient was sitting on his bed in his room with his head in his hands. The tech asked PI # 2 if he was okay and the patient looked at him, but did not respond verbally. The next time he saw PI # 2 the patient had a sheet tied around his neck. The sheet was tied to the inside door knob of the bathroom door. Another MHT and EI # 8 "lifted" PI # 2's body to relive the pressure on the patient's neck. When asked to recall more information about the event EI # 8 said, "I kind of blacked out after that."


3. During an interview on 1/7/16 at 9:00 AM, the Mental Health Technician (MHT)/ EI # 11 described PI # 2 as "already agitated." When asked to describe PI # 2's agitation, the MHT said the patient repeatedly said he wanted to leave. According to the MHT, another patient was wearing PI # 2's shirt. The MHT got the shirt from the other patient, laundered it and returned the shirt to PI # 2's room. Due to this incident, the MHT informed an RN PI # 2 needed to be moved to another room.

When the MHT (EI # 11) went to PI # 2's room to return the shirt, he noted all the sheets were stripped from the bed located on the right side of the room. After the technician entered the patient's room, he turned around and saw PI # 2 hanging from the bathroom door. The technician ran to the nurse's station, beat on the window and motioned the staff via hand gestures to quickly follow him. (There is no call system in patient rooms). He returned to PI # 2's room and saw a sheet was tied around the door knob on the inside of the bathroom door. According to the MHT, the patient said he was "homicidal."

4. During an interview on 1/5/16 at 1:00 PM, the Mental Health Technician (MHT)/ EI # 12, stated PI # 2 was upset because his roommate was wearing his shirt. PI # 2 was loud and cursing. Because of PI # 2's behavior, EI # 12 called a male technician for assistance.

According to the MHT when she returned from lunch she was advised PI # 2 had hung himself. When asked if changes were implemented after the event the MHT said, "Pretty much do the same."

5. During an interview on 1/5/16 at 1:38 PM, the Mental Health Technician (MHT)/ EI # 13, verified PI # 2 was pacing the whole unit. PI # 2 said his roommate was wearing his clothes. According to the MHT, this incident was reported by a male MHT to a Registered Nurse.

6. During an interview on 1/6/16 at 9:35 AM, the Psychiatrist/EI # 14, described PI # 2 as a male with a history of impulsivity. The psychiatrist assessed PI # 2 during treatment team on 12/16/15. The team included a Registered Nurse, therapist and the treatment coordinator.

According to the psychiatrist, PI # 2 denied suicidal ideation and corrected the psychiatrist three times during treatment team/psychiatric evaluation. "He (PI # 2) denied suicidal ideation, homicidal plans and denied having a role model (related to harming others). Still I did not believe him. He (PI # 2) was not agitated or violent. I did not trust him." The patient wanted to leave.

The psychiatrist identified three areas of concern:
1. Substance Abuse- The patient reported smoking marijuana nightly.
2. Klonopin use.
3. Mood Swings/impulsivity.

The psychiatrist reported Phenobarbital was ordered for detoxification from Klonopin (medication used to treat anxiety, certain seizure disorders, difficulty sleeping and alcohol withdrawal - www.nami.org/Learn-More/Treatment/Mental-Health). The psychiatrist explained Phenobarbital was a better option than Klonopin for detox due to the patient's history of drug use.

The patient was placed on 15 minute checks and suicide observations. The psychiatrist also stated PI # 2 had previous suicide attempts.

According to the psychiatrist (EI # 14), the patient (PI # 2) asked for his home medications to treat hypertension and glaucoma on 12/16/15 at approximately 11:00 AM. "He mislead me. Someone who wants meds (medications) wants to live."

When asked about documentation of the patient's suicide the psychiatrist said, "I did not write a note. He was being resuscitated. Whatever happened he (PI # 2) did in ten minutes." The psychiatrist was asked about the safety of mixing demented and agitated patients on the unit. He replied, "The problem was there were more agitated patients on the unit at the time."

A review of the BCH Incident Report received on 1/6/16 at 11:45 AM revealed:

Report date: 1/5/2016

Occurrence Date: 12/16/2015

Occurrence Time: 1:30 PM

Type of Occurrence: Patient Suicide

Brief Description: At approximately 11:00 AM, the patient (PI # 2) participated in treatment team where he repeatedly denied suicidal ideations. At approximately 1:28 PM, a Mental Health Tech stated that he rounded on and interacted with the patient in the patient's room. At approximately 1:30 PM, a second Mental Health Tech went into the patient's room to return some freshly laundered clothing and found the patient hanging from the bathroom door by a bedsheet.

CPR was started on the unit. Patient transported to ER for continued CPR. Patient expired. State called and police conducted investigation. Hospital investigation underway.

Summary:
PI # 2 was unknown to BCH staff. It was the patient's first psychiatric admission whose history included three documented suicide attempts, suicide committed by a family member, incarceration for extended periods and severe mental/physical abuse during childhood.

BCH nursing staff failed/to recognize and/or report PI # 2's concerns/symptoms of continued agitation, numerous request for Klonopin, repeated demands to leave the hospital and his undocumented "altercation" with his roommate to the psychiatrist. Instead, documentation revealed PI # 2 was told repeatedly by staff to discuss his concerns with the psychiatrist.

These factors were not recognized by staff as potential for self harm to warrant continuous observation (at a minimum until PI # 2 was assessed by the psychiatrist).

According to hospital policy regarding HI/SI, PI # 2 should have been placed on 1:1 observation.

The Occurrence report documents PI # 2 repeatedly denied suicidal ideation. However, this denial was not documented in the psychiatric H&P. Nor was there any documentation in the medical record about the patient's suicide by the psychiatrist or psychiatric nursing staff. There was no documentation in the medical record about the family's notification of the patient's suicide.






2. PI # 7 was admitted to the unit 12/16/15 with a diagnoses of Paranoid Schizophrenia, Aggressive Behavior and Insulin Dependent Diabetes Mellitus.

The 12/25/15 Nurses Notes sheet documented at 8:10 AM, " Patient (pt) alert verbal. Oriented to self. Pt sitting in w/c (wheelchair) cursing and yelling at staff. Pt is very impulsive, getting up and down in w/c. Pt noted drooling from mouth. Aggressive behavior noted towards staff...Auditory/Visual (A/V) hallucinations apparent..."

The Patient Round Flowsheet completed every 2 hours by the nursing staff dated 12/25/15:
8:00 AM- yelling out loud 1:1 in Dayroom
10:00 AM- yelling out loud 1:1 in Dayroom/TV (television) room
12:00 PM- yelling out loud 1:1 in TV room
2:00 PM- yelling out loud 1:1 in TV room
4:00 PM- Refused finger stick
6:00 PM- Yelling out 1:1 in TV room
8:00 PM- 1:1 in Dayroom.

The lack of activities while the patient remained in the TV room from 10:00 AM until 6:00 PM failed to assist staff to meet the patient's on going needs.

The 12/25/15 Nurses Notes sheet documented at 6:38 PM, " Pt. refused all meds (medications), Tx (treatment) and meals today."

The 12/25/15 Nurses Notes sheet documented at 9:45 PM, " Observed on unit, ambulates via wheelchair...disorganized, paranoid, delusional, auditory and visual hallucinations endorsed. Verbal threats made to unseen and present persons..."

The patient was on 1:1 for 10 hours due to yelling out and aggressive behavior. The nurse failed to notify the physician of the continued behavior, failed to identify a process to help patient cope with his agitation and aggressive behavior and failed to obtain an order for the 1:1 observation to provide for safe care for the patient, other patients and staff.

In an interview on 1/7/16 at 3:00 PM with Employee Identifier (EI) # 3, the Assistant Director of Nursing confirmed the nurse did not have an order for the 1:1 observation and did not notify the physician of PI # 7's behaviors through out the day.

3. PI # 8 was admitted on [DATE] with a diagnosis of Major Depressive Disorder, single, severe with suicide attempt.

History of present illness includes, " He has been very down, depressed, has mild neurocognitive disability, poor coping skills. Has cut his left forearm, needed sutures. Has tried to hang himself. Feels hopeless, helpless and worthless."

The admission orders for 12/29/15 included, " 1:1 for 24 hours, Q (every) 15 minute observations, suicidal/homicidal precautions..."

The Nurses Notes dated 12/30/15, " Arrive on the unit at 2257(10:57 PM)...admitted with diagnosis of suicidal attempt and depression...because patient cut left wrist and per patient attempted to hang himself...patient is currently on 1:1 observation for 24 hours..."

PI # 8 remained on 1:1 observation on 12/31/15, 1/1/16, 1/2/16, 1/3/16, 1/4/16, 1/5/16 and the physician wrote an order on 1/6/16 at 12:00 PM to change observation status to close observation LOS (line of sight).

The patient remained on 1:1 from 12/31/15 through 1/6/16 even though the original order was for 24 hours.

In an interview on 1/7/16 at 3:00 PM with Employee Identifier # 3, the Assistant Director of Nursing confirmed the order for 1;1 was only written for 24 hours and a discontinue order was not written until 1/6/16.
VIOLATION: ORGANIZATION OF NURSING SERVICES Tag No: A0386
Based on review of personnel files, job qualifications for exclusion from prospective payment system psychiatric system units 412.25 (A1184 and A 1185) and interview it was determined:

1. The Registered Nurse Unit Manager failed to meet the qualifications for the director of psychiatric nursing services.

2. Inaccurate data was submitted on 12/30/15 for staffing on the attestation to continue its participation as a PPS (Prospective Payment System) excluded Psychiatric unit.

Findings include:

412.25 Excluded Hospital Units: Common Requirements:

A1184 3(i) The director of psychiatric nursing services must be a registered nurse who has a master's degree in psychiatric and mental health nursing, or its equivalent from a school of nursing accredited by the National League of Nursing, or be qualified by education and experience in the care of the mentally ill. The director must demonstrate competence to participate in interdisciplinary formulation of individual treatment plans; to give skilled nursing care and therapy; and to direct, monitor, and evaluate the nursing care furnished.

In an interview with Employee Identifier (EI) # 4, Nurse Manager Psychiatric Unit on 1/7/16 at 11:38 AM, EI # 4 stated that she started working on the psychiatric unit in June 2014 and assumed the role of Nurse Manager in October 2014.

EI # 4 stated she had never worked with Psychiatric patients before her employment with Bullock County Hospital and that she had no previous experience in the care of mentally ill patients.

A review of the personnel file for EI # 4 failed to include any Psychiatric nursing experience. EI # 4 does not have a Master's or Bachelor's degree in nursing.

An interview was conducted with EI # 1, Co-Administrator on 1/7/16 at 1:16 PM, she confirmed EI # 4 failed to meet the documented requirements for overseeing the Psychiatric unit. When asked if the hospital Director of Nursing or the Assistant Director of Nursing had any Psychiatric experience the answer was," No." EI # 1 was agreeable to arrange for a consultant to work with EI # 4 to assist with her education and decision making on the unit.

The PPS exclusion form submitted 12/20/15 had yes marked in response to A1184(i) requirements for the director of psychiatric nursing services.

A1185(ii) The staffing pattern must ensure the availability of a registered nurse (RN) 24 hours each day. There must be adequate numbers of registered nurses, licensed practical nurses (LPN) and mental health workers to provide the nursing care necessary under each inpatient's active treatment plan.

Inaccurate data was submitted 12/30/15 for staffing on the attestation form to include:
Shift: 7 AM- 7 PM is 3 RNs, 1 LPN and 4 mental health workers (techs)
Shift: 7 PM- 7 AM is 3 RNs, 4 techs
according to the data submitted by Employee Identifier (EI) # 1, Co-Administrator.

During an interview on 1/5/16 at 11:45 AM, EI # 4, Nurse Manager Psychiatric unit explained the staffing as 18-24 patient = 3 nurses and 4 techs. If the census is less than 18 patients 2 nurses and 4 techs are scheduled.

In an interview with EI # 4 about the staffing recorded on the PPS form received on 12/30/15, the Nurse Manager stated that she did not know where EI # 1 came up with those numbers. They work the schedule according to the acuity of the patients. She has never been aware of having 4 nurses on the schedule for the unit.

The staffing for 1/5/16 (the first day of the survey) had 2 RNs and 4 techs with another tech in orientation. The unit had a census of 14 on 1/5/16.
VIOLATION: CONTENT OF RECORD Tag No: A0449
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical records, activity log, polices and procedures and interviews, it was determined the multidisciplinary treatment team failed to document appropriate and complete assessments to establish:

1. Multidisciplinary Treatment Plans

2. Individual note and counseling documentation

3. Activity assessment and activity plans for all patients treated prior to 1/6/16.

This affected 6 of 10 records reviewed and had the potential to affect all patients served in this facility. This affected Patient Indentifer (PI) # 4 ,
# 6 , # 7, # 8, # 9, and # 5.

Findings include:

Policy and Procedure:
Title: Multidisciplinary Treatment Plan

Purpose: " To provide individualized care response to the patient's specific need and to ensure the patient's participation in care is provided.

Policy:
A. " Each patient shall have a written individualized treatment plan based on the patient's present problems, physical health, emotional and behavioral status, and strengths and weaknesses. The Multidisciplinary Treatment Plan shall be derived from each discipline's assessment of the patient as well as the patient/family perceptions of the patient's needs. This includes a review of the data available at the time of the information of the plan, to include:
2. Psychiatric evaluation...
4. Nursing Admission Assessment
5. Psychosocial history...
8. Activity Recreation Therapy Assessment...

B. The plan of care is supervised by the attending psychiatrist. The Multidisciplinary Treatment Plan will be completed no later than 3 days following the date of admission. The Multidisciplinary Treatment Plan shall be signed by the attending physician and the treatment team..."


Policy and Procedure: 1.20
Title: InterDisciplinary Care /Treatment Plan

Policy: " An Interdisciplinary Care/Treatment Plan will be initiated for each patient by the RN (Registered Nurse). The care plan can be implemented and updated by either the RN or LPN (Licensed Practical Nurse). Care plans will be initiated within 24 hours of admission and will be reviewed every 24 hours and updated with a change in patient behavior/condition. The nurse responsible for the patient's care will notify the attending physician with any significant change in patient behavior or condition...

The Treatment Team (consisting of the Physician, Counselor, Case Manager/Discharge Planner and a RN) will meet at least weekly to review the care plans together to determine effectiveness and make recommendations..."



1. PI # 4 was admitted to the unit 12/15/15 with a diagnosis of Neuro-cognitive Disorder and Alzheimer's Mood Disorder.

The Psychosocial assessment was completed 12/18/15 by Employee Identifier (EI) # 9, Counselor. The initial treatment plan documented by the counselor included:
" Patient is not coping well as evidenced by mood swings, irritability and depressed mood. Goal: Stabilize mood, increase medication compliance and return to higher level of functioning. Intervention: Attend groups daily and work toward 100% treatment (compliance)".

The counseling form Therapy Progress note dated 12/22/15 included, " Pt (patient) stated I just want to go home b/c (because) yesterday a patient attacked him. Counselor assured patient he is safe and taken care of."

In response to questions provided to Administrative staff on 1/7/16 at 10:30 AM regarding daily group notes and an incident 12/21/15 the following information was received at 2:30 PM from EI # 3, Assistant Director of Nursing (ADON). " After reviewing chart, documentation of a 12/22 attack by another patient is not found. There is a nurse's note for 12/21 of a patient pushing the patient down. Documentation of notification of the Psychiatrist and/or family members of this incident is not noted in the nurse's documentation. An incident report was not submitted on this incident."

The patient only had two documented counseling notes in the medical record.

The counseling note documentation failed to provide interventions as the counselor documented 12/18/15, " Attend groups daily and work toward 100% treatment (compliance)".

There was no documentation of an Activity assessment, no activity plan developed and no documentation of participation in therapeutic activities.


The surveyor reviewed the Gateway Unit Schedule and Activities Log for 12/16/15 when PI # 4 was an active patient and the following areas were blank or incomplete on the form where the initials of the person conducting the activity was to be recorded:
8:30-9:00 Community Meeting (Current Events, Weather, Review Daily Schedule/Unit Rules)_________
9:00-9:30 Therapy Group:________
9:30-10:00 Nurse Group-Meds. Topic:_________
1:30-2:00 Nurse Group. Topic:_________
2:30-3:00 Therapy Group__________
9:00-9:30 Community Meeting/Relaxation Time/ Wrap-Up of Day's Activities____________.

A review of the Activities Log book 1/6/16 revealed the current week of January 4-6 were present. All prior sheets had been thinned from the Activity Log book until 9/15/15. A review of the log sheets consistently showed incomplete assignment of Groups and Topics to be presented on the following dates 9/15/15, 9/14/15, 9/10/15, 9/9/15, 9/6/15, 9/5/15, 9/1/15, 8/27/15, 8/26/15, 8/24/15, 8/23/15, 8/22/15, 8/18/15, 8/13/15, 8/11/15, 8/9/15, 8/4/15, 8/3/15, 7/30/15, 7/29/15, 7/26/15, 7/25/15, 7/21/15, 7/16/15, 7/11/15, 7/7/15, 7/6/15, 7/2/15 and 6/30/15.

During an interview on 1/6/16 at 10:35 AM, EI # 6, Activities Director, stated patient activities are not documented in the medical record. Failure to participate is reported to the RN.


2. PI # 6 was admitted to the unit 12/30/15 with a diagnosis of Schizophrenia, Chronic, with acute exacerbation.

The Admission History and Physical by the Psychiatrist included plans for the patient to be provided substance abuse dependence education and individual cognitive-behavioral counseling.

In response to questions provided to Administrative staff 1/7/16 at 10:30 AM regarding therapy/ group notes and an activity assessment the following information was received at 2:30 PM from EI # 3, ADON.

One therapy note dated 1/4/16 which is 5 days after admission and a new activity assessment completed 1/7/16. The one therapy note and the activity assessment are not a part of the Interdisciplinary Care/Treatment Plan which is to be in place within 3 days.

In an interview 1/7/16 at 3:00 PM with EI # 3, he confirmed the activities were not assessed and therapy notes were not a part of the established treatment plan.

3. PI # 7 was admitted to the unit 12/16/15 with diagnoses of Schizoaffective Disorder, bipolar type, manic and delusional. Neurocognitive Disorder and Insulin Dependent Diabetes Mellitus.

The admission History and Physical/ Psychiatric evaluation summary includes the following: " The patient is placed on falling precautions, suicidal precaution and homicidal precaution...Individual cognitive-behavioral counseling and group therapy will be offered."

In response to questions provided to Administrative staff 1/7/16 at 10:30 AM regarding therapy/ group notes and an activity assessment the following information was received at 2:30 PM from EI # 3, ADON.

One therapy note dated 12/29/15 which is 13 days after admission and a new activity assessment completed 1/7/16. The single therapy note and the activity assessment are not a part of the Interdisciplinary Care/Treatment Plan which is to be in place within 3 days.

During an interview on 1/6/16 at 10:35 AM, EI # 6, Activities Director, stated patient activities are not documented in the medical record. Failure to participate is reported to the RN.

The daily activity log failed to have documentation related to group therapy. There was no documentation the patient received the ordered group therapy. With only one therapy note for the 22 day stay, the patient is not receiving the individual therapy as ordered.

In an interview on 1/7/16 at 10:42 AM with EI # 10, Counselor, she stated that she usually saw the patients for individual counseling 2 times a week and participated in Group therapy 1 time a week.

In an interview on 1/7/16 at 3:00 PM, EI # 3 confirmed the activities were not assessed and therapy notes were not a part of the established treatment plan.

4. PI # 8 was admitted to the unit 12/29/15 with a diagnosis of Major Depressive Disorder, single, severe with suicide attempt.

History of present illness includes, " He has been very down, depressed, has mild neurocognitive disability, poor coping skills. Has cut his left forearm, needed sutures. Has tried to hang himself. Feels hopeless, helpless and worthless."

In response to questions provided to Administrative staff 1/7/16 at 10:30 AM regarding therapy/ group notes and an activity assessment the following information was received at 2:30 PM from EI # 3, ADON.

The surveyor received copies of Bradford counseling notes for 1/4/16, 1/5/16 and 1/6/16 and two counseling notes from the therapist/psychiatric counselor at Gateway. The notes from Bradford are a checklist related to attending classes for substance abuse with no time of the session and not part of the therapeutic plan for his/her diagnosis of Major Depressive Disorder.

PI # 8 had resided on the Psychiatric unit for 9 days before an Activity Assessment was completed 1/7/16. The patient had not received documented group therapy or therapeutic interventions to learn new coping skills related to his Depression and suicidal tendencies with a plan.

In an interview on 1/7/16 at 3:00 PM with EI # 3 confirmed the activities were not assessed and therapy notes were not a part of the established treatment plan.

5. PI # 9 was admitted to the unit 12/29/15 with a diagnosis of Chronic Schizoaffective disorder, Bipolar Type.

In response to questions provided to Administrative staff on 1/7/16 at 10:30 AM regarding therapy/ group notes and an activity assessment the following information was received at 2:30 PM from EI # 3, ADON.

The surveyor received copies of Bradford counseling notes for 1/4/16, 1/5/16 and 1/6/16 marking attendance at 11:15 AM and 1:30 PM the first two days and at 1:30 on 1/6/16. One counseling note from the therapist on 1/1/16. The notes from Bradford are checklist related to attending classes for substance abuse with no time of the session and are not part of the therapeutic plan for his/her diagnosis of Chronic Schizoaffective disorder.

PI # 9 had resided on the Psychiatric unit for 9 days before an Activity Assessment was completed 1/7/16. The patient had not received documented group therapy or therapeutic interventions to learn new coping skills related to his diagnosis.

In an interview on 1/7/16 at 3:00 PM EI # 3, confirmed the activities were not assessed and therapy notes were not a part of the established treatment plan.

6. PI # 5 was admitted on [DATE] with a diagnosis of Chronic Schizophrenia with Acute Exacerbation.

In response to questions provided to Administrative staff 1/7/16 at 10:30 AM regarding an activity assessment the following information was received at 2:30 PM from EI # 3, ADON.

A Recreation/Activities Assessment & Treatment Plan was developed 1/6/16 and provided to the surveyor 1/7/16 at 9:30 AM by EI # 2, Director of Nursing. EI # 2, states EI # 6, Activities Director will start immediately using the new tool today (1/7/16).
VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Tag No: A0724
Based on observation of the Gateway unit, patient rooms and interview it was determined patient care areas had potentially hazardous conditions that could cause harm to the patients.

Findings include:

On 1/5/16 at 9:20 AM the surveyors toured the south hall also referred to as the Geriatric hallway.

The surveyors were accompanied by Employee Identifier (EI) # 1, Co-Administrator, EI # 2, Director of Nursing (DON), and EI # 4, Registered Nurse (RN) Manager of the Psychiatric Unit.

The shower room and the bathroom also used for showers on the south hall failed to have locks on the doors. This presents a hazard for patients going into the areas and hiding or becoming lost due to their dementia diagnosis and short term memory loss.

Three beds were observed in Room 201, a semi-private room. The glass in the window had a broken area in the right bottom corner presenting a potential hazard. EI # 5, Environmental Services was notified by Administration to have the window repaired.

Room 203, a semi-private room, had three beds in the room.

Room 206, a semi-private room, was the room where Patient Identifier (PI) # 2 hung himself with sheets attached to a hand rail beside the toilet in the bathroom and over the door 12/16/15.

The hand rails were removed from all rooms on the Geriatric unit by 12/18/15 according to EI # 1, Co-Administrator, (room 201, 204, 206 and 207).

Tour of the north hallway for psychiatric patients 1/5/16 continued, room 218 is the private Restraint/Seclusion room and has paper stuck between the first and third lower section of window to prevent anyone from the outside seeing into the room. When EI # 1, Co-Administrator was asked why the paper was in the windows instead of the windows being frosted for privacy as the center window. EI # 1 stated the weather had not cooperated to frost the windows but she would get with maintenance to see when it could be completed.

Room 211 a semi-private room had two uncovered outlets in the room. The glass in the window had a broken area in the right bottom corner presenting a cutting hazard. EI # 5, Environmental Services was notified by Administration to have the window repaired.

Room 212 a semi-private room had two uncovered electrical outlets in the room.

Room 216 a semi-private room. The glass in the window had a broken area in the right bottom corner presenting a cutting hazard, EI # 5, Environmental Services was notified by Administration to have the window repaired.

The group room at the end of the hall has 4 uncovered electrical outlets.

A total of 28 physical beds were available for patient use on the psychiatric 24 bed unit 1/5/16.

In an interview on 1/5/16 at 10:30 AM with EI # 1, Co-Administrator, she confirmed the identified problems and would have them repaired immediately.

A tour of the psychiatric unit on 1/7/16 at 3:00 PM by the surveyors confirmed the broken windows in rooms 201, 211 and 216 had been covered while waiting for Lexan to replace the broken areas. Room 218 did not have the windows frosted for privacy due to the rain and temperatures interfering with the application of the material.