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.

OPELOUSAS GENERAL HEALTH SYSTEM 539 EAST PRUDHOMME STREET OPELOUSAS, LA 70570 Nov. 27, 2013
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Surveyor: Fremin, Wendy
Based on record reviews and interviews, the hospital failed to implement its grievance process as evidenced by failure to identify a patient's caregiver's complaint that required investigation as a grievance for 1 of 1 patient complaint reviewed (#2).
Findings:

Review of the hospital's policy titled "Patient and Family Complaint/Grievance Process", policy number NSG 44, reviewed 04/13, and presented as a current policy by S1Chief Nursing Officer (CNO), revealed that a grievance is a patient care complaint, either written or verbal, that is not resolved at the time of the complaint by staff present, referred to other staff for later resolution, requires investigation, and requires further action for resolution.

Review of the list of grievances from 09/01/13 to 11/25/13 presented by S1CNO revealed no documented evidence that a grievance for Patient #2 had been logged.

Review of a computer-generated incident report completed by S3Clinical Director of the 5th floor medical/surgical unit revealed she received a complaint on 11/08/13 from Patient #2's mother and father in person. There was no documented evidence of the time that the incident was reported. Review revealed the concern was that "parents very concern because they received a picture of their son that was posted on twitter last night at 9:30 PM by a visitor to his room last PM. They want to know where the security for there son broke down..." Review of the initial action taken revealed "investigation began with S13CNA (certified nursing assistant); she stated she followed patient to Room "a" from ICU (intensive care unit) and she was in the room when a Lady and a Gentleman came in to visit the patient and she asked they they they go to the desk to see if they could visit the patient and the lady responded that yes and the nurse told them they could visit the patient..." Review of the follow-up action revealed "Spoke to S1CNO and S7Executive Director of Compliance to make aware of incident and to see if possible HIPAA (Health Information Portability and Accountability Act) breech had occurred. Follow-up action: For failure to follow policy Pending."

Review of the typed notes of the investigation conducted by S3Clinical Director of the 5th floor medical/surgical unit revealed that she received the complaint from the parents of Patient #2 on 11/08/13 and spoke to S1CNO, S13CNA, S14RN, S7Executive Director of Compliance, and S16RN regarding the complaint.

In a face-to-face interview on 11/25/13 at 3:00 p.m., S1CNO indicated the hospital was in the process of transitioning occurrance reports from hard copy to the computer. She further indicated that S3Clinical Director of the 5th floor medical/surgical unit entered the report on 11/08/13 and submitted it to S7Executive Director of Compliance, but the report didn't get imported (means it never reached S7Executive Director of Compliance). She further indicated that she thought the system had a glitch that stated you submitted the report, but S3Clinical Director of the 5th floor medical/surgical unit didn't look for the message that stated it was a successful submission. S1CNO indicated that S3Clinical Director of the 5th floor medical/surgical unit typed her narrative of the report and printed her copy, the printed copy of the report did not include everything that she had typed. S1CNO indicated the computer glitch that didn't allow the entire narrative to be printed had since been corrected.

In a face-to-face interview on 11/26/13 at 8:00 a.m., S1CNO indicated if a patient's complaint could be resolved while the patient was still in the hospital, even if it took several days to be resolved, the complaint would remain a complaint and not become a grievance. She offered no explanation for this complaint not being considered a grievance since the hospital policy stated that a complaint that is not resolved at the time of the complaint by staff present and requiring investigation would be considered a grievance.

In a face-to-face interview on 11/26/13 at 2:50 p.m., S3Clinical Director of the 5th floor medical/surgical unit indicated the complaint voiced by Patient #2's parents was handled as a complaint and not a grievance. She further indicated that a complaint was something that could be resolved immediately, and a grievance goes on longer than 24 hours.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the hospital failed to ensure that all patients received care in a safe setting as evidenced by:

1) Failing to have documented evidence of training and competency evaluations of the RNs (registered nurses) in performing suicide risk assessments in the personnel files of 4 of 4 RN personnel files from the 5th floor medical/surgical unit reviewed for competency from a total of 23 RNs employed on the 5th floor medical/surgical unit (S3, S10, S14, S16) and 1 of 1 RN's personnel file reviewed for competency from the ICU (intensive care unit) from a total of 41 RNs employed in ICU (S15);
2) Failing to ensure the RNs assigned the care of patients on suicide precautions and under a Physician Emergency Certificate (PEC) to certified nursing assistants (CNAs) who were evaluated for competency to determine that they were competent to provide the assigned duties for 3 of 3 CNAs' personnel files reviewed for competency (S8, S13, S24). This resulted in S13CNA allowing visitors who were not listed as approved visitors to visit Patient #2 and who were alleged to have placed a picture of Patient #2 on a social media website;
3) Failing to ensure that all drugs and biologicals were kept in a secure, locked area as evidenced by having medications in an unlocked drawer on the medication carts located in the hall on the 5th floor medical/surgical unit that was accessible to patients, staff, and visitors;
4) Failing to ensure the RN supervised the observation of a patient on suicide precautions performed by the CNA or sitter. There was no documented evidence of observations of Patient #2 from 9:00 a.m. to 6:00 p.m. on 11/07/13 as required by hospital policy, and the observation record completed by S13CNA was recorded inaccurately (times of 6:00 a.m. to 6:15 p.m. on 11/07/13 rather than the correct time of 6:00 p.m. on 11/07/13 to 6:15 a.m. on 11/08/13).
Findings:

1) Failing to have documented evidence of training and competency evaluations of the RNs (registered nurses) in performing suicide risk assessments:
Review of the personnel files of S3Clinical Director of the 5th floor medical/surgical unit, S10RN, S14RN, S15RN, and S16RN revealed no documented evidence of training in performing suicide risk assessments and an evaluation of competency in performing the assessments.

In a face-to-face interview on 111/27/13 at 2:45 p.m., S1Chief Nursing Officer (CNO) confirmed that the above-listed nurses' personnel files did not have competency evaluations for performing suicide risk assessments.

2) Failing to ensure the RNs assigned the care of patients on suicide precautions and under a Physician Emergency Certificate to certified nursing assistants who were evaluated for competency to determine that they were competent to provide the assigned duties:
Review of the Certified Nursing Assistant orientation teaching plan revealed that CNAs received handouts and held a discussion related to suicide precautions, the monitoring form, guidelines for suicide precautions, and patient family education.

Review of the personnel files of S8CNA Supervisor, S13CNA, and S24CNA revealed no documented evidence that they had been evaluated for competency and determined to be competent to provide care to patients on suicide precautions and under a PEC.

Review of a computer-generated incident report completed by S3Clinical Director of the 5th floor medical/surgical unit revealed she received a complaint on 11/08/13 from Patient #2's mother and father in person. Further review revealed the concern was that "parents very concern because they received a picture of their son that was posted on twitter last night at 9:30 PM by a visitor to his room last PM. They want to know where the security for there son broke down..."

In a face-to-face interview on 11/27/13 at 9:10 a.m., S13CNA indicated that on 11/07/13 at about 9:00 p.m. a male and female asked to see Patient #2. She further indicated that she asked the 2 visitors if they had gotten permission from the nurse, and they told her that they went to ICU and was told that he was on this floor. S13CNA indicated that she asked the visitors if they had gotten permission from the nurse at the desk on this floor, and they answered "yes." S13CNA indicated that she was not told who the two designated visitors were, and she was not aware that only 2 individuals were designated as allowed visitors for Patient #2. She further indicated that S14RN came into the room and told the visitors they had to leave, because "he can't have visitors and a cell phone." S13CNA indicated that she did not have special training for sitting with patients on suicide precautions.

In a face-to-face interview on 11/27/13 on 11/27/13 at 10:00 a.m., S3Clinical Director of the 5th floor medical/surgical unit indicated that sitters/CNAs assigned to patients on suicide precautions have training on the policies and protocols, but they may not be certified in CPI (crisis prevention intervention). She further indicated that the hospital did not have a system in place for evaluating the competency of the sitter/CNA in performing the duties of observing patients on suicide precautions.

In a face-to-face interview on 11/27/13 at 11:55 a.m., S1CNO confirmed there was no documented evidence of an evaluation of competency in performing the duties of observing patients on suicide precautions for S8CNA Supervisor and S13CNA.

In a face-to-face interview on 11/27/13 at 12:00 p.m., S19Lead Nursing Supervisor indicated that it was her responsibility to make sitter/CNA assignments for patients on suicide precautions. She confirmed that she did not have a list of sitters and CNAs who had been evaluated for competency from which to select.

3) Failing to ensure that all drugs and biologicals were kept in a secure, locked area as evidenced by having medications in an unlocked drawer on the medication carts located in the hall on the 5th floor medical/surgical unit that was accessible to patients, staff, and visitors:
Review of the hospital policy titled "Accessibility Of Drugs", policy number PH 10.1, revised 01/12, and presented as a current policy for the security of medications by S1Chief Nursing Officer (CNO), revealed that all areas of the hospital which contain medications for patient care will only be accessible to personnel. Further review revealed that all medication will remain secured at all times either in the dispensing cabinet, in an individual medication bin, or under the supervision of nursing personnel. Review of the entire policy revealed no documented evidence how the medications contained in the medication carts were to be maintained.

Observation of the 5th floor medical/surgical unit on 11/25/13 at 11:15 a.m. revealed the second drawer of the medication cart located in the hall that was accessible to patients, staff, and visitors was unlocked and unattended by a nurse. Further observation revealed the drawer contained 1 tablet of Quinine Sulfate 324 mg (milligrams) labeled for Random Patient R1, 1 Furosemide tablet 40 mg, and 4 individual dose packs each containing Valsartan 160 mg. During the observation with S3Clinical Director of the 5th floor medical/surgical unit present, S3Clinical Director of the 5th floor medical/surgical unit indicated that she wasn't aware that the second drawer didn't lock when the entire cart was locked by the nurse.

Observation of the 5th floor medical/surgical unit on 11/25/13 at 11:40 a.m. revealed a second medication cart located in the hall that was accessible to patients, staff, and visitors was unlocked and unattended by a nurse. Further observation revealed the drawer contained a plastic bag labeled "375" with medications for Patient #7 which included 1 Ranexa 500 mg, 12 Renagel 800 mg, and 1 Nephrocap.

In a face-to-face interview on 11/25/13 at 11:45 a.m., S4P.I. (Performance Improvement) Coordinator indicated all medications should be kept in a secured and locked area. She further indicated the above-listed medications were not secured as the medication cart was unlocked, and no nurse was in attendance.

In a face-to-face interview on 11/25/13 at 12:15 p.m., S23RN (registered nurse) indicated the medications left in the cart for Patient #7 should have been placed in the labeled bin for Patient #7, and the entire medication cart should have been locked.

4) Failing to ensure the RN supervised the observation of a patient on suicide precautions performed by the CNA or sitter:
Review of the hospital policy titled "Suicide Precautions", policy number NSG 14, reviewed 02/13, and presented as the current policy by S1Chief Nursing Officer, revealed that any patient who presents as a danger to himself/herself or others shall be placed under suicide precautions. Patients on suicide precautions are to be placed on continuous visual observation by a family member, significant other, security guard, or hospital staff. The designated staff member or observer must be able to visualize the patient at all times. Continuous observation performed by staff will include documentation every 15 minutes on the observation flow chart. There was no documented evidence in the policy related to the RN's role of supervising the continuous observations performed by the CNA or sitter.

Review of Patient #2's medical record revealed he was an [AGE] year old male admitted on [DATE] at 7:30 a.m. with diagnoses of Hallucinations, Tachycardia, Hypokalemia, and Presumed Overdose with Suicide Gesture. Review of his physician orders revealed he was ordered to be on suicide precautions.

Review of Patient #2's "Patient Observation Record" revealed one record was dated 11/07/13 and completed by S13CNA for the hours of 6:00 a.m. through 6:15 p.m. The second observation record was completed by S8CNA Supervisor with no documented evidence of the date of the observations made from 6:30 a.m. through 3:15 p.m. Review of both observation records revealed no documented evidence of a means of identifying that a review of the observation documentation was performed by a nurse.

In a face-to-face interview on 11/26/13 at 3:35 p.m., S8CNA Supervisor indicated that she provided continuous visual observation of Patient #2 in the Emergency Department (ED) until he was transferred to the Intensive Care Unit (ICU). She further indicated that she sat with Patient #2 in ICU continuously until shift change about 6:30 p.m. at which time she was relieved by S13CNA. She indicated the undated observation record should have been dated 11/08/13. S8CNA Supervisor indicated she completed an observation record for Patient #2 while in the ED and when he was transferred to the ICU and couldn't explain why it wasn't in Patient #2's medical record.

In a face-to-face interview on 11/27/13 at 9:10 a.m., S13CNA indicated that she sat with Patient #2 on 11/07/13 from about 6:30 p.m. while in ICU and continued observations when he was transferred to the 5th floor medical/surgical unit. When told that her observation record revealed that she sat from 6:00 a.m. on 11/07/13 until 6:15 p.m., S13CNA indicated "that's not correct" and "I'm not too good with the military time." She indicated that a nurse doesn't usually review her observation record.

In a face-to-face interview on 11/27/13 at 10:00 a.m., when asked what the nurse's role was regarding the sitter or CNA doing continuous visual observations, S3Clinical Director of the 5th floor medical/surgical unit answered that the nurse provided the sitter with a copy of the allowed visitors and made sure the observation record was accurately completed. When asked how one could tell that the nurse did the above-listed functions, S3Clinical Director of the 5th floor medical/surgical unit answered that it should probably be documented in the patient's medical record, but she wasn't sure that one would find it documented.

In a face-to-face interview on 11/27/13 at 10:45 a.m., S1CNO indicated that after reviewing Patient #2's medical record, she could find no documented evidence that the nurse reported to the sitter, provided a copy of the allowed visitors, and reviewed the sitter's observation record for accuracy. She further indicated that she could find no observation record completed by S8CNA Supervisor for 11/07/13.
VIOLATION: PATIENT VISITATION RIGHTS Tag No: A0216
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the hospital failed to ensure that the patient's clinical restriction of visitation was implemented as evidenced by allowing two non-designated visitors to visit a patient on suicide precautions who were not listed as approved visitors for 1 of 1 patient's record reviewed with orders for suicide precautions from a sample of 10 patients (#2).
Findings:

Review of the hospital policy titled "Suicide Precautions", policy number NSG 14, reviewed 02/13, and presented as the current policy by S1Chief Nursing Officer, revealed that any patient who presents as a danger to himself/herself or others shall be placed under suicide precautions. Further review revealed that patients on suicide precautions would have visitors restricted to 2 names provided by the patient, and no other visitors were allowed.

Review of Patient #2's medical record revealed he was an [AGE] year old male admitted on [DATE] at 7:30 a.m. with diagnoses of Hallucinations, Tachycardia, Hypokalemia, and Presumed Overdose with Suicide Gesture. Review of his physician orders revealed he was ordered to be on suicide precautions.

Review of the hospital's "Guidelines for Suicide Precautions" revealed that Patient #2's visitors were restricted to his mother and father, and visitation would be for 30 minutes at 10:00 a.m. and 6:00 p.m.

Review of an incident report completed by S3Clinical Director of the 5th floor medical/surgical unit revealed she received the complaint on 11/08/13 from Patient #2's mother and father in person. There was no documented evidence of the time that the incident was reported. Review revealed the concern was that "parents very concern because they received a picture of their son that was posted on twitter last night at 9:30 PM by a visitor to his room last PM. They want to know where the security for there son broke down..." Review of the initial action taken revealed "investigation began with S13CNA; she stated she followed patient to Room "a" from ICU (intensive care unit) and she was in the room when a Lady and a Gentleman came in to visit the patient and she asked they they they go to the desk to see if they could visit the patient and the lady responded that yes and the nurse told them they could visit the patient..."

In a face-to-face interview on 11/27/13 at 9:10 a.m., S13CNA (certified nursing assistant) indicated that on 11/07/13 at about 9:00 p.m. a male and female asked to see Patient #2. She further indicated that she asked the 2 visitors if they had gotten permission from the nurse, and they told her that they went to ICU and was told that he was on this floor. S13CNA indicated that she asked the visitors if they had gotten permission from the nurse at the desk on this floor, and they answered "yes." S13CNA indicated that she was not told who the two designated visitors were, and she was not aware that only 2 individuals were designated as allowed visitors for Patient #2. She further indicated that S14RN (registered nurse) came into the room and told the visitors they had to leave, because "he can't have visitors and a cell phone."
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the hospital failed to ensure that the registered nurse (RN) supervised and evaluated the nursing care of each patient as evidenced by:
1) The RN delegating suicide risk assessments of patients to the LPN (licensed practical nurse) which was not a task that could be delegated according to the Louisiana Registered Nurse Practice Act for 1 of 10 sampled patients (#1) and
2) The RN failing to supervise the observation of a patient on suicide precautions performed by the CNA (certified nursing assistant) or sitter. There was no documented evidence of observations of Patient #2 from 9:00 a.m. to 6:00 p.m. on 11/07/13 as required by hospital policy, and the observation record completed by S13CNA was recorded inaccurately (times of 6:00 a.m. to 6:15 p.m. on 11/07/13 rather than the correct time of 6:00 p.m. on 11/07/13 to 6:15 a.m. on 11/08/13).
Findings:

1) The RN delegating suicide risk assessments of patients to the LPN which was not a task that could be delegated according to the Louisiana Registered Nurse Practice Act:
Review of the Louisiana State Board of Nursing's "Administrative Rules Defining RN Practice LAC46:XLVII" revealed, in part, "3703. Definition of Terms Applying to Nursing Practice ... Delegating Nursing Interventions - ... The registered nurse retains the accountability for the total nursing care of the individual. ... The registered nurse shall assess the patient care situation which encompasses the stability of the clinical environment and the clinical acuity of the patient, including the overall complexity of the patient's health care problems. The assessment shall be utilized to assist in determining which tasks may be delegated and the amount of supervision which will be required. a. Any situation where tasks are delegated should meet the following criteria: i. the person has been adequately trained for the task; ii. the person has demonstrated that the task has been learned; iii. the person can perform the task safely in the given nursing situation; iv. the patient's status is safe for the person to carry out the task; v. appropriate supervision is available during the task implementation; vi. the task is in an established policy of the nursing practice setting and the policy is written, recorded and available to all. b. The registered nurse may delegate to licensed practical nurses the major part of the nursing care needed by individuals in stable nursing situations, i.e. (that is), when the following three conditions prevail at the same time in a given situation: i. nursing care ordered and directed by R.N./M.D. (medical doctor) requires abilities based on a relatively fixed and limited body of scientific fact and can be performed by following a defined nursing procedure with minimal alteration, and responses of the individual to the nursing care are predictable; and ii. change in the patient's clinical conditions is predictable; and iii. medical and nursing orders are not subject to continuous change or complex modification...

Review of the hospital policy titled "Identifying patients at risk for suicide (Use of Sad Person Scale), policy number NSG 13, reviewed 02/13, and presented by S1Chief Nursing Officer (CNO) as a current policy, revealed that the policy related to all patients presenting to the inpatient unit or all patients who present to the hospital with a primary or secondary diagnosis or complaint of an emotional or behavioral disorder. Further review revealed the initial assessment should begin upon presentation to the Emergency Department or upon hospital admission. Re-assessment should occur every 24 hours for patients identified at risk for suicide and should be performed by social services during business hours and by the nurse caring for the patient outside of business hours.

Review of Patient #1's medical record revealed he was a [AGE] year old male admitted on [DATE] with diagnoses of Tylenol Overdose and Suicidal Gesture. Review of his "Admission History Change Report" revealed Patient #1's suicide risk assessment using the Sad Persons Scale were performed by the following LPNs:
11/15/13 at 7:32 p.m. - S25LPN;
11/16/13 at 5:43 a.m. - S25LPN;
11/16/13 at 7:30 p.m. - S25LPN;
11/17/13 at 7:25 p.m. - S25LPN;
11/18/13 at 8:00 a.m. - S12LPN;
11/18/13 at 8:00 p.m. - S26LPN;
11/19/13 at 4:52 a.m. - S26LPN;
11/19/13 at 8:00 a.m. - S12LPN.

In a face-to-face interview on 11/26/13 at 2:50 p.m., S3Clinical Director of the 5th floor medical/surgical unit indicated that the suicide risk assessment was performed by any nurse at various shifts. She further indicated that the RN could not delegate a patient assessment to a LPN, and the LPN should not be performing patients' suicide risk assessments.

2) The RN failing to supervise the observation of a patient on suicide precautions performed by the CNA or sitter:
Review of the hospital policy titled "Suicide Precautions", policy number NSG 14, reviewed 02/13, and presented as the current policy by S1Chief Nursing Officer, revealed that any patient who presents as a danger to himself/herself or others shall be placed under suicide precautions. Patients on suicide precautions are to be placed on continuous visual observation by a family member, significant other, security guard, or hospital staff. The designated staff member or observer must be able to visualize the patient at all times. Continuous observation performed by staff will include documentation every 15 minutes on the observation flow chart. There was no documented evidence in the policy related to the RN's role of supervising the continuous observations performed by the CNA or sitter.

Review of Patient #2's medical record revealed he was an [AGE] year old male admitted on [DATE] at 7:30 a.m. with diagnoses of Hallucinations, Tachycardia, Hypokalemia, and Presumed Overdose with Suicide Gesture. Review of his physician orders revealed he was ordered to be on suicide precautions.

Review of Patient #2's "Patient Observation Record" revealed one record was dated 11/07/13 and completed by S13CNA for the hours of 6:00 a.m. through 6:15 p.m. The second observation record was completed by S8CNA Supervisor with no documented evidence of the date of the observations made from 6:30 a.m. through 3:15 p.m. Review of both observation records revealed no documented evidence of a means of identifying that a review of the observation documentation was performed by a nurse.

In a face-to-face interview on 11/26/13 at 3:35 p.m., S8CNA Supervisor indicated that she provided continuous visual observation of Patient #2 in the Emergency Department (ED) until he was transferred to the Intensive Care Unit (ICU). She further indicated that she sat with Patient #2 in ICU continuously until shift change about 6:30 p.m. at which time she was relieved by S13CNA. She indicated the undated observation record should have been dated 11/08/13. S8CNA Supervisor indicated she completed an observation record for Patient #2 while in the ED and when he was transferred to the ICU and couldn't explain why it wasn't in Patient #2's medical record.

In a face-to-face interview on 11/27/13 at 9:10 a.m., S13CNA indicated that she sat with Patient #2 on 11/07/13 from about 6:30 p.m. while in ICU and continued observations when he was transferred to the 5th floor medical/surgical unit. When told that her observation record revealed that she sat from 6:00 a.m. on 11/07/13 until 6:15 p.m., S13CNA indicated "that's not correct" and "I'm not too good with the military time." She indicated that a nurse doesn't usually review her observation record.

In a face-to-face interview on 11/27/13 at 10:00 a.m., when asked what the nurse's role was regarding the sitter or CNA doing continuous visual observations, S3Clinical Director of the 5th floor medical/surgical unit answered that the nurse provided the sitter with a copy of the allowed visitors and made sure the observation record was accurately completed. When asked how one could tell that the nurse did the above-listed functions, S3Clinical Director of the 5th floor medical/surgical unit answered that it should probably be documented in the patient's medical record, but she wasn't sure that one would find it documented.

In a face-to-face interview on 11/27/13 at 10:45 a.m., S1CNO indicated that after reviewing Patient #2's medical record, she could find no documented evidence that the nurse reported to the sitter, provided a copy of the allowed visitors, and reviewed the sitter's observation record for accuracy. She further indicated that she could find no observation record completed by S8CNA Supervisor for 11/07/13.
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
Based on record reviews and interviews, the hospital failed to ensure that the RN (registered nurse) assigned the nursing care of each patient to other nursing personnel who were evaluated and determined to be competent to perform the assigned duties/tasks.
1) The RNs failed to have documented evidence of training and competency evaluations in performing suicide risk assessments in the personnel files of 4 of 4 RN personnel files from the 5th floor medical/surgical unit reviewed for competency from a total of 23 RNs employed on the 5th floor medical/surgical unit (S3, S10, S14, S16) and 1 of 1 RN's personnel file reviewed for competency from the ICU (intensive care unit) from a total of 41 RNs employed in ICU (S15).
2) The RNs assigned the care of patients on suicide precautions and under a Physician Emergency Certificate (PEC) to certified nursing assistants (CNAs) who were not evaluated for competency to determine that they were competent to provide the assigned duties for 3 of 3 CNAs' personnel files reviewed for competency (S8, S13, S24). This resulted in S13CNA allowing visitors who were not listed as approved visitors to visit Patient #2 and were alleged to have placed a picture of Patient #2 on a social media website.
Findings:

1) The RNs failed to have documented evidence of training and competency evaluations in performing suicide risk assessments:
Review of the personnel files of S3Clinical Director of the 5th floor medical/surgical unit, S10RN, S14RN, S15RN, and S16RN revealed no documented evidence of training in performing suicide risk assessments and an evaluation of competency in performing the assessments.

In a face-to-face interview on 111/27/13 at 2:45 p.m., S1Chief Nursing Officer (CNO) confirmed that the above-listed nurses' personnel files did not have competency evaluations for performing suicide risk assessments.

2) The RNs assigned the care of patients on suicide precautions and under a PEC to certified nursing assistants (CNAs) who were not evaluated for competency to determine that they were competent to provide the assigned duties:
Review of the Certified Nursing Assistant orientation teaching plan revealed that CNAs received handouts and held a discussion related to suicide precautions, the monitoring form, guidelines for suicide precautions, and patient family education.

Review of the personnel files of S8CNA Supervisor, S13CNA, and S24CNA revealed no documented evidence that they had been evaluated for competency and determined to be competent to provide care to patients on suicide precautions and under a PEC.

Review of a computer-generated incident report completed by S3Clinical Director of the 5th floor medical/surgical unit revealed she received a complaint on 11/08/13 from Patient #2's mother and father in person. Further review revealed the concern was that "parents very concern because they received a picture of their son that was posted on twitter last night at 9:30 PM by a visitor to his room last PM. They want to know where the security for there son broke down..."

In a face-to-face interview on 11/27/13 at 9:10 a.m., S13CNA indicated that on 11/07/13 at about 9:00 p.m. a male and female asked to see Patient #2. She further indicated that she asked the 2 visitors if they had gotten permission from the nurse, and they told her that they went to ICU and was told that he was on this floor. S13CNA indicated that she asked the visitors if they had gotten permission from the nurse at the desk on this floor, and they answered "yes." S13CNA indicated that she was not told who the two designated visitors were, and she was not aware that only 2 individuals were designated as allowed visitors for Patient #2. She further indicated that S14RN (registered nurse) came into the room and told the visitors they had to leave, because "he can't have visitors and a cell phone." S13CNA indicated that she did not have special training for sitting with patients on suicide precautions.

In a face-to-face interview on 11/27/13 on 11/27/13 at 10:00 a.m., S3Clinical Director of the 5th floor medical/surgical unit indicated that sitters/CNAs assigned to patients on suicide precautions have training on the policies and protocols, but they may not be certified in CPI (crisis prevention intervention). She further indicated that the hospital did not have a system in place for evaluating the competency of the sitter/CNA in performing the duties of observing patients on suicide precautions.

In a face-to-face interview on 11/27/13 at 11:55 a.m., S1CNO confirmed there was no documented evidence of an evaluation of competency in performing the duties of observing patients on suicide precautions for S8CNA Supervisor and S13CNA.

In a face-to-face interview on 11/27/13 at 12:00 p.m., S19Lead Nursing Supervisor indicated that it was her responsibility to make sitter/CNA assignments for patients on suicide precautions. She confirmed that she did not have a list of sitters and CNAs who had been evaluated for competency from which to select.
VIOLATION: SECURE STORAGE Tag No: A0502
Based on observations, record reviews, and interviews, the hospital failed to ensure that all drugs and biologicals were kept in a secure, locked area as evidenced by having medications in an unlocked drawer on the medication carts located in the hall on the 5th floor medical/surgical unit that was accessible to patients, staff, and visitors.
Findings:

Review of the hospital policy titled "Accessibility Of Drugs", policy number PH 10.1, revised 01/12, and presented as a current policy for the security of medications by S1Chief Nursing Officer (CNO), revealed that all areas of the hospital which contain medications for patient care will only be accessible to personnel. Further review revealed that all medication will remain secured at all times either in the dispensing cabinet, in an individual medication bin, or under the supervision of nursing personnel. Review of the entire policy revealed no documented evidence how the medications contained in the medication carts were to be maintained.

Observation of the 5th floor medical/surgical unit on 11/25/13 at 11:15 a.m. revealed the second drawer of the medication cart located in the hall that was accessible to patients, staff, and visitors was unlocked and unattended by a nurse. Further observation revealed the drawer contained 1 tablet of Quinine Sulfate 324 mg (milligrams) labeled for Random Patient R1, 1 Furosemide tablet 40 mg, and 4 individual dose packs each containing Valsartan 160 mg. During the observation with S3Clinical Director of the 5th floor medical/surgical unit present, S3Clinical Director of the 5th floor medical/surgical unit indicated that she wasn't aware that the second drawer didn't lock when the entire cart was locked by the nurse.

Observation of the 5th floor medical/surgical unit on 11/25/13 at 11:40 a.m. revealed a second medication cart located in the hall that was accessible to patients, staff, and visitors was unlocked and unattended by a nurse. Further observation revealed the drawer contained a plastic bag labeled "375" with medications for Patient #7 which included 1 Ranexa 500 mg, 12 Renagel 800 mg, and 1 Nephrocap.

In a face-to-face interview on 11/25/13 at 11:45 a.m., S4P.I. (Performance Improvement) Coordinator indicated all medications should be kept in a secured and locked area. She further indicated the above-listed medications were not secured as the medication cart was unlocked, and no nurse was in attendance.

In a face-to-face interview on 11/25/13 at 12:15 p.m., S23RN (registered nurse) indicated the medications left in the cart for Patient #7 should have been placed in the labeled bin for Patient #7, and the entire medication cart should have been locked.
VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Tag No: A0724
Based on observations, record reviews, and interviews, the hospital failed to ensure that all patient supplies were maintained at an acceptable level of safety and quality as evidenced by having needles and syringes in an unlocked drawer of the medication cart located in the hall of the 5th floor medical/surgical unit that was accessible to patients, staff, and visitors and having expired/unusable/opened, used single-use supplies available for patient use in the supply room, clean storage room, and the medication room on the 5th floor medical/surgical unit.
Findings:

Review of hospital policy titled "Cleaning Equipment Care" presented by S1CNO (Chief Nursing Officer) as a current policy revealed that the expiration date of medical equipment and supplies should be checked on a regular basis to ensure that the supply was not used beyond the expiration date.

Review of the hospital policy titled "Whole Blood Glucose Monitoring", effective 08/14/03 and presented as a current policy by S1CNO, revealed that blood glucose test strips and Quality Control supplies kept on the nursing units will be monitored monthly by the laboratory personnel during the "SureStepFlexx uploads" (process used by the laboratory department to upload unit meters). Reagents will be inspected for evidence of deterioration and for their expiration dates. Unsatisfactory reagents will be discarded and new reagents put in place. Further review revealed that the Materials Management Department was responsible for checking the par level on nursing units 3 times a week at which time expiration dates are monitored and supplies and reagents are refilled. Upon opening a new vial of reagent strips, staff must date and initial the vial, and record the new expiration on the vial. Any unused portion of the strips was to be discarded 3 months after opening. Review of the entire policy revealed no documented evidence that specific directions were included for the need to date and initial when opening test solutions and when to discard the test solution.

Observation on 11/25/13 at 11:15 a.m. revealed the second drawer of the medication cart located in the hall of the 5th floor medical/surgical unit that was accessible to patients, staff, and visitors was unlocked and contained multiple 19 gauge 1/2 inch filter needles and syringes. During the observation S3Clinical Director of the 5th floor medical/surgical unit indicated that the drawer should be locked, and it was a malfunction that prevented the second drawer from locking when the entire medication cart was locked by the nurse. She further indicated that she didn't know the medication cart was broken.

Observation in the Supply Room on the 5th floor medical/surgical unit on 11/25/13 at 11:30 a.m. revealed the Life Scan Sure Step Pro high glucose control solution was opened and not initialed or dated when it was opened. Further observation revealed the low glucose control solution was dated as opened on 10/04/13. During the observation S3Clinical Director of the 5th floor medical/surgical unit indicated the solutions should be dated when opened and discarded once the solution was opened for 30 days. Further observation revealed 2 bottles of Lifescan Sure Step Pro test strips were not dated or initialed when opened. During the observation S4P. I. (Performance Improvement) Coordinator indicated the test strips should be dated when opened and thought the strips were good for 30 days once opened. Further observation revealed 4 pre-saturated 3 inch by 3 inch Gluco-Chlor towelettes (used to clean the glucose meter) had expired 11/12. This observation was confirmed by S4P. I. Coordinator.

In a face-to-face interview on 11/25/13 at 11:35 a.m., S3Clinical Director of the 5th floor medical/surgical unit indicated the user should check all items before use. She further indicated she did not have a system for monitoring compliance of expiration checks of supplies on a monthly basis.

Observation of the Clean Storage Room of the 5th floor medical/surgical unit on 11/25/13 at 11:35 a.m. revealed one 1000 ml (milliliter) evacuation container (drainage collection bottle used for thoracentesis and paracentesis) with an expiration date of 08/14/13, one BD Vacutainer urinalysis transfer straw kit with an expiration date of 06/12, one Sure Step low control solution for use with the glucometer with an expiration date of 10/13 that was dated as opened on 11/07/13, Gluco-Chlor towelettes that expired 08/13, and one Sure Step high control solution that was opened and not dated when opened.

Observations on 11/25/13 at 11:40 a.m. revealed two medication carts and one COW (computer on wheels) labeled "Respiratory" located in the hall on the 5th floor medical/surgical unit that was unattended, unlocked and contained the following syringes and needles:
Medication Cart #1, drawer #2 - ten 10 ml syringes and twelve 19 gauge, 1/2 inch filter needles;
Medication Cart #2, drawer #2 - twenty 10 ml syringes, thirteen 19 gauge by 1 1/2 inch needles, one 23 gauge by 1 inch needle, one 22 gauge by 1 1/2 inch needle, and one 18 gauge by 1 1/2 inch needle;
COW labeled "Respiratory ", drawer #2 - three 23 by 1 inch needles and one insulin syringe.

In a face-to-face interview on 11/25/13 at 11:45 a.m., S4P.I. Coordinator indicated all supplies and equipment for patients' use should be secured and locked to ensure safety and quality. She further indicated the syringes and needles should have been secured and locked in the carts, and all expired supplies should not be accessible for patient use.

Observation of the Medication Room on the 5th floor medical/surgical unit on 11/25/13 at 11:45 a.m. revealed 51 Gluco-Chlor towelettes that had expired 08/31/13, an Arrow-Clarke Pleura-Seal Thoracentesis Kit that expired 10/31/13, and Curad 1 inch by 5 yards of Iodoform packing strip that expired 08/31/13. These observations were confirmed by S3Clinical Director of the 5th floor medical/surgical unit.

Observation of the Supply Room on the 5th floor medical/surgical unit on 11/25/13 at 12:05 p.m. revealed an 11 ounce can of shaving cream on the shelf without a cover and a string of dried shaving cream at the spout of the can. Further observation revealed an opened box of Kleenex on the shelf available for patient use. During the observation S3Clinical Director of the 5th floor medical/surgical unit indicated she couldn't confirm that the shaving cream had not been used, and the opened box of Kleenex should not be on the shelf.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observations, record reviews, and interviews, the hospital failed to ensure that infection control officer implemented measures to identify, prevent, and control infections and communicable diseases within the hospital by assuring the maintenance of a sanitary hospital environment. Observations on the 5th floor medical/surgical unit on 11/25/13 revealed chipped over-bed tables with exposed particle board and rough edges, a medication refrigerator with a missing grill cover and exposed vents, coils, and drip pan covered with dust, dirt, and grime, and computers on wheels (COWs) with sticky residue on the screen frame, dust on the computer screen and cart surface, and an attached garbage container with the lid open exposing soiled paper and used gloves.
Findings:

Review of the hospital policy titled "Refrigerator daily maintenance in patient care areas", presented as a current policy by S1Chief Nursing Officer (CNO), revealed that each Department Manager was responsible to maintain cleanliness of refrigerators. Further review revealed that nursing was responsible the cleaning of medication refrigerators.

Review of the hospital policy titled "Cleaning Equipment/Equipment Care", revised 01/11 and presented as a current policy by S1CNO, revealed that high touch areas on rolling computer equipment (COWs) in patient care areas will be cleaned and disinfected daily by staff utilizing the equipment, and the remaining framework will be cleaned and disinfected by Environmental Service Staff weekly. Noninvasive, reusable medical equipment such as bedside equipment and hospital beds should be cleaned and disinfected as soon as its use is discontinued, or if it becomes soiled during use by wiping with a cleaner when the room is being cleaned on a regular basis during use.

Observation of Room "a" on 11/25/13 at 11:20 a.m. revealed the over-bed table was chipped and had exposed particle board. Observation of Room "b" on 11/25/13 at 12:10 p.m. revealed the edges of the over-bed table were chipped that left rough edges. During each of these observations S3Clinical Director of the 5th floor medical/surgical unit indicated the presence of exposed particle board and chipped, rough edges on the over-bed tables prevented the patient equipment from being disinfected properly.

Observation on 11/25/13 at 12:10 p.m. of the medication refrigerator located in the medication room on the 5th floor medical/surgical unit revealed the front grill was missing which allowed exposure of vents, coils, and the drip pan. Continued observations revealed the coils and vents were covered with a thick layer of dust, dirt, and grime, and the removable drip pan was covered in a 1/2 to 3/4 inch of caked-on, thick gray particles with a button (used in clothing) in the center of the drip pan.

In a face-to-face interview on 11/25/13 at 12:15 p.m., S3 Clinical Director of the 5th floor medical/surgical unit indicated it was the responsibility of the Nursing Staff to maintain cleanliness of the medication refrigerator. She further indicated there was no documented evidence of a cleaning log for the medication refrigerator, and therefore she was unable to recall the last date the medication refrigerator had been cleaned.

Observation of the COWs on the 5th floor medical/surgical unit on 11/25/13 at 12:10 p.m. revealed the following:
COW labeled 5N06 - soiled, sticky substance around the computer screen; the lid to the garbage container attached to the side of the COW was open exposing papers and used gloves that were contained within;
COW labeled 5N08 - computer screen with a layer of dust that could be wiped off with one's finger and a sticky residue on the screen and the surface of the cart.

In a face-to-face interview on 11/25/13 at 12:10 p.m., S4P. I. (Performance Improvement) Coordinator indicated that the condition of the COWs presented an infection control issue.
VIOLATION: IMPLEMENTATION OF A DISCHARGE PLAN Tag No: A0820
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the hospital failed to ensure each patient's discharge plan was implemented as evidenced by failure of the nurse or case manager to attempt to make the post-discharge medical appointment for 1 of 5 discharged patients' records reviewed from a sample of 10 patients (#2).
Findings:

Review of the hospital policy titled "Discharge Planning", revised 08/24/09 and presented as the hospital's current policy by S1Chief Nursing Officer (CNO), revealed that each patient's needs for continuing care are assessed by all members of the healthcare team. The assessment may begin prior to admission but no later than at the time of the admission nursing assessment. Further review revealed that the purpose of discharge planning was to identify a patient's unique needs for continuing physical, emotional, housekeeping, transportation, social, and other needs and to arrange services to meet those needs. Based on the nursing assessment, patients that demonstrate more complex discharge planning needs are referred to the discharge planner who will arrange services or care to meet those needs. An automatic referral to the discharge planner for focused discharged planning is made for all "high-risk" patients. Adult high-risk patients include those admitted through the Emergency Department (ED).

Review of the hospital policy titled "Discharge Process", reviewed 02/13 and presented as the hospital's current policy by S1Chief Nursing Officer (CNO), revealed that prior to discharge, the nurse caring for the patient must arrange or assist in arranging the services needed by the patient after discharge in order to meet his/her ongoing needs for care and services. Further review revealed that on the day of discharge the nurse was responsible for verifying the patient's/family's understanding of the post-discharge appointments and follow-up. The case manager/discharge planner/social service personnel was responsible for addressing post-discharge care and encouraging follow-up compliance with appropriate professionals and/or diagnostic orders.

Review of Patient #2's medical record revealed he (MDS) dated [DATE], was PEC'd (Physician Emergency Certificate) on 11/07/13 at 7:00 a.m. due to being a danger to himself (took about 6 sleep aid pills), and admitted to the ICU (intensive care unit) with diagnoses of Hallucinations, Tachycardia, Hypokalemia, and Presumed Overdose with Suicidal Gestures. Patient #2 had physician orders to transfer to the medical/surgical unit on 11/07/13 at 6:30 p.m.

Review of S9Physician's psychiatric progress note dated 11/08/13 at 12:50 p.m. revealed that Patient #2 was not suicidal and not in need of inpatient psychiatric hospitalization .

Review of Patient #2's "Physician's Orders" revealed an order by S6Physician (attending hospitalist) on 11/08/13 at 1:20 p.m. to discharge Patient #2 to home and follow-up with his PCP (primary care physician) when available.

Review of Patient #2's "Initial Care Plan" dated 11/07/13 at 7:28 p.m. by S17RN (registered nurse) revealed a problem identified was discharge planning. Further review revealed interventions included arranging follow-up care with physician(s) and/or clinic, educating on discharge planning arrangements, and post discharge referrals. Further review revealed that S16RN documented on 11/08/13 at 3:40 p.m. that Patient #2's discharge readiness needs were met.

Review of S16RN's "Nursing Documentation Report" dated 11/08/13 at 3:39 p.m. revealed that hand outs were given on suicide prevention, discharge teaching was given to Patient #2 and a family member, and both were instructed to call and schedule a follow-up appointment (no documented evidence of the name of the physician).

Review of Patient #2's "Patient Discharge Instruction Sheet", signed by Patient #2's mother and S16RN on 11/08/13 at 3:20 p.m. revealed a notation of "Primary Care Provider Call & (and) Schedule."

Review of S22LMSW's (licensed medical social worker) "Progress Notes" dated 11/08/13 at 1:30 p.m. revealed that Patient #2 was cleared to go home, and his psychiatric placement was canceled. Further review revealed she the following information/handouts to Patient #2: resources for alcohol and substance abuse, community resources, Suicide Hotline, and Mental Health Advocate. S22LMSW instructed Patient #2 on the 24 hour services of the Suicide Hotline number. There was no documented evidence that a discussion was held regarding a follow-up appointment with a PCP.

In a face-to-face interview on 11/27/13 at 8:40 a.m., S16RN indicated that she was the RN who discharged Patient #2. She further indicated that if a patient did not have a PCP, the patient had to call to schedule the follow-up appointment. S16RN indicated that Patient #2 didn't have a physician, and that was why he was attended by the hospitalist. She further indicated that most of the time she doesn't try to find out which physician the patient wants to see after discharge. S16RN indicated that as part of Patient #2's discharge planning, she did not address the fact that Patient #2 did not have a PCP.

In a face-to-face interview on 11/27/13 at 11:35 a.m., S18Social Services Case Worker indicated that one function of the social service department is discharge planning. She further indicated that she did not provide services to Patient #2, but she could answer questions about the department since S22LMSW (who provided services to Patient #2) was off today. S18Social Services Case Worker indicated that her department can help to make medical appointments if the case manager notify them of the need.

In a face-to-face interview on 11/27/13 at 12:20 p.m., S20Certified Case Manager (CCM) indicated that she usually tried to find out who a patient's PCP was and made the follow-up appointment at discharge. She further indicated that if the PCP's office was closed at the time of discharge, she would instruct the patient to call to make the appointment and does not send any patient information to the PCP unless the unit secretary had been requested by the hospitalist to do so. S20CCM indicated if a patient didn't have a PCP, she tried to get an appointment at the primary care clinic and would fax them the patient information. When asked if it was a lack of discharge planning to have the patient instructed to call to schedule a post-discharge physician appointment with a PCP rather than having the appointment made before discharge, S20CCM answered "Yes."