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.

NORTH METRO MEDICAL CENTER 1400 BRADEN STREET JACKSONVILLE, AR 72076 April 27, 2016
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
Based on document review and interview it could not be determined 10 of 10 nursing personnel were trained to provide nursing care to patients admitted to the Transitions Geropsychiatric Unit. This failed practice had the likelihood of not meeting the patient's needs and prolonging unnecessary hospitalization for all patients admitted to the Transitions Geropsychiatric Unit. Findings follow:
A. A list of all nursing personnel that worked on the Transitions Geropsychiatric Unit was requested. Nine nursing personnel were chosen and all training and orientation material was requested for review.
1) 9 (#1- #6, #8 and #9) of 9 (#1-#6, #8 and #9) staff had no current Nonviolent Crisis Intervention Program Certification or its equilivant.
2) 3 (#1, #5 and #6) of 9 (#1-#6, #8 and #9) staff had no evidence of orientation to the Transitions Geropsychiatric Unit.
3) 4 (#1, #3, #5, #6) of (#1-#6, #8 and #9) staff had no documentation of any training related to psychiatric nursing.

B. In an interview with the Director of Nursing at 1240 on 04-07-16 it was verified that no other documents of training were available for review.
VIOLATION: GOVERNING BODY Tag No: A0043
Based on interview, record review and observation it was determined the Governing Body failed to have an effective Governing Body based on deficiencies cited on the complaint survey conducted 04-05-16 thru 04-07-16 and 04-28-16. The failed practice had the likelihood to affect all patients admitted to the hospital. See A130, A144, A145 and A307.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on clinical record review, policy and procedure review and interview it was determined the Facility failed to protect the rights of patients and failed to provide care in a safe setting. Review of the clinical record for Patient #1 revealed no evidence staff identified and assessed skin breakdown on the buttocks and sacral area which resulted in actual harm to Patient #1. See A 144, and failed to assure Patient # 15 was monitored 1:1 to prevent integration into the common area of the Unit to prevent the spread of infection. See 144
Based on clinical record review, policy and procedure review and interview it was determined the Facility failed to protect Patient #5 when there was an allegation of physical abuse. See 145
Based on document review and interview it could not be determined 9 of 10 nursing personnel were trained to provide nursing care to patients admitted to the Transitions Geropsychiatric Unit. See 397
Based on clinical record review, document review, policy and procedure review and interview the Multidisciplinary Treatment Plan was not followed in providing group therapy for patients admitted to the Transitions Geropsychiatric Unit. See A130
VIOLATION: PATIENT RIGHTS: PARTICIPATION IN CARE PLANNING Tag No: A0130
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of clinical records, policy and procedure review, document review and interview, it was determined the Multidisciplinary Treatment Plan was not followed. No group therapy was provided for patients admitted to the Geropsychiatric Unit. This failed practice did not allow patients admitted to the Geropsychiatric Unit the opportunity for patients to verbalize, share feelings, and identify issues that contributed to their current problems. The lack of individual and group therapy had the liklihood of affecting all 26 patients on census (for example Patient #1 and Patient #5). Findings follow:

A. Review of the Master Treatment Plan for Patient #1-#5 revealed the plan identified three problems in which group therapy was listed as an intervention. For Example:

1) Review of the Master Treatment Plan for Patient #1 revealed the following:
a) Patient #1 was admitted [DATE] with a diagnosis of Major Neurocognitive disorder with behavioral disturbance.
The Multidisciplinary Problem List dated 02-26-16 contained documentation of 3 (#1, #4 and #5) Problems. Problems #2 and #3 were blank.

b)Problem 1-Altered thought processes related to major neurocognitive disorder with behavioral disturbance ...
Objectives/Goals-By end of the first week patient will have evidence of decreased aggression, tearfulness ...
Plans and Interventions- "Individual and group therapy ...". Frequency/Days-4 x (times) daily

c) Problem 4-Behavioral disturbances and ineffective coping skills related to major neurocognitive disorder ...
Objectives/Goals-Patient will be involved in establishment of realistic goals ...
Plans and Interventions- "Individual and group therapy sessions to assist in developing insight into the disease process ...". Frequency/Days-4 x daily.

d) Problem 5-Behavioral disturbances and ineffective coping skills related to major neurocognitive disorder ...
Objectives/Goals- "Patient will successfully return to live in a setting, which is appropriate, supportive ...".
Plans and Interventions- " Individual and family therapy to assist in identifying discharge needs ..." . Frequency/Days-4 x daily

e) There was no evidence of a change or revision in the Multidisciplinary Treatment Plan from admission 02-26-16 till discharge 03-24-16.

2) Review of the Master Treatment Plan for Patient #5 revealed the following:
a) Patient #5 was admitted [DATE] with a diagnosis of Personality Changes Secondary to Stroke
The Multidisciplinary Problem List dated 02-23-16 contained documentation of 3 (#1, #4 and #5) Problems. Problems #2 and #3 were blank.

b) Problem #1-Altered thought processes related to personality change secondary to stroke ...
Objectives/Goals-Patients' disturbance in thought will not interfere with activities of daily living...
Plans and Interventions- "Individual and group therapy ...". Frequency/Days-4 x daily.

c) Problem #4-Behavioral disturbances and ineffective coping skills related to personality change secondary to stroke. Objectives/Goals-"Patient will be involved in establishment of realistic goals ... ".
Plans/Interventions- "Individual and group therapy ...". Frequency/Days-4 x daily

d) Problem #5-Limited discharge options and potential for relapse...".
Objectives/Goals- "Patient will successfully return to live in a setting, which is appropriate...".
"Individual and group therapy ...". Frequency /Days-4 x daily

e) There was no evidence of a change or revision in the Multidisciplinary Treatment Plan from admission 02-20-16 till 04-07-16 Patient #5 was still an inpatient.

B. Interview conducted with the Activities Director on 04-07-16 at 1000 she stated no therapy was conducted other than activities which consisted of singing, color pages, arts and crafts, search a word sheets, etc.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on clinical record review, interview and policy review, it was determined there was no evidence the nursing staff identified and assessed skin breakdown on the buttocks and sacral area which resulted in actual harm to Patient #1; failed to assure Patient #15 was monitored 1:1 to prevent integration into the common area of the Unit to prevent the spread of infection. This failed practice affected two (#1 and #13) patients and had the likelihood of affecting all 26 patients admitted to the Transitions Geropsychiatric Unit.

A. Patient #1 was admitted [DATE] to the Transitions Geropsychiatric Unit with a diagnosis of [DIAGNOSES REDACTED]. Review of the Monitoring Sheets from 02-26-16 thru 03-04-16, 03-06-16 thru 03-08-16, 03-13-16 thru 03-16-16, 03-18-16 thru 03-23-16 revealed that although staff provided incontinent care (cleaning and changing the patient ' s brief) there was no evidence the skin breakdown on Patient #1 ' s buttocks and sacral area was reported and treated..

Review of Transitions Geropsychiatric Unit Nursing Policy and Procedure titled Skin Care Policy: Management, Treatment and Prevention of Decubitus Ulcers revealed the following: All patients will be assessed for skin integrity on admission and every shift. Preventive measures will be instituted on patients with a risk factor of greater than 14 ...

During an interview with theTransitions Geropsychiatric Unit Program Manager and Director of Nursing on 04-27-16 at 1000 after review of the Transitions Geropsychiatric Unit clinical record, it was verified that at no time during the stay of Patient #1 on the Transitions Geropsychiatric Unit was there documentation of redness or pressure ulcers on Patient #1 ' s buttocks or sacral area nor was it reported.

On 03-24-16 Patient #1 was discharged from the Transitions Geropsychiatric Unit back to the Nursing Home. On 03-24-16 the Nursing Home transferred Patient #1 to an acute hospital. The History and Physical-Consultation dictated 03-25-16 at the acute hospital (Named) revealed the following:
" This is n [AGE] year old white female (admitted [DATE]), ... Integumentary:with a stage I left buttocks decubitus ulceration with dimensions of 11cm x7 cm, and a stage II left buttock decubitus ulceration with dimensions of 1.5 cm x1.9cm and deep tissue unstageable sacral decubitus ulceration of 4.7cm x 3.5cm ...

B. Patient #15 was admitted [DATE] to the Transitions Geropsychiatric Unit with a diagnosis of [DIAGNOSES REDACTED][DIAGNOSES REDACTED] enterococci) in urine-use other bathroom. Physician ' s Order dated 03-31-16 at 1150- " DC (discontinue) contact isolation; keep patient 1:1 and do not integrate into common population " .

Review of the Monitoring Sheet dated 04-05-16 at 1500-Patient #15 was in bedroom-watching TV-calm
At 1515-Patient #15 was in bedroom-walking-agitated. At 1530-Patient #15 was in bedroom-walking-agitated. However review of the Transitions Geropsychiatric Unit Shift assessment dated [DATE]-at 1618 indicated " Patient was walking in Unit by nurses station (which was a common area) ... she stumbled and fell in floor by nurses station and landed on her right shoulder and hip ... " .
The Director of Nursing on 04-06-16 at 1000 verified the above findings for Patient #15.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on clinical record review, interview and policy review, it was determined The staff on the Transitions Geropsychiatric Unit failed protect Patient #5 when there was an allegation physical abuse. This failed practice affected one (#5) patient and had the likelihood of affecting all 26 patients admitted to the Transitions Geropsychiatric Unit.

Patient #5 was admitted to the Transitions Geropsychiatric Unit on 02-10-16 for Personality Changes Secondary to Stroke. Review of the Transitions Shift assessment dated [DATE] at 0632 revealed Pt (Patient) is in the dayroom and stated, "I am afraid of that woman." Pt pointing to (Named). Pt stated, "She hugs all over me and touches me on the breast. I don't know her and I am not like that."

The Surveyor at 0945 on 04-06-16 asked the Director of Nursing if an investigation was conducted regarding the above allegation by Patient #5. The Director of Nursing had no knowledge of the incident and stated it had not been reported.