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.

ANAHEIM GENERAL HOSPITAL 3350 W BALL ROAD ANAHEIM, CA Dec. 7, 2012
VIOLATION: GOVERNING BODY Tag No: A0043
Based on observation, interview and record review, the Governing Body failed to be responsible for the institutional conduct of the hospital as evidenced by:

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

2. Vulnerable patients were not supervised and patients were not monitored by the Behavioral Health Staff to ensure safety. This resulted in the sexual assaults of of two patients (Patients 1 and 2) by another patient (Patient 13).
Cross References to A-0144, A-0145, and A-0395 #1.

3. The hospital failed to ensure suspected sexual abuse was reported and immediately investigated. Cross Reference to A-0145.

4. The hospital's QAPI program failed to ensure data submitted from the Behavioral Health Unit was validated and accurate and quality issues from the data gathered from the Reported Events Log and the patient satisfaction surveys were used to monitor, collect, process, and respond to information about patient care. Cross Reference to A-0273.

5. The hospital failed to ensure the scope of the quality assurance program included measuring and analyzing reported adverse events for two patients (Patients 31 and 32) creating the risk of persistent poor healthcare practices and outcomes for the patients receiving care at the hospital. Cross Reference to A-0286.

6. The P&P for Assessment/Reassessment was not implemented for seven of the 14 open medical records reviewed (Patients 5, 10, 11, 12, 14, 16 and 20). There was no documented evidence to show the RN directly conducted assessments and initiated/reviewed the care plans for these patients prior to delegating the care of the patients to the LVN. This resulted in potential harm to patients as decisions were made and executed regarding delivery of care to patients on the basis of an assessment. Cross Reference to A-0395 #3.

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality healthcare in a safe environment.
VIOLATION: CONTRACTED SERVICES Tag No: A0083
The Governing Body failed to ensure services to the patients in the Behavioral Health Unit were provided in a safe manner. Vulnerable patients were admitted to the Unit who did not meet established criteria for a voluntary admission to the Unit. The patients were not supervised and monitored by the Behavioral Health Unit's staff. This resulted in the sexual assaults of two patients (Patients 1 and 2) by another patient (Patient 13). In addition, when Patient 13 spoke of the sexual assault in a group meeting, the hospital's social worker failed to report the sexual assault incident formally and to follow the hospital's abuse reporting protocol.

Findings:

Cross References to A-0131, A-0144, A-0145, and A-0395.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on interview and record review, the hospital failed to protect the patient's rights to safe care as evidenced by:

1. The patients in the Behavioral Health Unit were not provided care in a safe manner. Vulnerable patients were admitted to the unit who did not meet established criteria for a voluntary admission to the Unit as they were unable to give informed consents for treatment due to confusion and poor judgement. The patients were not supervised and were not monitored by the Behavioral Health Unit's staff. This resulted in the sexual assaults of two patients (Patients 1 and 2) by another patient (Patient 13). Cross References to A-0131, A-0144, A-0145, and A-0395 #1.

2. The hospital failed to ensure an incident of suspected sexual abuse was reported and immediately investigated. Cross Reference to A-0145.

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality healthcare in a safe environment.
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview and record review, the hospital failed to develop a process to ensure patients with cognitive deficits were represented by a legal guardian, or if none, by a multidisciplinary team during the consent process for admission to the Behavioral Health unit for treatment and the use of psychotropic medications. For three patients reviewed (Patients 1, 2, and 15) with documented diagnoses of [DIAGNOSES REDACTED].

Findings:

The hospital's P&P titled Informed Consent, last revised 4/11, showed the informed consent is the legal and ethical precondition for medical treatment with the exception of emergency procedures. It is the treating physician's responsibility to obtain the informed consent. The hospital is responsible to verify the informed consent has been obtained. The patient must be able to verbalize their understanding of the procedure they will undergo as explained by their physician. The P&P also showed the informed consent was required from a patient prior to the use of psychotropic drugs in the Behavioral Health Unit. Only the physician may determine the patient's competency to consent to medical treatment.

1. Medical record review for Patient 1 began on 12/5/12. The patient was admitted on [DATE] at 1730 hours.

Review of the physician's H&P dated 11/19/12, showed Patient 1 had multiple medical and psychiatric problems including history of TIA and Alzheimer's disease. The Psychiatric Evaluation showed Patient 1 had disorganized thought processes.

Review of the nursing assessment showed numerous references to Patient 1's inability to respond to questions regarding history. The mental status portion of the document showed Patient 1 was confused at all times.

Review of the Adult Psych Request for Voluntary Admission and Authorization for Treatment form showed in the area for the patient's signature, "Patient unable to sign due to medical condition." One RN signed the form.

Review of the Psych Patient Consents to Receive Medications forms showed in the space provided for Patient 1's signature, the "patient unable to sign due to medical condition but willing to take medications." One RN signed the form as a telephone order from the physician.

No documentation was found to show what "medical condition" had caused the patient's inability to sign the form. In addition, there was no documentation to show the physician had determined the patient's competency to consent to medical treatment.

2. Medical record review for Patient 2 began on 12/5/12. The patient was admitted on [DATE].

Review of the physician's H&P dated 11/20/12, showed Patient 2 was alert and oriented to person and place only. The patient's thought processes were confused and disorganized at times. Documentation showed the patient had a diagnosis of [DIAGNOSES REDACTED]

Review of the Adult Psych Request for Voluntary Admission and Authorization for Treatment form dated 11/20/12, showed on the line for Patient 2's signature, "unable to sign but willing to stay." The form was witnessed by one RN.

Review of the Psych Patient Consent to Receive Medications forms showed in the space for the patient's signature, "patient is unable to sign due to medical condition, but agrees to take medications." The form was witnessed by one RN as a telephone order from the physician.

Review of the Conditions of Admission form dated 11/20/12, showed in the space for the patient's signature, "Patient unable to sign due to being disabled."

No documentation was found to show why the patient was unable to sign the form. In addition, there was no documentation to show the physician had determined the patient's competency to consent to medical treatment.





3. The medical record for Patient 15 was reviewed on 12/6/12. The patient was transferred from a SNF on 10/29/12, due to increasing agitation, refusing care and medications, verbally abusing staff, and yelling and screaming.

Review of the H&P dated 10/29/12, showed Patient 15 was confused with impaired memory.

Review of Patient 15's Psychiatric Evaluation dated 10/29/12, showed the patient was alert and oriented times two (person and place) with disorganized thought processes and confusion at times. Perception was impaired. Insight and judgment were fair to poor.

Review of the Consents for Admission to the hospital and the Request for Voluntary Admission and Authorization for Treatment forms showed the patient's signature was witnessed by one RN. The Patient Consent to Receive Medications form listing four psychotropic drugs was signed by Patient 15 and witnessed by one RN as a telephone order from the physician.

There was no documentation to show Patient 15 was evaluated for his ability to give the informed consent.

During a meeting with the CEO, CNO, and the Corporate Compliance Officer on 12/7/12 at 0900 hours, concerns regarding cognitively impaired patients being asked to give informed consents for admission and treatment in the Behavioral Health Unit were brought to the hospital's administrative staff. The hospital's administrative staff confirmed during their investigation of the sexual abuse of Patients 1 and 2 by another patient, it was brought to their attention the patients who were admitted to the Behavioral Health Unit did not meet the established criteria for voluntary admission. The staff screening prospective patients was not utilizing the admission protocols correctly.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview and record review, the hospital failed to provide patients in the Behavioral Health Unit with a safe environment for care as evidenced by:

1. Patients 1 and 2 were not screened correctly to meet the established criteria for admission to be mentally capable of requesting and signing for a voluntary admission. Due to their physical and mental conditions both Patient 1 and Patient 2 were unable to defend themselves or call for help.

2. Patients in the Behavioral Health Unit were not supervised and closely monitored by nursing staff.

3. Suspected sexual abuse was not reported and investigated by hospital staff when they were first made aware to ensure the safety of all the patients and as required by law.

The failure to admit vulnerable patients to the Behavioral Health Unit and to not supervise the patients by conducting monitoring rounds every fifteen minutes resulted in the sexual assault of Patient 1 by a male patient (Patient 13). In addition, the abuse was not reported and investigated when first suspected. During the following night, when not supervised and monitored by nursing staff, Patient 13 entered the room of Patient 1 and her roommate, Patient 2 and sexually assaulted both patients.

Findings:

1. Review of the hospital's P&P titled Admission Criteria showed all patients must request and be mentally capable of requesting and signing voluntary admission. The P&P showed the mental health unit is therapeutically oriented, and to safeguard this orientation, all patients admitted to the program must have significant potential for treatment.

a. Medical record review for Patient 1 began on 12/5/12. The patient was admitted from a SNF on 11/19/12. An Emergency Physician Record and Psych Medical Clearance Record showed Patient 1 was non-communicative, her orientation could not be determined and she was wheelchair bound.

Psychiatric notes dated 11/19/12, showed Patient 1 had a history of a major depressive disorder. A mental status exam showed Patient 1 was confused at all times.

A physician's note dated 11/21/12, showed Patient 1 had psychotic symptoms profound enough to cause significant impairments in her day to day functioning.

Review of the Adult Psych Request for Voluntary Admission and Authorization for Treatment form showed in the area for the patient's signature, "Patient unable to sign due to medical condition." One RN signed the form.

Review of the the Psych Patient Consents to Receive Medications forms showed in the space provided for Patient 1's signature, the "patient unable to sign due to medical condition but willing to take medications." One RN signed the form as a telephone order from the physician.

No documentation was found to show what "medical condition" caused the patient's inability to sign the form.

b. Medical record review for Patient 2 began on 12/5/12. The patient was admitted on [DATE], for yelling and screaming at a SNF. Patient 2 was wheelchair bound.

Review of the H&P dated 11/20/12, showed Patient 2 was oriented to person and place only. The patient's thought processes were confused and disorganized at times. Documentation showed the patient had a diagnosis of [DIAGNOSES REDACTED]

Review of the Adult Psych Request for Voluntary Admission and Authorization for Treatment form dated 11/20/12, showed on the line for Patient 2's signature, "unable to sign but willing to stay." The form was witnessed by one RN.

Review of the Psych Patient Consent to Receive Medications forms showed in the patient's signature space, "patient is unable to sign due to medical condition, but agrees to take medications." The form was witnessed by one RN as a telephone order from the physician.

Review of the Conditions of Admission form dated 11/20/12, showed in the space for the patient's signature, "Patient unable to sign due to being disabled."

No documentation was found to show why the patient was unable to sign the form.

During a meeting with the CEO, CNO, and the Corporate Compliance Officer on 12/7/12 at 0900 hours, concerns regarding cognitively impaired patients being asked to give informed consents for admission and treatment in the Behavioral Health Unit were brought to the hospital's administrative staff. The hospital's administrative staff confirmed during their investigation of the sexual abuse of Patients 1 and 2 by another patient, it was brought to their attention the patients who were admitted to the Behavioral Health Unit did not meet the established criteria for voluntary admission. The staff screening prospective patients was not utilizing the admission protocols correctly.

2. The CNO and the CEO were interviewed on 12/5/12 at 1015 hours. The CEO stated the sexual assault of Patient 1 by Patient 13 on 11/22/12, was reported to them two days later. The assault was confirmed after watching the video surveillance tapes of the activity room where Patients 1 and 13 were left alone with the doors closed. Staff failed to perform rounds every fifteen minutes even though the rounds were documented in the patient's records. Patient 13 was observed to repeatedly sexually assault Patient 1 for one and a half hours on 11/23/12. No staff supervision or monitoring of the two patients occurred during that time. Their investigation showed staff falsified documents to show rounds were done and staff was also found to be sleeping on the job. Although two RNs stated they stopped Patient 13 from entering Patients 1 and 2's room on the night of 11/23/12, the video surveillance tapes showed no one had stopped him. The tapes also confirmed the MHWs were not conducting every 15 minute rounds during that night, 11/23/12.

The CNO and CEO stated Patient 13 discussed the sexual contact with Patient 1 during a group meeting held on 11/23/12 with MSW 1 who did not report or investigate the patient's allegation. The second sexual assault of both Patients 1 and 2 occurred that night.

The CEO stated Patient 2 reported to staff during care on 11/24/12, Patient 13 was in the room she shared with Patient 1 the previous night. Patient 2 stated Patient 13 had kissed her and touched her breasts and had done the same to Patient 1. The CEO stated during further review of the video surveillance tapes, Patient 13 was observed entering Patients 1 and 2's room at about 0200 hours on 11/24/12, and remained there for about five minutes. There was no staff intervention at that time. During a group meeting the next day with MFTI on 11/24/12, Patient 13 discussed the sexual contact with Patient 1 for the past two days and stated she "was his girlfriend." MFTI reported the patient's allegation to the charge nurse of the unit and when no action was taken she called the Nurse Manager. The MFTI reported the suspected abuse to Adult Protective Services and the police department at 1230 hours on 11/24/12.

3. Review of the hospital's P&P titled Adult Protective Service showed the hospital strives to take actions to prevent/address conditions or situations that adversely affect the health and safety of patients.

Review of the hospital's policy titled Elder and Dependent Adult Abuse showed mandated reporters working at the hospital will report all suspected or known instances of elder or dependent adult abuse to the appropriate agency as soon as practically possible by telephone and submit a written report to the same agency within 36 hours. The document defined a dependent adult as any person residing in this state, between ages of 18 and 64, who has physical or mental limitation which restricts his or her ability to carry out normal activities or to protect his or her rights including, but not limited to persons who have physical or developmental disability or whose physical or mental abilities have diminished because of age.

During the interview with the CNO and the CEO on 12/5/12 at 1015 hours, the CEO stated during their investigation they confirmed an RN and a MSW did not report the allegations of sexual abuse by Patient 13.

Documented interviews by the hospital with the Behavioral Health Unit's staff during their investigation were provided for review. On 11/23/12, during the group therapy Patient 13 told MSW 1 he had sexual contact with Patient 1 and planned on doing it again, he was just waiting for the opportunity. MSW 1 stated the patient had never previously made a statement that he had done something specific, it was always what he "wanted to do." MSW 1 stated Patient 13 informed two staff nurses of the patient's statement after the group; however, there was no follow-up report as directed in the P&P by any of the staff and Patient 13 was not monitored closely.

Patient 2 reported to staff during care at 0800 on 11/24/12, Patient 13 was in the room she shared with Patient 1 the previous night. Patient 2 stated Patient 13 had kissed her and touched her breasts and had done the same to Patient 1.

The CNO stated their investigation into the sexual assault incident led to termination of six employees on the Behavioral Health Unit.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview and record review, the hospital failed to implement P&Ps to monitor and protect patients in the Behavioral Health Unit and to investigate and report allegations of sexual abuse in a timely manner. These failures resulted in the repeated sexual abuse of two female patients (Patients 1 and 2) by Patient 13.

Findings:

Review of the hospital's P&P titled Unit Safety Guidelines showed the dayroom (activity room) was to be monitored by staff at all times when patients were present.

Review of the hospital's P&P titled Inpatient Rounds and Close Observations showed rounds activity included making rounds every fifteen minutes, monitoring for the safety of all patients on a continuing basis, documenting the location and condition of patient with staff's initials and signatures, and providing and initiating close observation of patients exhibiting behavior warranting increased staff supervision.

Review of the hospital's P&P titled Adult Protective Service showed the hospital strives to take actions to prevent/address conditions or situations that adversely affect the health and safety of patients.

Review of the hospital's P&P titled: Elder and Dependent Adult Abuse, showed mandated reporters working at the hospital will report all suspected or known instances of elder or dependent adult abuse to the appropriate agency as soon as practically possible by telephone and submit a written report to the same agency within 36 hours. The document defined a dependent adult as any person residing in this state, between ages of 18 and 64, who has physical or mental limitation which restricts his or her ability to carry out normal activities or to protect his or her rights including, but not limited to persons who have physical or developmental disability or whose physical or mental abilities have diminished because of age.

The CNO and the CEO were interviewed on 12/5/12 at 1015 hours. The CEO stated the sexual assault of Patient 1 by Patient 13 on 11/22/12, was reported to them two days later. The assault was confirmed after watching the video surveillance tapes of the activity room where Patients 1 and 13 were left alone with the doors closed. Staff failed to perform rounds every fifteen minutes even though the rounds were documented in the patient's records. Patient 13 was observed to repeatedly sexually assault Patient 1 for one and a half hours on 11/23/12. No staff supervision or monitoring of the two patients occurred during that time. Their investigation showed staff falsified documents to show rounds were done and staff was also found to be sleeping on the job. Although two RNs stated they stopped Patient 13 from entering Patients 1 and 2's room on the night of 11/23/12, the video surveillance tapes showed no one had stopped him. The tapes also confirmed the MHWs were not conducting every 15 minute rounds during that night, 11/23/12.

The CNO and CEO stated Patient 13 discussed the sexual contact with Patient 1 during a group meeting held on 11/23/12 with MSW 1 who did not report or investigate the patient's allegation. The second sexual assault of both Patients 1 and 2 occurred that night.

The CEO stated Patient 2 reported to staff during care on 11/24/12, Patient 13 was in the room she shared with Patient 1 the previous night. Patient 2 stated Patient 13 had kissed her and touched her breasts and had done the same to Patient 1. The CEO stated during further review of the video surveillance tapes, Patient 13 was observed entering Patients 1 and 2's room at about 0200 hours on 11/24/12, and remained there for about five minutes. There was no staff intervention at that time. During a group meeting the next day with MFTI on 11/24/12, Patient 13 discussed the sexual contact with Patient 1 for the past two days and stated she "was his girlfriend." MFTI reported the patient's allegation to the charge nurse of the unit and when no action was taken she called the Nurse Manager. The MFTI reported the suspected abuse to Adult Protective Services and the police department at 1230 hours on 11/24/12.

Review of hospital documentation showed Patient 13 was placed on a one to one monitoring by staff on 11/24/12. The patient was transferred to another psychiatric hospital on [DATE].

The CNO stated the hospital's investigation of the sexual assault of Patients 1 and 2 led to termination of six employees on the Behavioral Health Unit.
VIOLATION: QAPI Tag No: A0263
Based on interview and record review, the hospital failed to develop, implement, and maintain an effective QAPI program as evidenced by:

1. The hospital's QAPI program failed to show evidence the ongoing collection of data for goals met at 98-100% in the Nursing Department and the Behavioral Health Unit for the past 18 months would continue to identify and reduce medical errors. Cross Reference to A-0266 #1.

2. The hospital's QAPI program failed to set priorities for its performance improvement activities to monitor patient safety and the quality of care in the Behavioral Health Unit. Data showing 100% compliance with the appropriate use of chemical restraints for the past 18 months was not validated by the hospital, and when investigated was found to be inaccurate. Cross Reference to A-0283 #1.

3. Data gathered from the past three months showed 100% of the medical records monitored over a three month period in the Behavioral Health Unit met the established criteria for admission to the voluntary unit; however, medical record review and interview with hospital administration show vulnerable patients were admitted to the unit who were unable to give informed consent due to confusion and poor judgement. Cross References to A-0131 and A-0283 #1.

4. The hospital's QAPI program failed to use the data collected in the Reported Events Log and from patient satisfaction surveys to identify opportunities for improvement. Cross Reference to A-0273 #2.

5. The hospital failed to ensure the scope of the quality assurance program included measuring and analyzing reported adverse events for two patients (Patients 31 and 32) creating the risk of persistent poor healthcare practices and poor healthcare outcomes for patients using the facility. Cross Reference to A- 0286.

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality healthcare in a safe environment.
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on interview and document review, the hospital's QAPI program failed to show evidence the ongoing collection of data for goals met at 98-100% in the Nursing Department and the Behavioral Health unit for the past 18 months would continue to identify and reduce medical errors. These failures created the risk of persistent poor healthcare practices and outcomes for the patients receiving care at the hospital.

Findings:

The Director of Quality and the Corporate Compliance Officer were interviewed on 12/6/12 at 0935 hours. When asked how the hospital's QAPI program was organized, the Director stated each of the hospital departments reviewed and discussed their PI projects in their staff meetings. The information was forwarded to her for inclusion into the quarterly Patient Safety/PI committee meeting.

Review of the 2012 PI Dashboard on 12/6/12, showed the data submitted for each of the departments including the indicators, the actions, and the follow-up reports for the year 2011 and the first two quarters of 2012. Review of the data submitted by the Behavioral Health Unit and the ICU and the Medical-Surgical/Telemetry units showed the following:

1. The data submitted by the Behavioral Health Unit showed one PI project was monitored during this time period, the use of chemical restraints and seclusion. The data showed the goal was met at a 100% for 2011, and the first two quarters of 2012. The documented action was to "continue to monitor."

When asked if any other areas had been identified for monitoring in the Behavioral Health Unit, the Corporate Compliance Officer stated, after a year and a half of 100% results for one indicator perhaps a new area could have been chosen for monitoring. The staff's meeting minutes for the Behavioral Health Unit were requested for review at this time in order to show discussion of PI topics.

During the subsequent interview with the Director of Quality on 12/6/12 at 1500 hours, the Director stated upon investigation, no staff meetings were held in the Behavioral Health Unit since the new manager was hired in June, 2012.

During the interview with the PI Committee on 12/7/12 at 0900 hours, the Committee Members stated falls were monitored in the Behavioral Health Unit. They identified the Morse fall risk scale did not apply to psychiatric patients. This information was presented in the PI/Patient Safety Committee meeting on 9/25/12. A P&P was being developed.

Review of the PI/Patient Safety Committee's meeting minutes dated 9/25/12, showed 18 falls occurred in the hospital during the second quarter of 2012, 11 of which were in the Behavioral Health Unit. No other documentation of the monitoring of falls or other actions taken was found in the report.

2. The data submitted by the ICU and the Medical-Surgical/Telemetry units was reviewed. Both units were monitoring for maintenance of skin integrity and turning of patients every two hours. The data showed both the units were 98-100% compliant for the past 18 months. The action plan showed "continue to monitor."

During an interview with the PI Committee on 12/7/12 at 0900 hours, the Committee Members stated the ICU goals were changing in 2013.

The hospital's patient satisfaction surveys for the time period of April through June, 2012, were discussed with the QAPI Committee. Sixteen of the 18 areas marked for an action strategy required improvement. Areas for nursing improvement included nurse communication and courtesy/respect of nurses, pain management, quietness of the room at night, and talking to patients about help after discharge. The Committee Members were asked if these areas were incorporated into their QAPI program. The Committee Members stated the survey information went to the Medical Executive Committee and they had just started follow-up monitoring on these areas.

No documentation was provided to show monitoring was implemented on the areas identified in the patient satisfaction surveys.
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on interview and document review, the hospital's QAPI program failed to ensure data submitted from the Behavioral Health Unit was validated and accurate and quality issues from the data gathered from the Reported Events Log and the patient satisfaction surveys were used to monitor, collect, process, and respond to information about patient care. These failures created the risk of persistent poor healthcare practices and outcomes for the patients receiving care at the hospital.

Findings:

1. The Director of Quality and the Corporate Compliance Officer were interviewed on 12/6/12 at 0935 hours. When asked how the hospital's QAPI program was organized, the Director stated each of the hospital departments reviewed and discussed their PI projects in their staff meetings and the information was forwarded to her for inclusion into the quarterly PI committee meeting.

Review of the 2012 PI Dashboard on 12/6/12, showed the data submitted for each of the departments including the indicators and actions and follow-up reports for the year 2011 and the first two quarters of 2012.

Review of the data submitted by the Behavioral Health Unit showed one PI project was monitored during this time period, the use of chemical restraints and seclusion. The data showed the goal was met at a 100% for 2011 and the first two quarters of 2012. The documented action was to "continue to monitor."

When asked if any other areas had been identified for monitoring in the Behavioral Health Unit, the Corporate Compliance Officer stated after a year and a half of 100% results for one indicator perhaps a new area could have been chosen for monitoring. The staff meeting minutes for the Behavioral Health Unit were requested for review at this time in order to show discussion of PI topics.

The Corporate Compliance Officer stated a Corporate Compliance Program had been initiated beginning in September, 2012. He explained the indicators to be reviewed, however, were goals chosen by the corporation.

Review of the Corporate Compliance Program indicators for the Behavioral Health Unit showed two of the four indicators monitored were: the patients met criteria for admission and all patients had consented to treatment. Review of the data submitted showed for September, 2012, 20 of the 20 records audited were 100% compliant and for October, 2012, 40 of the 40 records audited were 100% compliance for all four issues.

The concerns during the survey regarding appropriateness of admissions to the Behavioral Health Unit were discussed with the Corporate Compliance Officer. The admissions of the patients identified unable to give informed consents for voluntary treatment were not captured in the data collected for patients meeting criteria for admission. The Corporate Compliance Officer confirmed in their investigation they also had noted the review process prior to a patient's admission was not understood and was not done correctly by staff. The Corporate Compliance Officer was asked to provide validation of the data monitored in the Behavioral Health Unit. The Corporate Compliance Officer stated the Corporate Compliance Program monitoring had not been validated yet as it was too new.

During a subsequent interview with the Corporate Compliance Officer on 12/7/12 at 1400 hours, the Officer stated when the audit tools for PI project for the monitoring of chemical restraints were reviewed the results did not match those reported to the PI Committee.

2. During an interview with the Director of Quality on 12/6/12 at 1015 hours, the Director stated staff reported unusual occurrences by submitting a Confidential Event Report via interoffice mail. These occurrences could be medication errors, nursing or medical errors, a near miss, or a patient safety concern. The Manager of the unit where the event occurred was to investigate the incident. All reported incidents were documented on the Reported Events Log

On 12/6/12, review of the Reported Events Logs dated September to November, 2012, showed the following:

a. For September, there were 50 reported patient events. 21 of the events were for patients who left the ED AMA or left after being registered.

For October, there were 50 reported patient events. 19 of the events were for leaving the ED AMA or after being registered.

For November, there were 35 reported patient events. 18 of the events were for AMA or after the patient was registered in the ED.

b. Several laboratory issues were reported such as delayed transfusions related to incomplete paperwork or the paperwork not being submitted; laboratory tests not done; and a chest x-ray not done.

During an interview with the PI Committee on 12/7/12 at 0900 hours, the Committee Members stated the Emergency Department's AMA was trended. They stated the patients who left AMA were called as a follow-up. The laboratory issues reported were also monitored. The Committee Members stated all adverse events were tracked and a summary went to the PI Committee for discussion.

No documentation was provided to show the tracking and trending of these areas.

3. Review of the patient satisfaction surveys for the time period of April through June, 2012, showed 16 of 18 areas marked for an action strategy required improvement.

During an interview with the PI Committee on 12/7/12 at 0900 hours, the Committee Members were asked if these areas were incorporated into their QAPI program. The Committee Members stated the survey information went to the Medical Executive Committee and they had just started follow-up monitoring on these areas.

No documentation was provided to the surveyors to show monitoring was implemented on the areas identified in the patient satisfaction surveys.
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
Based on interview and document review, the hospital failed to set priorities for its performance improvement activities to monitor patient safety and the quality of care in the Behavioral Health Unit. Data showing 100% compliance with the appropriate use of chemical restraints for the past 18 months was not validated by the hospital, and when investigated, was found to be inaccurate. In addition, the hospital failed to use the data collected in the Reported Events Log and from patient satisfaction surveys to identify opportunities for improvement. These failures created the risk of persistent poor healthcare practices and outcomes for the patients receiving care at the hospital.

Findings:

1. Review of the data gathered from the past three months showed 100% of the medical records monitored over a three month period in the Behavioral Health Unit met the established criteria for admission to the voluntary unit; however, medical record review and interview with hospital administration show vulnerable patients were admitted to the unit who were unable to give informed consent due to confusion and poor judgement. Cross Reference to A-0131

2. The Director of Quality and the Corporate Compliance Officer were interviewed on 12/6/12 at 0935 hours. When asked how the hospital's QAPI program was organized, the Director stated each of the hospital departments reviewed and discussed their PI projects in their staff meetings and the information was forwarded to her for inclusion into the quarterly PI committee meeting.

Review of the 2012 PI Dashboard on 12/6/12, showed the data submitted for each of the departments including the indicators and actions and follow-up reports for the year 2011 and the first two quarters of 2012.

Review of the data submitted by the Behavioral Health Unit showed one PI project was monitored during this time period, the use of chemical restraints and seclusion. The data showed the goal was met at a 100% for 2011 and the first two quarters of 2012. The documented action was to "continue to monitor."

When asked if any other areas had been identified for monitoring in the Behavioral Health Unit, the Corporate Compliance Officer stated after a year and a half of 100% results for one indicator perhaps a new area could have been chosen for monitoring. The staff meeting minutes for the Behavioral Health Unit were requested for review at this time in order to show discussion of PI topics.

The Corporate Compliance Officer stated a Corporate Compliance Program had been initiated beginning in September, 2012. He explained the indicators to be reviewed, however, were goals chosen by the corporation.

Review of the Corporate Compliance Program indicators for the Behavioral Health Unit showed two of the four indicators monitored were: the patients met criteria for admission and all patients had consented to treatment. Review of the data submitted showed for September, 2012, 20 of the 20 records audited were 100% compliant and for October, 2012, 40 of the 40 records audited were 100% compliance for all four issues.

The concerns during the survey regarding appropriateness of admissions to the Behavioral Health Unit were discussed with the Corporate Compliance Officer. The admissions of the patients identified unable to give informed consents for voluntary treatment were not captured in the data collected for patients meeting criteria for admission. The Corporate Compliance Officer confirmed in their investigation they also had noted the review process prior to a patient's admission was not understood and was not done correctly by staff. The Corporate Compliance Officer was asked to provide validation of the data monitored in the Behavioral Health Unit. The Corporate Compliance Officer stated the Corporate Compliance Program monitoring had not been validated yet as it was too new.

During a subsequent interview with the Corporate Compliance Officer on 12/7/12 at 1400 hours, the Officer stated when the audit tools for PI project for the monitoring of chemical restraints were reviewed the results did not match those reported to the PI Committee.

3. During an interview with the Director of Quality on 12/6/12 at 1015 hours, the Director stated staff reported unusual occurrences by submitting a Confidential Event Report via interoffice mail. These occurrences could be medication errors, nursing or medical errors, a near miss, or a patient safety concern. The Manager of the unit where the event occurred was to investigate the incident. All reported incidents were documented on the Reported Events Log

On 12/6/12, review of the Reported Events Logs dated September to November, 2012, showed the following:

a. For September, there were 50 reported patient events. 21 of the events were for patients who left the ED AMA or left after being registered.

For October, there were 50 reported patient events. 19 of the events were for leaving the ED AMA or after being registered.

For November, there were 35 reported patient events. 18 of the events were for AMA or after the patient was registered in the ED.

b. Several laboratory issues were reported such as delayed transfusions related to incomplete paperwork or the paperwork not being submitted; laboratory tests not done; and a chest x-ray not done.

During an interview with the PI Committee on 12/7/12 at 0900 hours, the Committee Members stated the Emergency Department's AMA was trended. They stated the patients who left AMA were called as a follow-up. The laboratory issues reported were also monitored. The Committee Members stated all adverse events were tracked and a summary went to the PI Committee for discussion.

No documentation was provided to show the tracking and trending of these areas.

4. Review of the patient satisfaction surveys for the time period of April through June, 2012, showed 16 of 18 areas marked for an action strategy required improvement.

During an interview with the PI Committee on 12/7/12 at 0900 hours, the Committee Members were asked if these areas were incorporated into their QAPI program. The Committee Members stated the survey information went to the Medical Executive Committee and they had just started follow-up monitoring on these areas.

No documentation was provided to the surveyors to show monitoring was implemented on the areas identified in the patient satisfaction surveys.
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on interview and document review, the hospital failed to ensure the scope of the quality assurance program included measuring and analyzing reported adverse events for two patients (Patients 31 and 32) creating the risk of persistent poor healthcare practices and outcomes for the patients receiving care at the hospital.

Findings:

Review of the Reported Events Log on 12/6/12, showed the following:

1. In September 2012, an RT inserted a nasal trumpet into Patient 31's nose to secure an open airway during suctioning (a tube with a flared end that is designed to be inserted into the nasal passageway to secure an open airway. The purpose of the flared end of the airway (trumpet) is to prevent the device from becoming lost inside the patient's nose. The correct size airway is chosen by measuring the device on the patient). The flared end on the trumpet failed to prevent the device from slipping into Patient 31's throat. The patient went into respiratory distress and required transfer to the ICU. The physician intubated the patient (the placement of a flexible plastic tube into the windpipe to maintain an open airway) and removed the nasal trumpet with forceps.

On 12/6/12 at 1530 hours, an interview was conducted with RN F. RN F stated the RTs were shown different sizes of nasal trumpets available, but the hospital did not evaluate the competency of the RTs for the sizing and placement of nasal trumpets. After the incident, RN F stated the hospital researched nasal trumpets for a less flimsy one that did not fold easily and cause the trumpet to become dislodged.

No documentation was provided to show the hospital had analyzed the event for possible cause and actions were developed for staff training to prevent future events.

2. In November, 2012, Patient 32's primary nurse in the ICU failed to identify the need for intervention and give medication as requested by another staff when the patient's respiratory rate increased to 40 breathes per minute (normal rate for adults is 12-20 breathes per minute). Another nurse intervened and administered the medication.

During a review of the investigation report with RN F on 12/6/12 at 1530 hours, RN F stated the nurse was counseled. However, there was no documentation provided to show the primary nurse and the nurse who intervened were interviewed to determine the reason the primary nurse did not identify the need for intervention and did not administer the medication when asked.

No documentation was provided to show if the primary nurse was competent to care for patients with respiratory issues or if nurses in the ICU required additional education on respiratory patients. There was no documentation to show if preventive actions were taken to ensure learning throughout the hospital.
VIOLATION: EXECUTIVE RESPONSIBILITIES Tag No: A0309
Based on interview and record review, the governing body, medical staff, and administrative staff failed to ensure:

1. Patient safety was maintained on the Behavioral Health Unit. Data gathered from the past three months showed 100% of the medical records monitored over a three month period in the Behavioral Health Unit met the established criteria for admission to the voluntary unit; however, medical record review and interview with hospital administration showed vulnerable patients were admitted to the unit who were unable to give informed consent due to confusion and poor judgement. Cross References to A-0131 and A-0283 #1 and #2.

2. The hospital's QAPI program showed evidence the ongoing collection of data for goals met at 98-100% in the Nursing Department and the Behavioral Health unit for the past 18 months would continue to identify and reduce medical errors. These failures created the risk of persistent poor healthcare practices and poor healthcare outcomes for patients using the facility. Cross Reference to A- 0266 #1.

3. The data gathered from the Reported Events Log and the patient satisfaction surveys were used to monitor, collect, process, and respond to information about patient care. Cross Reference to A-0273 #2.

4. The scope of the quality assurance program included measuring and analyzing reported adverse events for two patients (Patients 31 and 32). Cross Reference to A-0286.

These failures created the risk of persistent poor healthcare practices and outcomes for the patients receiving care at the hospital.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on interview and record review, the hospital failed to ensure a well organized nursing service providing quality and safe care for patients supervised by an RN as evidenced by:

1. The RN did not closely supervise the nursing care of patients on the Behavioral Health Unit. The activities of patients on the unit were not monitored to ensure the patients' safety. This resulted in the repeated sexual assaults of Patients 1 and 2 by another patient, Patient 13. The RN did not ensure the safe care of Patient 13 during the night shift on 11/24/12. In lieu of providing the ordered a one to one nursing supervision during the investigation of the sexual abuse of Patients 1 and 2, Patient 13 was medicated and placed in a locked seclusion room without a physician's order. In addition, the RN did not implement the P&P for Assessment/Reassessment for seven of 14 open medical records reviewed (Patients 5, 10, 11, 12, 14, 16, and 20). There was no documented evidence to show the RN had directly conducted the assessments and initiated/reviewed the care plans for these patients prior to delegating the care of the patients to the LVN. This resulted in potential harm to patients as decisions were made and executed regarding delivery of care to patients on the basis of an assessment. Cross Reference to A-0395.

2. The RN did not ensure the care plans were initiated and was individualized with stated goals and interventions for six of the 14 patients reviewed for care plans (Patients 5, 11, 12, 14, 16, and 20). Cross Reference to A-0396.

The cumulative effect of these systemic failures resulted in the hospital's inability to provide quality healthcare in a safe environment.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and medical record review, the hospital failed to:

1. Ensure RNs closely supervised the nursing care of patients on the Behavioral Health Unit to monitor the activities of the patients on the unit to ensure the patients' safety. This resulted in the repeated sexual assault of Patients 1 and 2 by another patient, Patient 13.

2. Ensure the safe care of Patient 13 during the night shift on 11/24/12. In lieu of providing the ordered one to one nursing supervision during the investigation of the sexual abuse of Patients 1 and 2, Patient 13 was medicated and placed in a locked seclusion room without a physician's order.

3. Implement the P&P for Assessment/Reassessment for seven of the 14 open medical records reviewed (Patients 5, 10, 11, 12, 14, 16 and 20). For Patient 5, the hospital failed to insure the initial nursing assessment of the patient was completed within the required 24 hour timeframe. For Patients 10, 11, 12, 14, 16 and 20, there was no documented evidence to show the RN had directly conducted the assessments and initiated/reviewed the care plans for these patients prior to delegating the care of the patients to the LVN. This resulted in potential harm to patients as decisions were made and executed regarding delivery of care to patients on the basis of an assessment.

4. Ensure the P&P for nursing documentation on skin impairment photographs was implemented for four of 32 sampled patients (Patients 1, 2, 27, and 28).

Findings:

1. Review of the hospital's P&P titled Unit Safety Guidelines showed the dayroom (activity room) was to be monitored by staff at all times when patients were present.

Review of the hospital's P&P titled Inpatient Rounds and Close Observations showed rounds activity included making rounds every fifteen minutes, monitoring for the safety of all patients on a continuing basis, documenting the location and condition of patient with staff's initials and signatures, and providing and initiating close observation of patients exhibiting behavior warranting increased staff supervision.

Medical record review for Patient 13 began on 12/5/12.

The Inquiry/Admission Sheet dated 11/19/12, showed one of the reasons for admission included sexual inappropriateness.

A Psychiatric Evaluation dated 11/19/12, showed Patient 13 was not taking his medication on a regular basis and needed to be monitored more closely.

Physician's orders dated 11/19/12, showed an order for every fifteen minute checks by staff.

Documentation on the Multidisciplinary Patient Record dated 11/19/12 at 1915 hours, showed Patient 13 was sexually inappropriate in his behaviors and was verbally abusive.

Documentation on the Multidisciplinary Patient Record dated 11/22/12 at 1130 hours, showed Patient 13 made inappropriate sexual comments to female staff and was demanding and irritable. Patient 13 used profanity, banged on the nurses' station window with his fist, showed poor impulse control, and was unable to be redirected.

The CNO and the CEO were interviewed on 12/5/12 at 1015 hours. The CEO confirmed Patient 1 and Patient 13 were left alone in the activity room with the doors closed between 1400 and 1600 hours on 11/22/12. The CEO stated the sexual assault of Patient 1 by Patient 13 on 11/22/12, was not reported to them until two days later. The sexual assault was confirmed after watching the video surveillance tapes of the activity room during which the two patients were left alone on 11/22/12. The video surveillance tapes also confirmed staff failed to perform every fifteen minutes rounds. Patient 13 was observed to repeatedly sexually assault Patient 1 for an hour and a half on 11/22/12, when there was no staff supervision or monitoring of the two patients in the activity room.

The CEO stated Patient 2 reported to staff during care on 11/24/12, Patient 13 was in the room she shared with Patient 1 the previous night. Patient 2 stated Patient 13 had kissed her and touched her breasts and had done the same to Patient 1. The CEO stated during the interviews with staff, Patient 13 was re-directed away from Patient 1 and 2's room on that night; however, further review of video surveillance tapes showed Patient 13 entered Patient 1 and 2's room at about 0200 hours on 11/24/12, and remained there for about five minutes. There was no staff intervention at that time.

The CNO and CEO acknowledged during their investigation, interviews with staff, and review of video surveillance tapes in the Behavioral Health Unit, every 15 minute checks of the patients were documented by staff; however, Patient 1 and Patient 13 were left alone in the activity room on 11/22/12, for one and a half hours and no staff monitoring was observed on the video tapes. Further review of the video tapes on the night shifts of 11/23 and 11/24/12, showed the lights were turned off for several hours at the nurses' station while staff dozed. No staff was observed monitoring the safety of the patients in the Behavioral Health Unit per the hospital's P&P.

The CNO stated the hospital's investigation into the sexual assault of Patients 1 and 2 led to termination of six employees on the Behavioral Health Unit.

2. The CNO and the CEO were interviewed on 12/5/12 at 1015 hours. They stated after the abuse of Patients 1 and 2 was reported, the CNO advised the Charge Nurse on the Behavioral Health Unit to institute a one to one staff monitoring of Patient 13 at all times until a transfer to another psychiatric facility could be arranged. The CNO stated review of the video surveillance tapes of the Behavioral Health Unit for the night shift of 11/24/12, showed Patient 13 was chemically restrained (administration of an anti-psychotic medication) and placed in a locked seclusion room without a physician's order and without nursing supervision and every 15 minute checks for his safety.

The CNO and CEO stated the nursing staff had falsified their medical record entries for monitoring and supervising the activity of Patient 13.





3. The hospital's P&P titled Assessment/Reassessment, last revised 12/10, was reviewed on 12/5/12. The stated purpose of the policy was to ensure each patient's physical, psychological and social status is assessed to determine the patient's care needs. On the nursing units the patient is assessed upon arrival focusing on chief complaint, vital signs, and baseline data. The RN must review the data, identify patient problems that require planning and interventions and the need for further assessment and interdisciplinary referrals. An RN completes a reassessment every shift and documents on a Patient Care Flow Sheet.

The hospital's P&P Multidisciplinary Care Plan/Teaching Record, last revised 1/10, was reviewed on 12/5/12. The policy showed the care plan is initiated by the RN in concert with members of the multidisciplinary team as appropriate within eight hours of admission and updated as necessary. Other members of the team will make entries on the care plan throughout the patient's hospital stay. The RN assigned to the patient will identify those nursing diagnosis/problems that relate to each patient and completes the information to individualize the plan of care.

During an interview with RN A on 12/5/12 at 1145 hours, the RN was asked how LVNs were utilized on the Medical-Surgical/Telemetry unit. The RN stated the LVNs were covered by the charge nurse. RN A stated the RN co-signed the LVN's assessment. The RN stated he did not reassess the LVN's patients, but he would go in to see the patients at about 1000 hours (three hours from the start of the shift). RN A stated the RNs did not routinely document on the patient's care plan after the initiation unless a change was made.

a. The medical record for Patient 20 was reviewed on 12/5/12. The patient was admitted to the telemetry unit of the hospital for continuous heart monitoring on 12/4/12, with diagnoses which included stomatitis (an inflammation of the mucous lining of any of the structures in the mouth), dehydration, and low potassium level. The patient was developmentally disabled and was non-verbal. The patient's lower lip was assessed as "red and bleeding on an off."

Review of the Patient Initial Assessment form dated 12/4/12 at 2040 hours, showed all portions of the admission assessment were completed and signed by the LVN. The only documentation by the RN was a signature in the area for RN signature on the initial assessment. The every four hour reassessments completed at 0000 hours and 0400 hours for the remainder of the night shift were completed and signed by the LVN. The only documentation by the RN at 0630 on 12/5/12, showed "agrees with all of the above." There was no documentation to show the RN had directly assessed the patient.

RN D was interviewed at 1000 hours on 12/5/12. When asked about the care needs of Patient 20, the RN stated the patient required a one to one sitter at the bedside as the patient continuously tried to get out of the bed and was non-verbal and was anxious. The patient had mouth sores and did not want to eat when admitted but this had improved.

Review of the care plan for Patient 20 showed the care plan was initiated on 12/4/12, by the LVN. There was no RN signature. The only care problem initiated for Patient 20 was for skin integrity due to stomatitis; however, the interventions listed did not address the sores on the patient's mouth.

b. The medical record for Patient 16 was reviewed on 12/5/12. The patient was admitted on [DATE], for a open reduction and pining of the left 5th toe.

Review of the 24 hour Flowsheet dated 12/4/12, showed the LVN completed and documented the night shift assessment for the patient. The RN cosigned the assessment and documented at 0600 on 12/5/12, "agree with above."

Review of the care plan for Patient 16 showed the care plan was initiated by the LVN on 12/4/12. Interventions listed for each of the problems were pre-printed. None were checked off for Patient 16.

There was no documentation to show the RN had directly assessed the patient to determine the patient's care needs and develop the care plan with appropriate interventions and goals.





c. The medical record for Patient 10 was reviewed on 12/5/12. Review of the 24 hour Flowsheet dated 12/4/12, showed the patient's assessments was completed at 2000 and 0400 hours by the LVN which included cardiovascular, neurological, and respiratory assessments. The RN documented at 0630 hours, under the note section on the flowsheet, "agree with all of the above." There was no documentation to show the RN had directly assessed the patient.

d. The medical record for Patient 11 was reviewed on 12/5/12.

The Patient Initial Assessment for Patient 11 was completed on 12/1/12, by an LVN. There was no documentation to show the information had been reviewed by an RN.

The Physician Orders/Risk Factor Assessment for Patient 11 was completed by an LVN. There was no documentation to show it had been reviewed by an RN.

The Multidisciplinary Care Plan/Teaching Record for Patient 11 was initiated by an LVN. There was no documentation to show it had been reviewed by an RN.

Patient 11's 24 hour Flowsheets dated 12/3 and 12/4/12, showed the assessments at 2000 and 0400 hours for each of the night shifts were completed by an LVN. The flowsheet dated 12/3/12 at 0700 hours, showed documentation the RN "agreed with all of the above." There was no documentation to show an RN had reviewed the assessments.

e. The medical record for Patient 12 was reviewed on 12/5/12.

Patient 12's 24 hour Flowsheets dated 12/1, 12/2 and 12/3/12, showed the assessments were completed by an LVN at 2000 and 0400 hours for each of the three night shifts. There was no documentation to show an RN had reviewed the assessments completed by the LVN.

The Care Plan for Patient 12 showed the patient had the potential for pain. Interventions were to assess and reassess the pain scale, type of pain, location, duration, precipitating factors, and relieving factors. The initial problem was identified by the RN; however, documentation on the intervention area showed the reassessments were completed by an LVN on 11/29, 11/30, 12/1 and 12/5/12 . There was no documentation to show an RN had reviewed the care plan for Patient 12 following the initiation.

f. The medical record for Patient 14 was reviewed on 12/5/12.

Patient 14's Initial Patient Assessment form was completed by an LVN. There was no documentation to show the RN had reviewed the form.

Patient 14's care plan showed the LVN initiated the care plan on 12/4/12, and identified the problem areas. There was no documentation to show the RN reviewed or agreed with the identified areas. There were no interventions identified for the problem areas.

The above six medical record records were reviewed with RN A on 12/5/12 between 1300 and 1600 hours, and the findings were confirmed.

During an interview with the CNO on 12/5/12 at 1630 hours, the CNO stated only RNs were to conduct assessments of patients.

g. Review of the hospital's P&P titled Assessment/Reassessment, revised 12/10, showed upon admission Case Management would assess patient to determine acute level of care needs and for discharge planning. Nursing would do an initial assessment upon arrival to nursing areas. In the ICU, the assessment would be completed within 24 hours. The nutritional screen would be completed by the nursing department during the patient admission assessment.

Review of the hospital's P&P Skin Care Guidelines - Pressure Ulcers Prevention and Management, revised 6/10, showed it was the hospital's expectation that upon admission or transfer from any inpatient care unit, including the emergency department, within the hospital, two RNs will complete a skin assessment within four hours, and document the assessment on the Patient Initial Assessment or the 24 hour Flowsheet for every patient. Assessment will include a head-to-toe visual assessment, inspecting all skin surfaces and bony prominences. Reassessment of pressure ulcer risk will be completed and documented every shift.

Review of Patient 5's medical record on 12/5/12, showed the patient was admitted on [DATE], from a long-term care facility.

The Patient Initial Assessment Form dated 12/4/12, showed the areas for nutritional screening, functional screening, and discharge planning/case management screening were not completed.

The transfer paperwork from the long-term care facility showed the patient had a reddened area on his coccyx and a purple discoloration on his right shoulder at the time of transfer. Review of the skin assessment area on the Patient Initial assessment dated [DATE], showed no skin problems were identified on the Wound Status Tool other than cellulitis (inflammation of cell or connective tissues) on the patient's left leg. The Wound Status Tool was not signed or dated.

On 12/5/12 at 1330 hours the WCN was interviewed. The WCN stated the initial skin assessments were done by the RNs. The WCN stated as an LVN he did the follow-up assessments. The WCN stated he saw Patient 5 after admission and observed only a reddened perianal area. Further review of Patient 5's 24 hour Flowsheets and Wound Status Tool showed no documentation of a reddened perianal area.

4. Review of the P&P titled Skin Care Guidelines/Pressure Ulcers Prevention and Management, last revised 6/10, showed photographs will be taken for any impairment of skin integrity. A measuring device will be placed proximate to the impairment to demonstrate the approximate size of the ulcer. The RN taking the photograph will also document the following with a signature: type of photograph (admission, transfer, change in stage) and location of the pressure ulcer.

The medical records for Patients 1, 2, 27, and 28 were reviewed. Decubitus Ulcer Photo Mount Sheets were noted in each medical record. There was no documentation on the forms to show the date and time of the photos, the measurements of the wounds, the location of the wounds, and the signatures of the licensed nurses.
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview and medical record review, the hospital failed to ensure the care plans were initiated by the RN and was individualized with stated goals and interventions for six of the 14 patients' medical records reviewed for care plans (Patients 5, 11, 12, 14, 16 and 20). A lack of comprehensive care plan development may result in interventions not initiated which can further compromise the patient's medical status.

The hospital's P&P titled Multidisciplinary Care Plan/Teaching Record last revised 1/10, was reviewed on 12/5/12. The policy showed the care plan is initiated by the RN in concert with members of the multidisciplinary team as appropriate within eight hours of admission and updated as necessary. Other members of the team will make entries on the care plan throughout the patient's hospital stay. The RN assigned to the patient will identify those nursing diagnosis/problems that relate to each patient and completes the information to individualize the plan of care.

RN A was interviewed on 12/5/12 at 1145 hours. The RN stated the RN did not document the care plan was reviewed each shift unless a change was made. If the care plan was reviewed, it would be noted in the narrative notes.

1. The medical record for Patient 20 was reviewed on 12/5/12. The patient was admitted to the telemetry unit of the hospital for continuous heart monitoring on 12/4/12, with diagnoses which included stomatitis, dehydration, and low potassium level. The patient was developmentally disabled and was non-verbal. The patient's lower lip was assessed as "red and bleeding on an off."

RN D was interviewed at 1300 hours on 12/5/12. When asked about the care needs of Patient 20, the RN stated the patient required a one to one sitter at the bedside as the patient continuously tried to get out of the bed and was non-verbal and was anxious. The patient had mouth sores and did not want to eat when admitted but this had improved.

Review of the care plan for Patient 20 showed the care plan was initiated on 12/4/12, by the LVN. There was no RN signature. The only care problem initiated for Patient 20 was for skin integrity due to stomatitis; however, the interventions listed did not address the sores on the patient's mouth.

2. The medical record for Patient 16 was reviewed on 12/5/12. The patient was admitted on [DATE], for an open reduction and pining of the left 5th toe.

Review of the care plan for Patient 16 showed the care plan was initiated by the LVN on 12/4/12. Interventions listed for each of the problems were pre-printed; however, no interventions were checked off for Patient 16.





3. On 12/7/12, review of Patient 5's medical record was conducted. The Multidisciplinary Care Plan/Teaching Record showed potential problems had been identified; however, interventions for the identified areas of knowledge deficit and skin integrity were not completed. The area regarding skin integrity showed the patient had a potential for skin breakdown related to immobility. Review of the daily treatment flowsheets showed the patient was admitted with skin issues on his feet and left leg.

4. Review of the medical record for Patient 14 showed the patient's care plan was initiated by the LVN on 12/4/12. The LVN identified the patient's problem areas. There was no documentation to show the RN had reviewed or agreed with the LVN's identified areas. There were no interventions identified for the problem areas.

5. Review of the medical record for Patient 11 showed the Multidisciplinary Care Plan/Teaching Record was initiated by an LVN. There was no documentation to show the RN had reviewed the care plan.

6. Review of the medical record for Patient 12 showed the RN identified the patient with a potential for pain in the care plan. Interventions listed were to assess and reassess the pain scale, type of pain, location, duration, precipitating factors, and relieving factors. Signatures in the intervention area showed the assessments were completed by an LVN on 11/29, 11/30, 12/1 and 12/5/12. There was no documentation to show an RN had reviewed the assessments completed by the LVN.
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
Based on interview and medical record review, the hospital failed to ensure the medical records were complete and accurate for 10 of 32 sampled patients (Patients 1, 2, 4, 7, 24, 26, 27, 28, 29, and 30).

Findings:

Review of the P&P titled Health Information Services/Assembly and Analysis of Records showed documented treatment data accumulated during the course of the patient's hospitalization becomes the patient's medical record. Physicians, nursing, and ancillary personnel assisting in patient care are responsible for documenting and completing their portion of the record.

1. Patient 1's medical record was reviewed on 12/6/12. Review of the Adult Psych Request for Voluntary Admission and Authorization for treatment form dated 11/19/12, showed the physician signed the form; however, there was no date or time documented in the space provided.

2. Patient 2's medical record was reviewed on 12/6/12.

a. Review of the Adult Psych Request for Voluntary Admission and Authorization for Treatment form showed the physician signed the form; however, there was no date or time documented in the space provided.

b. Review of Decubitus Ulcer Photo Mount Sheet form showed two photographs of Patient 2's wounds. To the right of the page, next to the mounted photograph, the area for documentation of the date/time of the assessment of the wound and a space for the signature of the licensed nurse were blank.

3. Patient 4's medical record was reviewed on 12/6/12.

a. Review of the Adult Psych Request for Voluntary Admission and Authorization for Treatment form showed showed the physician signed the form; however, there was no date or time documented in the space provided.

b. Review of the Inpatient Psychiatric Hospital Services Certification form showed no date/time entry by the physician's signature and the remainder of the form was left blank. The form allowed spaces for the physician to list forms of treatment, diagnostic studies, and anticipated length of stay.

4. Patient 7's medical record was reviewed on 12/7/12.

a. Review of the Adult Psych Request for Voluntary Admission and Authorization for Treatment form showed the physician signed the form; however, there was no date or time documented in the space provided.

b. Review of the Inpatient Psychiatric Hospital Services Certification form showed no date/time entry by the physician's signature and the remainder of the form was left blank.

5. Patient 24's medical record was reviewed on 12/6/12.

a. Review of the Inpatient Psychiatric Hospital Services Certification form showed no date/time entry by the physician's signature and the remainder of the form was left blank.

b. Review of the Suicidal Risk Assessment form showed no date/time by the signing physician.

6. Patient 26's medical record was reviewed on 12/6/12.

a. Review of the Psych Patient Consent to Receive Medications form showed no date by the physician's signature.

b. Review of the Inpatient Psychiatric Hospital Services Certification form showed no date/time entry by the physician's signature and the remainder of the form was left blank.

7. Patient 27's medical record was reviewed on 12/6/12.

Review of the Suicidal Risk Assessment form dated 11/6/12, showed no physician signature, date, or time.

8. Patient 28's medical record was reviewed on 12/6/12.

a. Review of the Inpatient Psychiatric Hospital Services Certification form showed no date/time entry by the physician's signature and the remainder of the form was left blank.

b. Review of Decubitus Ulcer Photo Mount Sheet form showed two photographs of Patient 28's wounds. To the right of the page, next to the mounted photograph, the area for documentation of the date/time of the assessment of the wound and a space for the signature of the licensed nurse were blank.

9. Patient 29's medical record was reviewed on 12/6/12.

Review of the Inpatient Psychiatric Hospital Services Certification form showed no date/time entry by the physician's signature and the remainder of the form was left blank.

10. Patient 30's medical record was reviewed on 12/6/12.

Review of the Inpatient Psychiatric Hospital Services Certification form showed no date/time entry by the physician's signature and the remainder of the form was left blank.

On 12/7/12 at 1030 hours, the Corporate Compliance Officer verified the findings.
VIOLATION: INFECTION CONTROL OFFICER(S) Tag No: A0748
Based on observation and interview, the hospital failed to ensure a staff member removed gloves and washed hands before exiting a patient room and entering the unit's kitchen area. This had the potential for the spread of bacteria.

Findings:

Review of the hospital's P&P Standard Based Precautions, revised date 10/09, showed staff were to remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and were to perform hand hygiene immediately to avoid transfer of microorganisms to other patients and environments.

During a tour of the Medical-Surgical unit on 12/5/12 at 1045 hours, accompanied by RN A, a CNA was observed exiting a patient's room wearing gloves and holding a water pitcher. The CNA entered the kitchen area and filled the water pitcher with ice and water from the ice dispenser.

The CNA was interviewed as he exited the kitchen and was about to re-enter the patient's room. When asked why he was wearing gloves in the hallway, the CNA stated he forgot to remove the gloves and wash his hands before leaving the patient's room.