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.

LEONARD J CHABERT MEDICAL CENTER 1978 INDUSTRIAL BLVD HOUMA, LA 70363 Oct. 25, 2012
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on record review and interview, the hospital failed to meet the requirements of the Condition of Participation for Patient Rights as evidenced by:

1) Failing to ensure effective implementation of the grievance process for prompt resolution of patient grievances as evidenced by:
a) failing to determine whether patient concerns were complaints or grievances for 6 of 6 (R5, R6, R7, R8, R9, R10) complaint/grievances reviewed;
b) failing to investigate patient grievances for 1 of 2 grievances reviewed (R7);
c) failing to acknowledge a grievance in writing to the patient for 1 of 2 grievances reviewed (R7); and
d) failing to document a log of grievances received according to hospital policy (see findings at A0118 and A0123).

2) Failing to ensure that patients received care in a safe setting.
a) The hospital failed to ensure that a patient exhibiting increased agitation that required security guards to escort him to a quiet area was escorted by using approved IMAB (intervention management of aggressive behavior) techniques for 1 of 1 patient's record reviewed who required an escort by security guards from a total sample of 6 patients (#5).
b) The hospital failed to implement its policy for the care and monitoring of psychiatric patients who have had a PEC (physician emergency certificate) completed by allowing the PEC'd patient to be alone in the bathroom, while hospital policy required that PEC'd patients outside the psychiatric unit have continuous visual observation conducted according to physician's orders for 1 of 6 patients' records reviewed who had been PEC'd from a total of 6 sampled patients (#5) (see findings at A0144).
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on record reviews and interviews, the hospital failed to ensure effective implementation of the grievance process for prompt resolution of patient grievances as evidenced by: 1) failing to determine whether patient concerns were complaints or grievances for 6 of 6 (R5, R6, R7, R8, R9, R10) complaint/grievances reviewed; 2) failing to investigate patient grievances for 1 of 2 grievances reviewed (R7); 3) failing to acknowledge a grievance in writing to the patient for 1 of 2 grievances reviewed (R7); and 4) failing to document a log of grievances received according to hospital policy. Findings:

1) Failing to determine whether patient concerns were complaints or grievances:
Review of the Documentation of Patient Complaint/Grievance Forms for R5, R6, R7, R8, R9, and R10 revealed a space to check to indicate whether the concern was a complaint or a grievance. None of the above complaint/grievance forms were checked for complaint or grievance.

On 10/25/12 at 10:00 a.m., in a face-to-face interview S26 Patient Advocate confirmed she was responsible for receiving and investigating complaints/grievances. After reviewing the complaint/grievance forms for R5, R6, R7, R8, R9, and R10, S26 verified she had documented the forms and none of the complaint/grievance forms had documentation of whether the concern was a complaint or a grievance. When asked what the difference between a complaint and a grievance was, S26 stated a grievance was, "a mail in you receive and you have 7 days to investigate and respond to the person who complained." S26 stated most of the complaints she received were by telephone. After review of the hospital's policy on complaints and grievances, S26 verified she did not understand the difference between a complaint and a grievance.

2) Failing to investigate patient grievances:
Review of the Complaint/Grievance Form for R7 revealed in part the following:
___Complaint ____Grievance (Check Appropriate Box) (Left blank)
Date received: 09/24/12.
Location: Emergency Department
Patient Issue: Patient in ER (emergency room ) 19th - Long wait-patient states no reason for wait - back pain.
Plan of Action: Patient called 24th with complaint. I spoke to patient, apologized for long wait-explained to patient level of care, wait times, etc.
Resolution: Tried to make clinic appointment for patient, did not want. Apologized numerous times to patient for long wait.
Date resolved: 09/24/12

On 10/25/12 at 10:00 a.m., in a face-to-face interview S26 Patient Advocate stated she offered to make an appointment in the clinic for the patient and apologized for the wait. S26 verified she had not done an investigation of the patient's complaint of waiting a long time in ER. S26 verified she had not reviewed the patient's ER record or talked to the staff in the ER. S26 verified the patient's complaint was not received until 5 days after the ER visit and confirmed the complaint was not resolved at the point of care.

3) Failing to acknowledge a grievance in writing to the patient:
Review of the Complaint/Grievance Form for R7 revealed in part the following:
___Complaint ____Grievance (Check Appropriate Box) (Left blank)
Date received: 09/24/12.
Location: Emergency Department
Patient Issue: Patient in ER (emergency room ) 19th - Long wait-patient states no reason for wait - back pain.
Plan of Action: Patient called 24th with complaint. I spoke to patient, apologized for long wait-explained to patient level of care, wait times, etc.
Resolution: Tried to make clinic appointment for patient, did not want. Apologized numerous times to patient for long wait.
Date resolved: 09/24/12
Date written notification forwarded to patient:____ (Left Blank)

On 10/25/12 at 10:00 a.m., in a face-to-face interview S26 Patient Advocate stated she offered to make an appointment in the clinic for the patient and apologized for the wait. S26 verified she had not done an investigation of the patient's complaint of waiting a long time in ER. S26 verified she had not done a written notification to the patient

4) Failing to document a log of grievances received according to hospital policy:
On 10/23/12 at 10:10 a.m., during the entrance conference, the hospitals grievance log was requested for review.

Review of the documents provided revealed no documented evidence of a grievance log. At 11:45 a.m., S1 Quality Management Director indicated the hospital did not have any grievances. Documentation of any complaints received by the hospital was requested for review. S1 provided a log of complaints from May 2012 to October 2012 for review.

Review of the Complaint/Issue log revealed the log included the date, the patient's name, the complaint/issue, and the department only.

Review of the Documentation of Patient Complaint/Grievance Form for R5 dated 09/10/12, revealed an investigation of the patient's complaint was done after the patient's daughter contacted the Department of Health & Hospitals (DHH). The Grievance Form also included a written response to the patient. There was no documented evidence this grievance was included on the Complaint/Issue Log.

In a face-to-face interview with S26 Patient Advocate on 10/25/12 at 10:00 a.m., S26 verified the grievance for R5 was not documented on the Complaint/Issue log. S26 stated the patient's daughter called DHH and DHH called them (hospital staff) and said to write it as a grievance. S26 stated S2 Director of Nursing did the investigation and sent a letter to the patient's daughter. After reviewing the hospital policy on Patient Complaints and Grievances, S26 verified the current Complaint/Issue log did not contain the required components of the type of grievance, the outcome/resolution, or the closure date. S26 verified she was not familiar with the hospital's policy on Complaints and Grievances.

Review of the hospital policy titled, Policy on Patient Complaints and Grievances, Policy Number 6508-11, reviewed date of 12/12/2011, and provided by the Quality Management Director (S1) as current, revealed in part the following:
I. Policy: It is the policy of LSU Health Care Services Division (LSU-HCSD) to protect patient health and safety and to ensure that high-quality care is afforded to all patients.....
II. Definitions: Grievance - A formal, informal, written or verbal request/complaint by a patient, his/her designated representative to have the facility formally review a concern or objection about the quality or appropriateness of patient care....E-mail and faxed correspondence are recognized forms of communication. It is expected that the facility will have a process to comply with a minor request (such as room change, dietary request) in a more timely manner than a written response. Written responses are not required for a relatively minor grievance that can be resolved quickly.
VI. General Guidelines
1. Each HCSD health care facility will have at least one person identified as a "Patient Advocate" who will be responsible for receiving and investigating issues that have not been resolved by the unit management. This person will work as a facilitator/mediator to resolve the issues in the best interest of the patient and the facility, and identify underlying problems that should be corrected....
5. Grievances must be acknowledged in writing within 10 days and resolved within 40 days. Written documentation must be kept on each grievance received. This written documentation is to be kept along with a log of incoming grievances. The log should contain the date the grievance was received, type of grievance, area of hospital involved and outcome/resolution including a closure dated. The log serves as a reference point for monthly statistics as well as an "at a glance" reference point for open and closed grievances.
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on record review and staff interview, the hospital failed to ensure that a written notice of a grievance resolution was provided to 1 of 2 random sampled grievances reviewed (R7). Findings:

Review of the Complaint/Grievance Form for R7 revealed in part the following:
___Complaint ____Grievance (Check Appropriate Box) (Left blank)
Date received: 09/24/12.
Location: Emergency Department
Patient Issue: Patient in ER (emergency room ) 19th - Long wait-patient states no reason for wait - back pain.
Plan of Action: Patient called 24th with complaint. I spoke to patient, apologized for long wait-explained to patient level of care, wait times, etc.
Resolution: Tried to make clinic appointment for patient, did not want. Apologized numerous times to patient for long wait.
Date resolved: 09/24/12
Date written notification forwarded to patient:____ (Left Blank)

On 10/25/12 at 10:00 a.m., in a face-to-face interview S26 Patient Advocate stated a grievance was "a mail in you receive and you have 7 days to investigate and respond to them". After reviewing the Complaint/Grievance Form for R7, S26 stated she offered to make an appointment in the clinic for the patient and apologized for the wait. S26 verified she had not done a written notification to the patient. After reviewing the hospital's policy on Patient Complaints and Grievances, S26 verified she did not know the difference between a complaint and a grievance and she was not familiar with the policy.

Review of the hospital policy titled, Policy on Patient Complaints and Grievances, Policy Number 6508-11, reviewed date of 12/12/2011, and provided by the Quality Management Director (S1) as current, revealed in part the following:
5. Grievances must be acknowledged in writing within 10 days and resolved within 40 days. Written documentation must be kept on each grievance received. This written documentation is to be kept along with a log of incoming grievances.....
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

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

1) The hospital failed to ensure that a patient exhibiting increased agitation that required security guards to escort him to a quiet area was escorted by using approved IMAB (intervention management of aggressive behavior) techniques for 1 of 1 patient's record reviewed who required an escort by security guards from a total sample of 6 patients (#5).

2) The hospital failed to implement its policy for the care and monitoring of psychiatric patients who have had a PEC (physician emergency certificate) completed by allowing the PEC'd patient to be alone in the bathroom, while hospital policy required that PEC'd patients outside the psychiatric unit have continuous visual observation conducted according to physician's orders for 1 of 6 patients' records reviewed who had been PEC'd from a total of 6 sampled patients (#5). Findings:

1)
Review of Patient #5's medical record revealed that he was a [AGE] year old male admitted on [DATE] with diagnoses of Psychoses, Suicidal Ideation, Essential Hypertension, and Coronary Atherosclerosis. Further review revealed that he was PEC'd on 10/05/12 at 12:40am due to being suicidal and a danger to himself.

Review of Patient #5's nurses' notes revealed that on 10/05/12 at 10:10am RN (registered nurse) S27 documented that Patient #5 became agitated when the staff attempted to get his cell phone from him. Further review revealed that the security guard escorted Patient #5 to the quiet room where he was administered Ativan 2 mg (milligrams) intramuscularly for severe agitation.

In a face-to-face interview on 10/24/12 at 2:25pm, Police Officer S7 indicated that he and Security Officer S28 were called to the psychiatric unit for a problem sometime around the beginning of October. He further indicated that Patient #5 refused to give his cell phone to a staff member.. S7 indicated that he asked Patient #5 3 or 4 times to give him the cell phone, but Patient #5 refused, saying that his cell phone had "drilling missile sites" in it. S7 indicated that while Patient #5 was seated in a chair, Security Officer S28 reached down to get the phone. He further indicated that he (S7) grabbed Patient #5's left arm, and Security Officer S28 grabbed his right arm and escorted Patient #5 to the restraint room. S7 indicated that since he (S7) had a splint on his finger due to it being broken, Security Officer S28 stood behind Patient #5, brought both of his (patient's) arms around to his (patient's) back, and walked Patient #5 to the restraint room (S7 demonstrated the position that was used by S28 to escort Patient #5). When asked if this type of hold was an approved IMAB hold, S7 indicated that it was.

In a face-to-face interview on 10/24/12 at 3:33pm, RN Instruction Coordinator S10 indicated that it required 2 people to hold a patient when escorting a patient, but using 3 people would be better. When S10 was shown the hold that was demonstrated by Police Officer S7, S10 indicated that holding a patient's arms from behind by one person to escort a patient was not an approved hold technique taught in IMAB. When asked if it was appropriate for someone to hold a patient's arm on each side to escort a patient, S10 indicated "no". She further indicated that a one person escort of a patient was not an approved IMAB technique.

RN S27 and Security Officer S28 were not available to be interviewed during the survey.

Review of Police Officer S7's personnel file revealed that he had completed Part 1 of 2 of the IMAB Renewal course on 01/30/12. Further review revealed no documented evidence that he had completed Part 2 of the IMAB Renewal course. There was no documented evidence that S7 had been assessed for competency as evidenced by his "Initial Skill / Competency Validation" having the column titled "Validator & (and) Date" being blank and the lines titled "Evaluating Supervisor Signature" and "Employee Signature" being blank.

Review of Security Officer S28's personnel file revealed that he was hired on 11/29/10. Further review revealed that he had completed the 2011 IMAB Renewal Part 1 on 04/28/11 and Part 2 on 02/13/11. Further review revealed that S28 had completed the 2012 IMAB Renewal Part 1 on 06/16/12 and was scheduled for Part 2 on 11/07/12. There was no documented evidence that S28 had attended a renewal course (Part 1 and 2) every 12 months as required by hospital policy.

In a face-to-face interview on 10/25/12 at 2:00pm, RN Instruction Coordinator S10 indicated she conducted the IMAB renewal training course. She further indicated that Part 1 covered the communication and de-escalation skills, general awareness of the environment, and areas that can be completed online and don't require a classroom setting. She further indicated that Part 2 was conducted in a classroom setting and included the physical holds and protection skills for the staff and required demonstration of the skills. S10 confirmed that Security Officer S28 was late with completion of his IMAB training (greater than 12 months since completed). She confirmed that Police Officer S7 had completed Part 1 of IMAB in January 2012 but had not attended Part 2 and was not scheduled until 11/07/12, which meant that his IMAB training had expired.

In a face-to-face interview on 10/25/12 at 2:35pm, Security Chief S29 indicated that Police Officer S7 had terminated his employment on 07/25/12 and returned to the job on 09/10/12. He further indicated that S7 had completed a self-evaluation of competency, but he (S29) had 6 months to complete a competency validation. After review of S7's employee file, S29 confirmed that there was no documented evidence that Police Officer S7 had been assessed for competency prior to S7 being assigned to his job duties.

Review of the hospital policy titled "IMAB (Interventions and management in Aggressive Behavior) Provider Course", policy number 2-165, revised 06/11, and presented by RN Manager S9 as the current policy, revealed, in part, "...Staff whose job requires IMAB completion shall have 6 months after hire to complete the training, and shall attend a renewal course every 12 months. The following employees require IMAB course completion as above: ... Security staff..."

Review of the hospital policy titled "Competency of Employee", policy number 4-040, revised 07/12, and presented by RN Manager S9 as the current policy, revealed, in part, "...Initial Skill/Competency planning shall be initiated for all new employees... Competencies shall be assessed continually. ... Supervisors shall validate each competency listed by initial and date. ... An employee shall not perform unsupervised skills until a preceptor has validated each required competence... The original completed Skill/Competency Form shall be hand-delivered to the Human Resources Department..." There was no documented evidence that the policy allowed 6 months for the competency validation to be completed.

2)
Review of Patient #5's medical record revealed that he arrived by ambulance to the Emergency Department (ED) on 10/04/12 at 2228 (10:28pm). Review of Patient #5's PEC revealed that he was examined on 10/04/12 at 2250 (10:50am). Further review revealed the history of present illness included "55 y/o (year old) WM (white male) sent per (ambulance) for text messages on phone threatening to kill himself..." Further review revealed that Patient #5 was PEC'd due to being suicidal and a danger to himself on 10/05/12 at 0040 (12:40am).

Review of Patient #5's ED "Nurses Notes" revealed that Patient #5 ambulated to the restroom on 10/05/12 at 1:45am with the security guard.

Observation on 10/23/12 at 10:55am of the bathroom used by patients in the ED revealed the bathroom door had a mechanism that allowed the door to be locked from within the bathroom.

In a face-to-face interview on 10/23/12 at 10:55am, ED Director S4 (physician) indicated that when a patient who was PEC'd needed to go to the bathroom, a security guard would take the patient to the bathroom and stand outside the closed bathroom door. He further indicated that the bathroom door did have a lock that provided the means for a patient to lock the door when he/she was inside the bathroom. S4 indicated that the key to unlock the bathroom door was kept in the ED nursing station. S4 indicated that when the physician completed a PEC for an ED patient, the patient was placed on continuous visual observation. When asked if a patient was continuously observed visually by staff when the patient was alone in the bathroom with the door closed, S4 indicated "no".

In a face-to-face interview on 10/25/12 at 8:53am, Security Guard S20 indicated that he took Patient #5 to the bathroom in the ED for him (#5) to change into paper scrubs. S20 further indicated that stepped outside the bathroom while Patient #5 provided a urine specimen. S20 indicated the bathroom door was closed while Patient #5 was inside, and he (S20) was waiting outside the closed door.

Review of the hospital policy titled "Psychiatric Patients, Care of, policy number 6-311, revised 08/12, and presented by Director of Nursing S2 as the current policy, revealed, in part, "...Guidelines for Care and Monitoring Patients with Behavioral Health Diagnosis: ...While in the Emergency Department, security will be notified to escort the patient any time the patient leaves the exam room. ...All PEC / CEC (coroner's emergency certificate) patients cared for outside of the Psychiatric Unit will have continuous "visual observation" per physician / extender's orders..."
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0166
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the hospital failed to ensure the patient's plan of care (Treatment Plan) was updated/revised when restraints were used for 2 of 4 random sampled patients reviewed for restraint usage (R1, R4). Findings:

Patient R1
Review of the Violent/Self-Destructive Restraint Log for October 2012 revealed Patient R1 was placed in 4 point restraints on 10/14/12 at 4:00 p.m. The log indicated the reason for restraint use was the patient was combative, agitated, violent to staff/self/others, and self-destructive.

Review of the medical record for Patient R1 revealed the patient was a [AGE] year old female admitted to ACPU (Acute Care Psychiatric Unit) on 10/10/12 with diagnoses of Opiate Dependence, Benzodiazepine Abuse, Panic Disorder, PTSD (Post Traumatic Stress Disorder), and Bipolar II Disorder. The patient was admitted under a PEC (Physician Emergency Certificate) for suicidal ideations. Review of the progress notes revealed an entry by the nurse on 10/14/12 at 4:00 p.m. indicating the patient was agitated, throwing a chair and a table, was yelling, screaming, and cursing, and was combative with staff. The entry also indicated the patient was placed in 4 point restraints.

Review of the physician orders dated/timed 10/14/12 at 4:15 p.m. revealed an order for 4 point restraints for a maximum of 4 hours.

Review of the Interdisciplinary Treatment Plan for Patient #R1 revealed no documented evidence that the care plan was updated or revised with the use of 4 point restraints.

On 10/25/12 at 11:20 a.m., in a face-to-face interview, Psychiatric Nurse Manager S5 indicated the Treatment Plan should be updated when restraints are used. S5RN indicated that a separate page should be added to the Treatment Plan when restraints are used. After reviewing the medical record for R1, S5 verified the Treatment Plan was not updated when Patient R1 was placed in restraints on 10/14/12.

Review of the hospital policy titled, Restraints and/or Seclusion (for Violent, Self-Destructive Patient) policy number 6-350, revised 9/2012, and provided as current policy by S1 Quality Management Director, revealed in part the following: Policy: Restraint shall only be used to protect the immediate physical safety of the patient, staff, or others.....The use of restraint must be included in the patient's plan of care...

Patient R4
Record review revealed Patient R4 had been admitted on [DATE] at 10:20 a.m. with diagnoses which included Paranoid Schizophrenia, Mood Disorder, Cocaine Abuse, and Alcohol Abuse.

Review of a document titled Violent, Self-Destructive Restraint and/or Seclusion Orders revealed Patient R4 was placed in 4 point restraints for 30 minutes on 09/05/12 at 1:55 p.m. for violent and aggressive behavior.

Review of the Treatment Plans for Patient R4 revealed the Problems of Altered Thoughts and Medications Noncompliance. No treatment plans were in the medical record addressing the use of restraints.

In an interview on 10/25/12 at 11:00 a.m. with Psychiatric Nurse Manager S5, she indicated that Patient R4 should have had a restraint treatment plan included in his medical record after the use of restraints on 9/5/12. S5 said the restraint treatment plan was a separate form that the staff had been informed to put in the patient's charts after the use of restraints.

Review of the Policy Restraints and/or Seclusion, revised 9/2012 revealed in part: The use of restraint must be included in the patient's plan of care.
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 RN (registered nurse) supervised and evaluated the nursing care of each patient. The nurse failed to supervise the MHTs' (mental health tech) observation of the patients on the psychiatric unit which resulted in MHTs not initialing their documentation on the patient's observation record, inaccurate documentation of the location of patients, and no documentation by the MHT who provided relief for bathroom and meal breaks for 5 of 6 sampled patients (#1, #2, #3, #4, #5) and 1 of 4 random patients reviewed for restraint usage from a total of 10 random sampled patients (R2). Findings:

Patient #1
Record review revealed Patient #1 was a [AGE] year old male admitted on [DATE] for complaints of SI/HI (suicidal/homicidal ideations) and depression. Further review revealed he had been admitted under a PEC (Physician's Emergency Certificate). A CEC (Coroner's Emergency Certificate was completed on 10/15/12 at 11:00 a.m.
Review of the Admission Physician's Order sheet for Patient #1 dated 10/14/12 at 1848 (6:48 p.m.) revealed the box next to the observation order "Suicide Precautions" was checked.
Review of Patient #1's "ACPU (Acute Care Psychiatric Unit) Special OBS (observation) Flow Sheet" dated 10/16/12 through 10/21/12 revealed no documented evidence that any of the following choices had been selected as evidenced by the absence of a check mark or an x in the box: visual contact, frequent interaction q15 (every 15 minutes), touch contact, suicidal, violence precautions, disruptive to milieu, detox, elopement, unable to care for self, fall precautions. Further review revealed the time, condition, location, and care provided was documented by the numeric symbol, but the documented evidence of the initials of the staff member who made and documented the observation was only completed for 14 of the 629 total observations. Further review revealed the nurse and MHT had each signed or initialed the section at the bottom of the page that was available for signatures for each shift.

Patient #2
Record review revealed Patient #2 was a [AGE] year old male admitted on [DATE] with diagnoses of Amphetamine Induced Psychosis, Amphetamine Abuse, and Alcohol Abuse. Further review revealed the patient had been admitted under a PEC (Physician's Emergency Certificate). A CEC (Coroner's Emergency Certificate) was completed on 10/11/12 at 10:30 a.m. for dangerous to self, others and gravely disabled.
Review of the Admission Physician's Order sheet for Patient #2 dated 10/10/12 at 1445 (2:45 p.m.) revealed no special observations were checked.
Review of Patient #2's "ACPU Special OBS (observation) Flow Sheet" dated 10/10/12 through 10/22/12 revealed no documented evidence that any of the following choices had been selected as evidenced by the absence of a check mark or an x in the box: visual contact, frequent interaction q15 (every 15 minutes), touch contact, suicidal, violence precautions, disruptive to milieu, detox, elopement, unable to care for self, fall precautions. Further review revealed the time, condition, location, and care provided was documented by the numeric symbol, but the documented evidence of the initials of the staff member who made and documented the observation was only completed for 33 of the 1178 total observations. Further review revealed the nurse and MHT had each signed or initialed the section at the bottom of the page that was available for signatures for each shift.

Patient #3
Review of Patient #3's medical record revealed that he was a [AGE] year old male admitted on [DATE] with diagnoses of Depressive Disorder and Suicidal Ideations. Further review revealed a PEC was signed on 10/19/12 at 11:05am due to Patient #3 being suicidal and a danger to himself. Further review revealed that a CEC was signed on 10/22/12 at 10:30am due to Patient #3 being suicidal and a danger to himself.

Review of Patient #3's "ACPU Physician's Orders Sheet" dated 10/20/12 at 1600 (4:00pm) revealed the blank next to "Special Observations" had no writing present, and the choices of Detox Precautions, Elopement Precautions, and Suicide Precautions had no check mark placed in the box in front of each precaution. Further review revealed no documented evidence of an order for the type of observation to be maintained for Patient #3.

Review of Patient #3's "ACPU Special OBS Flow Sheet" dated 10/20/12 and 10/21/12 revealed no documented evidence that any of the following choices had been selected as evidenced by the absence of a check mark or an x in the box: visual contact, frequent interaction q15 (every 15 minutes), touch contact, suicidal, violence precautions, disruptive to milieu, detox, elopement, unable to care for self, fall precautions. Further review revealed the time, condition, location, and care provided was documented by the numeric symbol, but there was no documented evidence of the initials of the staff member who made and documented the observation. Further review revealed the nurse and MHT had each signed or initialed the section at the bottom of the page that was available for signatures for each shift. Review of the flow sheet for 10/22/12 revealed the same findings as those for 10/20/12 and 10/21/12, except the blank for "suicidal" was checked.

Review of the flow sheet for 10/21/12 revealed documentation from 11:00pm through 7:15am on 10/22/12 was written by the same MHT with no documented evidence of documentation by the person relieving him/her. Further review revealed observation from 7:30pm on 10/22/12 through 7:15am on 10/23/12 was documented by the same staff member with no documented evidence of relief for 11 hours and 45 minutes.

Patient #4
Record review revealed Patient #4 was a [AGE] year old male admitted on [DATE] with diagnoses of Mood Disorder and PTSD (Post Traumatic Stress Disorder). Further review revealed the patient had been admitted under a PEC (Physician's Emergency Certificate). A CEC (Coroner's Emergency Certificate) was completed on 10/10/12 at 10:00 a.m. for dangerous to others and gravely disabled.
Review of the Admission Physician's Order sheet for Patient #4 dated 10/10/12 at 0138 (1:38 a.m.) revealed no special observations were checked.
Review of Patient #4's "ACPU Special OBS (observation) Flow Sheet" dated 10/10/12 through 10/22/12 revealed no documented evidence that any of the following choices had been selected as evidenced by the absence of a check mark or an x in the box: visual contact, frequent interaction q15 (every 15 minutes), touch contact, suicidal, violence precautions, disruptive to milieu, detox, elopement, unable to care for self, fall precautions. Further review revealed the time, condition, location, and care provided was documented by the numeric symbol, but the documented evidence of the initials of the staff member who made and documented the observation was only completed for 25 of the 1229 total observations. Further review revealed the nurse and MHT had each signed or initialed the section at the bottom of the page that was available for signatures for each shift.

Patient #5
Review of Patient #5's medical record revealed that he was a [AGE] year old male admitted on [DATE] with diagnoses of Psychoses, Suicidal Ideation, Essential Hypertension, and Coronary Atherosclerosis. Further review revealed that he was PEC'd on 10/05/12 at 12:40am due to being suicidal and a danger to himself. Further review revealed that a CEC was signed on 10/06/12 at 1:00pm due to Patient #5 being gravely disabled.

Review of Patient #5's "ACPU Physician's Orders Sheet" dated 10/05/12 at 0215 (2:15am) revealed the blank next to "Special Observations" had no writing present, and the choices of Detox Precautions and Suicide Precautions had no check mark placed in the box in front of each precaution. Further review revealed the choice of "Elopement Precautions" was checked. Further review revealed no documented evidence of an order for the type of observation to be maintained for Patient #5.

Review of Patient #5's "ACPU Special OBS Flow Sheet" dated 10/05/12 through 10/10/12 revealed elopement was the only selection with a check mark from the choices that also included visual contact, frequent interaction q15 (every 15 minutes), touch contact, suicidal, violence precautions, disruptive to milieu, detox, unable to care for self, fall precautions. Further review revealed that no selection was checked for 10/11/12 and 10/12/12. Further review revealed the time, condition, location, and care provided was documented by the numeric symbol, but there was no documented evidence of the initials of the staff member who made and documented the observation. Further review revealed the nurse and MHT had each signed or initialed the section at the bottom of the page that was available for signatures for each shift.

Review of the flow sheet for 10/05/12 revealed documentation from 7:30am on 10/06/12 through 3:00pm on 10/06/12 was written by the same MHT with no documented evidence of documentation by the person relieving her. Further review revealed that documentation by MHT S12 from 10:00am through 10:30am on 10/05/12 revealed that Patient #5 was awake, in the hallway, interacting with others, agitated, delusional, and combative at 10:00am, awake, in the hallway, on the telephone, agitated, and delusional at 10:15am, and awake, in the hallway, and on the telephone at 10:30am, while the nurses' notes at 10:10am revealed that Patient #5 became agitated and had to be escorted to the quiet room where he received an injection for agitation. Further review revealed observation from 7:30pm on 10/06/12 through 7:15am on 10/07/12 was documented by the same staff member with no documented evidence of relief for 11 hours and 45 minutes.

In a face-to-face interview on 10/24/12 at 1:35pm, Psychiatric Nurse Manager S5 confirmed that the observations made on the "ACPU Special OBS Flow Sheet" were documented every 15 minutes, but she was unable to confirm who made the observations, because there were no initials next to each individual observation. S5 stated every patient is observed every 15 minutes and any other type of observation level requires a specific physician's order. S5 verified the observation level was not checked on the flow sheets for the above patients.

In a face-to-face interview on 10/24/12 at 4:08pm, MHT S12 indicated that she was assigned to Patient #5 on 10/05/12. After reviewing her documentation of the observation record, S12 confirmed that there was no way to determine who relieved her for bathroom breaks and lunch, since the MHT who relieved her did not sign the observation record. She further indicated that her documentation did not reveal that Patient #5 was ever in the restraint room.

Patient R2
Review of the Violent/Self-Destructive Restraint Log for August 2012 revealed Patient R2 was placed in 4 point restraints on 08/03/12 at 10:25 p.m. The log indicated the reason for restraint use was the patient was combative, agitated, and violent to staff/self/others.

Review of the medical record for Patient R2 revealed the patient was a [AGE] year old male admitted to ACPU on 07/31/12 with diagnoses of Mood Disorder, Suicidal Ideations, Homicidal Ideation, Poly-Substance Abuse, and Rule Out Bipolar Disorder. The patient was admitted under a PEC (Physician Emergency Certificate) for suicidal ideations. Review of the progress notes revealed an entry by the nurse on 08/03/12 at 10:25 p.m. indicating the patient was violent, combative with staff and completely uncooperative, and was placed in 4 point restraints. The progress notes also revealed the patient was released from restraints at 11:55 p.m.

Review of Patient R2's "ACPU Special OBS Flow Sheet" dated 08/03/12 through 08/04/12 revealed the MHT documented the patient was "A, D, H" (Awake, Agitated and Physical Threats) from 10:30 p.m. to 10:45 p.m. The MHT documented "A, N, D" (Awake, Bedroom, Agitated) from 11:00 p.m. to 12:00 p.m. Further review of the Flow Sheet revealed an option for "CC. See restraint flow sheet", but this was not documented on the Flow Sheet.

On 10/25/12 at 11:20 a.m., in a face-to-face interview, S5 RN Psychiatric Nurse Manager indicated the MHT should have used "CC. See restraint flow sheet" when the patient was placed in the restraints. S5 verified the MHT flow sheet did not accurately indicate the patient's location during the time period the patient was in 4 point restraints.

Review of the hospital policy titled "Routine Patient Checks", policy number P-142, reviewed 01/12, and presented by RN Manager S9 as a current policy, revealed, in part, "...It shall be the policy of the Acute Care Psychiatric Unit ... that each patient will be observed at a minimum every 15 minutes, twenty-four (24) hours a day. ... A. The Registered Nurse of each shift assigns checks to staff members for all hours of that shift. B. The assigned staff member checks every patient a minimum of once every 15 minutes and makes visual, and when appropriate, verbal contact. ... All information is written and recorded on the checks sheet or special precautions check sheet. ... If the staff member is to take a break, the responsibility will be transferred to another appropriate staff member. ... H. When the assigned staff member is to be changed, the current staff member is responsible for accounting for each patient and for reporting pertinent observations to the next staff member to be assigned".

Review of the hospital policy titled "Psychiatric Patients, Care of", policy number 6-311, revised 08/12, and presented by Director of Nursing S2 as the current policy, revealed, in part, "...After verifying competency of the employee, the charge nurse will assign the patient to an observer (sitter), and the patient will be observed at the level of observation indicated. If the staff member is to take a break (i.e.[that is] lunch, restroom, etc) the responsibility will be transferred to another appropriate staff member. ... Documentation ... A physician will order visual observation if indicated. Observation will be recorded on the Observation Log Tool. ... Population Identification for Suicide Prevention: ... To be completed by the nurse on the patient with psychiatric symptoms during the initial nursing assessment. Check yes or no for each question. Does the patient have a PEC / CEC? Are you here because you tried to hurt yourself? In the past week, have you been having thoughts about killing yourself? Have you ever tried to hurt yourself in the past other than this time? Has something very stressful happened to you in the past few weeks? If YES to any of the above, place on suicidal observation precautions as ordered by the physician / provider. Document on "Observation log" every 15 minutes..."
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the hospital failed to ensure that the nursing staff developed and kept current a nursing care for each patient.
1) The nursing staff failed to include the patient's medical problems in his/her nursing care plan for 3 of 10 patients whose care plans were reviewed for inclusion of medical problems from a total of 6 sampled patients and 10 random patients (#1, #5, R4).
2) The nursing staff failed to implement the patients' nursing care plan as evidenced by failure to conduct psycho-education groups according to the patients' interdisciplinary treatment plan for 6 of 6 sampled patients (#1, #2, #3, #4, #5, #6).
3) The nursing staff failed to revise the patient's nursing care plan with the use of restraints for 2 of 4 patients' records reviewed for inclusion of restraints in the nursing care plan from a total of 6 sampled patients and 10 random patients (R1, R4).
4) The nursing staff failed to develop a nursing care plan for 1 of 10 patients' records reviewed for a nursing care plan from a total of 6 sampled patients and 10 random patients (R3).
5) The nursing staff failed to revise the patient's treatment plan with new approaches when the patient refused psychotropic medications for 1 of 6 sampled patients (#4). Findings:

1) The nursing staff failed to include the patient's medical problems in his/her nursing care plan: Patient #1
Record review revealed Patient #1 was a [AGE] year old male admitted on [DATE] for complaints of SI/HI (suicidal/homicidal ideations) and Depression. Further review revealed he had been admitted under a PEC (Physician's Emergency Certificate).
Review of Patient #1's Psychiatry Unit MD (Medical Doctor) Progress Notes dated 06/18/12 at 1515 (3:15 p.m.) revealed ETOH dep (alcohol dependency) was listed as one of Patient #1's diagnosis.
Review of the Psychiatry notes for Patient #1 dated 10/19/12 at 1958 (7:58 p.m.) revealed an entry that stated the patient expressed he wants tx (treatment) for ETOH (alcohol) abuse. On 10/20/12 at 2100 (9:00 p.m.), pt (patient) stated focused on wanting substance tx.

Review of the medical record for Patient #1 revealed an alcohol level collected on 10/14/12 at 1932 (7:32 p.m.). The results were 41 mg/dl (milligrams/deciliter). Normal values were listed as <15 mg/dl.
Review of the Physician's orders for Patient #1 revealed an order dated 10/18/12 at 1515 (3:15 p.m.) for Ultram (pain medication) 25mg PO (by mouth) q (every) 6 hours PRN (as needed) pain. Further review revealed an order dated 10/21/12 to increase Ultram 50 mg PO q 6 hours PRN pain.
Review of the medication administration record for Patient #1 revealed he received Ultram 25 mg for pain on 10/19/12 at 12:35 p.m., 10/20/12 at 17:45 (5:45 p.m.), and 10/21/12 at 11:55 a.m. Patient #1 also received Ultram 50 mg for pain on 10/21/12 at 18:27 (6:27 p.m.) and 10/22/12 at 17:12 (5:12 p.m.).
Record review revealed Patient #1 had Interdisciplinary Treatment Plans with the Problems of Depression and Suicidal Ideations listed. Further review revealed no documented evidence of treatment plans in the medical record for pain or alcohol dependence/substance abuse.
In an interview on 10/25/12 at 11:00 a.m. with Psychiatric Nurse Manager S5, she confirmed that no treatment plans were in Patient #1's medical record for pain or alcohol abuse/dependence. S5 indicated that Patient #1 should have had treatment plans for pain and substance abuse.

Patient #5
Review of Patient #5's medical record revealed that he was a [AGE] year old male admitted on [DATE] with diagnoses of Psychoses, Suicidal Ideation, Essential Hypertension, and Coronary Atherosclerosis. Further review revealed that he was PEC'd on 10/05/12 at 12:40am due to being suicidal and a danger to himself.

Review of Patient #5's medical record revealed that he had orders for and received Ultram 50 mg by mouth on 10/07/12 at 6:21pm, 10/07/12 at 8:57pm, 10/08/12 at 3:58pm, 10/09/12 at 9:13pm, 10/10/12 at 9:06pm, and 10/11/12 at 9:00am and 10:50pm for complaints of back pain. Further review revealed Patient #5 had orders for and ophthalmic drops instilled on 10/06/12 at 8:49pm for complaints of eye dryness. Further review revealed Psychiatrist S21 documented that Patient #5 had eye irritation on 10/07/12. Review of Patient #5's nursing care plan revealed no documented evidence that his back pain and eye irritation were addressed or added to his care plan.

In a face-to-face interview on 10/24/12 at 1:35pm, Psychiatric Nurse Manager S5 indicated that Patient #5's medical problems of back pain and eye irritation were not incorporated in his nursing care plan. She further indicated that a patient's medical problems should be included their care plan along with their psychiatric nursing problems.

Patient R4
Record review revealed Patient R4 had been admitted on [DATE] at 10:20 a.m. with diagnoses which included Paranoid Schizophrenia, Mood Disorder, Cocaine Abuse, and Alcohol Abuse.

Review of a laboratory result for Patient R4 collected on 09/01/12 at 21:10 (9:10 p.m.) revealed an alcohol level of 229 mg/dl with the normal value reference range being less than 15 mg/dl.

Review of the Treatment Plans for Patient R4 revealed the problems identified were Altered Thoughts and Medications Noncompliance. There was no documented evidence in the record that substance abuse had been addressed in the nursing care plan.

In an interview on 10/25/12 at 11:05 a.m. with Psychiatric Unit Manager S5, she confirmed that Patient R4 had no treatment plans for substance abuse. S5 indicated that she would have included a treatment plan for substance abuse in Patient R4's record.

Review of the hospital policy titled "Interdisciplinary Treatment Team and Treatment Plan", policy number P-105, revised 08/2010, and presented by RN Manager S9 as current policy, revealed in part, "All treatment team members......will cooperate and collaborate in the assessment of patients, initiation of the Master Treatment Plan, on-going evaluation of progress, and appropriate revision of the treatment plan.....Accommodation of various assessments and observations (i.e. Psychiatric Evaluation, Psychosocial, Nursing Assessment, and Recreational Therapy Assessment) are used to determine the individualized treatment plan....The Treatment Plan shall include specific interventions suggested by the treatment team and ordered by the staff psychiatrist or his designee. The responsible discipline and frequency of each intervention shall be indicated..."

2) The nursing staff failed to implement the patients' nursing care plan as evidenced by failure to conduct psycho-education groups according to the patients' interdisciplinary treatment plan:
Patient #1
Review of Patient #1's medical record revealed that he was admitted on [DATE]. Review of his "Interdisciplinary Treatment Plan" revealed the clinical intervention for his identified problem of Suicidal Ideations was attendance at a psycho-education group 1 time a day for 1 hour for 1 to 4 days per week. Further review revealed the clinical intervention for his identified problem of Depressed Mood was attendance at a psycho-education group 1 time a day for 1 hour for 1 to 5 days per week. Review of Patient #1's medical record revealed no documented evidence that he had attended or refused to attend a psycho-education group from admission on 10/16/12 through 10/22/12.

Patient #2
Review of Patient #2's medical record revealed that he was admitted on [DATE] and discharged on [DATE]. Review of his "Interdisciplinary Treatment Plan" revealed the clinical intervention for his identified problem of Suicidal Ideations was attendance at a psycho-education group 1 time a day for 1 hour for 1 to 4 days per week. Further review revealed the clinical intervention for his identified problems of Altered Thoughts, Inability to remain Alcohol/Drug Free, and Depressed Mood was attendance at a psycho-education group 1 time a day for 1 hour for 1 to 5 days per week. Review of Patient #2's medical record revealed no documented evidence that he had attended a psycho-education group during his entire hospital stay.

Patient #3
Review of the "Interdisciplinary Treatment Plan" for Patient #3 revealed the clinical intervention for his identified problem of Depressed Mood was attendance at a psycho-education group 1 time a day for 1 hour for 1 to 5 days per week. Further review revealed the clinical intervention for his identified problem of Suicidal Ideations was attendance at a psycho-education group 1 time a day for 1 hour for 1 to 4 days per week. Review of Patient #3's medical record revealed no documented evidence that he had attended a psycho-education group since his admission on 10/20/12 (chart reviewed on 10/23/12).

Patient #4
Review of Patient #4's medical record revealed that he was admitted on [DATE]. Review of his "Interdisciplinary Treatment Plan" revealed the clinical intervention for his identified problem of Altered Thoughts was attendance at a psycho-education group 1 time a day for 1 hour for 1 to 5 days per week. Review of Patient #4's medical record revealed no documented evidence that he had attended a psycho-education group since his admission (chart reviewed on 10/24/12).

Patient #5
Review of Patient #5's "Interdisciplinary Treatment Plan" revealed the clinical intervention for his identified problem of Suicidal Ideations was attendance at a psycho-education group 1 time a day for 1 hour for 1 to 4 days per week. Further review revealed the clinical intervention for his identified problem of Altered Thoughts was attendance at a psycho-education group 1 time a day for 1 hour for 1 to 5 days per week. Review of Patient #5's medical record revealed no documented evidence that he had attended a psycho-education group during his entire stay from 10/05/12 to 10/12/12.

Patient #6
Review of Patient #6's medical record revealed that he was admitted on [DATE] and discharged [DATE]. Review of his "Interdisciplinary Treatment Plan" revealed the clinical intervention for his identified problem of Suicidal Ideations was attendance at a psycho-education group 1 time a day for 1 hour for 1 to 4 days per week. Further review revealed the clinical intervention for his identified problem of Poor Impulse Control was attendance at a psycho-education group 1 time a day for 1 hour for 1 to 5 days per week. Review of Patient #6's medical record revealed no documented evidence that he had attended a psycho-education group or refused to attend a group during his hospital stay.

In a face-to-face interview on 10/24/12 at 1:35pm, Psychiatric Nurse Manager S5 indicated that the nurse education groups had been one of the interventions that had been decreased or eliminated on some shifts when the nursing staff was busy since the budget cuts had been implemented by the state.

In a face-to-face interview on 10/24/12 at 3:40pm, RN S11 indicated that he didn't always document in the nurses' notes when he conducted group therapy. S11 indicated that when group was held, it was usually on life style or medications. He further indicated that patient education was usually done at the time of discharge or just prior to discharge.

In a face-to-face interview on 10/25/12 at 7:38am, RN S17 indicated that since the unit increased to 24 beds and the clerk had been laid off, the nurses had not been doing group therapy regularly.

In a face-to-face interview on 10/25/12 at 8:03am, RN S18 indicated that sometimes the nurse did an education group on the night shift with patients who were awake. She further indicated that if a group was held, it would be documented on the education group form that should be placed in each patient's medical record. S18 indicated that when the shift was short of staff for MHTs, the nurse would have to help the MHTs with patient needs and observations and could not hold group therapy. After reviewing Patient #5's medical record, S18 confirmed that there was no documented evidence that Patient #5 had attended or refused to attend any education groups.

In a face-to-face interview on 10/25/12 at 11:05am, Psychiatric Nurse Manager S5 indicated that the psychiatric unit had been understaffed for the last fiscal year. She further indicated that the unit's weaknesses were group activity and documentation (clarified that what's being done "isn't coming out on that piece of paper").

Review of the hospital policy titled "Group Therapy & Psycho-Education", policy number P-124, revised 09/2011, and presented by RN Manager S9 as current policy, revealed in part, "The Counseling Staff will facilitate Group Therapy/Psycho-education and the Nursing Staff will facilitate Psycho-education sessions. These sessions may include, but are not limited to topics such as Coping Mechanisms, Anger Management, Grief & Loss Issues, Goal Setting, Discharge Planning, Medications, ADLs, Healthy Living, Stress Management.....Appropriate documentation is completed in each of the patient's charts by the staff member providing the services - this includes the education sheet and/or a brief entry in the interdisciplinary progress notes describing the patient's presentation, level of engagement and/or understanding of concepts presented."

3) The nursing staff failed to revise the patient's nursing care plan with the use of restraints:
Patient R1
Review of the Violent/Self-Destructive Restraint Log for October 2012 revealed Patient R1 was placed in 4 point restraints on 10/14/12 at 4:00 p.m. The log indicated the reason for restraint use was the patient was combative, agitated, violent to staff/self/others, and self-destructive.

Review of the medical record for R1 revealed the patient was a [AGE] year old female admitted to ACPU (Acute Care Psychiatric Unit) on 10/10/12 with diagnoses of Opiate Dependence, Benzodiazepine Abuse, Panic Disorder, PTSD (Post Traumatic Stress Disorder), and Bipolar II Disorder. The patient was admitted under a PEC (Physician Emergency Certificate) for suicidal ideations. Review of the progress notes revealed an entry by the nurse on 10/14/12 at 4:00 p.m. indicating the patient was agitated, throwing a chair and a table, was yelling, screaming, and cursing, and was combative with staff. The entry also indicated the patient was placed in 4 point restraints.

Review of the physician orders dated/timed 10/14/12 at 4:15 p.m. revealed an order for 4 point restraints for a maximum of 4 hours.

Review of the Interdisciplinary Treatment Plan for R1 revealed no documented evidence that the care plan was updated or revised with the use of 4 point restraints.

On 10/25/12 at 11:20 a.m., in a face-to-face interview, S5 RN Psychiatric Nurse Manager indicated the Treatment Plan should be updated when restraints are used. S5 RN stated a separate page should be added to the Treatment Plan when restraints are used. After reviewing the medical record for R1, S5 verified the Treatment Plan was not updated when Patient R1 was placed in restraints on 10/14/12.

Patient R4
Record review revealed Patient R4 had been admitted on [DATE] at 10:20 a.m. with diagnoses which included Paranoid Schizophrenia, Mood Disorder, Cocaine Abuse, and Alcohol Abuse.

Review of a document titled Violent, Self-Destructive Restraint and / or Seclusion Orders revealed Patient R4 was placed in 4 point restraints for 30 minutes on 09/05/12 at 1:55 p.m. for violent and aggressive behavior.

Review of the Treatment Plans for Patient R4 revealed the problems identified were Altered Thoughts and Medications Noncompliance. There was no documented evidence in the medical record that the use of restraints had been addressed.

In an interview on 10/25/12 at 11:00 a.m. with Psychiatric Nurse Manager S5, she indicated that Patient R4 should have had a restraint treatment plan included in his medical record after the use of restraints on 09/05/12. S5 further indicated that the restraint treatment plan was a separate form that the staff had been informed to put in the patient's chart after the use of restraints.

Review of the hospital policy titled, Restraints and/or Seclusion (for Violent, Self-Destructive Patient) policy number 6-350, revised 9/2012, and provided as current policy by S1 Quality Management Director, revealed in part the following: Policy: Restraint shall only be used to protect the immediate physical safety of the patient, staff, or others.....The use of restraint must be included in the patient's plan of care...

4) The nursing staff failed to develop a nursing care plan:
Review of the medical record for Patient R3 revealed he had been admitted on [DATE] at 20:30 (8:30 p.m.) with the diagnosis of Schizophrenia. Further review revealed no treatment plans were located in the medical record.

In an interview on 10/25/12 at 11:00 a.m. with Psychiatric Unit Manager S5, she confirmed that Patient R3's record did not have treatment plans in it. S5 further indicated that the medical record was incomplete, and she would look elsewhere to locate the treatment plans. No additional medical record documents were presented for Patient R3 by the conclusion of the survey.

5) The nursing staff failed to revise the patient's treatment plan with new approaches when the patient refused psychotropic medications:
Review of the medical record for Patient #4 revealed the patient was a [AGE] year old male admitted on [DATE] with diagnoses of Mood Disorder and PTSD (Post Traumatic Stress Disorder).

Review of the Interdisciplinary Treatment Plan for Patient #4 revealed Altered Thoughts was identified as Problem #1 and the interventions for this problem included monitoring the patient's response to psychotropic medications.

Review of the physician orders revealed the following antipsychotic medications were ordered: On 10/11/12 Seroquel 100 mg. at bedtime was started and increased to 200 mg. at bedtime on 10/12/12. On 10/16/12 Risperdal 1 mg. at bedtime was started and increased on 10/17/12 to 2 mg. at bedtime. Further review of the physician orders revealed the Seroquel was discontinued on 10/19/12 (Patient took one dose on 10/18/12).

Review of the MARs (Medication Administration Records) revealed the patient refused the Seroquel from 10/11/12 through 10/17/12 (7 days), and the patient refused the Risperdal from 10/16/12 through 10/17/12 (2 days).

Further review of the Interdisciplinary Treatment Plan revealed no documented evidence the Treatment Plan was updated to include new approaches when the patient refused the antipsychotic medications.

On 10/25/12 at 11:20 a.m., in a face-to-face interview, S5 Psychiatric Nurse Manager verified the treatment plan should be updated when patients refuse interventions. After reviewing the record for Patient #4, S5 verified the patient had refused the antipsychotic medications and the treatment plan was not updated with new interventions to meet the patient's goals.

Review of the hospital policy titled "Interdisciplinary Treatment Team and Treatment Plan", policy number P-105, revised 08/2010, and presented by RN Manager S9 as current policy, revealed in part, "All treatment team members......will cooperate and collaborate in the assessment of patients, initiation of the Master Treatment Plan, on-going evaluation of progress, and appropriate revision of the treatment plan....
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the hospital failed to ensure medications were administered in accordance with accepted standards of practice and approved policies and procedures as evidenced by: 1) failing to develop and implement medication administration policies to include time frames for the administration of Now and Stat doses. This resulted in 2 of 6 sampled patients receiving Now doses of medications over 1 hour after ordered (#2, #4) and 2) failing to ensure medication was administered as ordered by the physician for 1 of 6 sampled patients (#5). Findings:

1) Failing to develop and implement medication administration policies to include time frames for the administration of Now and Stat doses:
Patient #2
Review of the medical record for Patient #2 revealed the patient was a [AGE] year old male admitted to ACPU (Acute Care Psychiatric Unit) on 10/10/12 with diagnoses of Amphetamine Induced Psychosis, Amphetamine Abuse, and Alcohol Abuse.

Review of the physician orders revealed on 10/14/12 at 12:00 p.m., the physician ordered Zithromax (antibiotic) 250 mg. 2 (500 mg) one time now, then 1 daily starting 10/15/12 for 4 days.

Review of the MAR (Medication Administration Record) dated 10/14/12 revealed the Zithromax "Now" dose of 500 mg. was administered at 13:47 (1:47 p.m.), 1 hour and 47 minutes after ordered by the physician.

Patient #4
Review of the medical record for Patient #4 revealed the patient was a [AGE] year old male admitted to ACPU on 10/10/12 with diagnoses of Mood Disorder and PTSD (Post Traumatic Stress Disorder), Hypertension, and Diabetes Mellitus.

Review of the physician orders revealed on 10/22/12 at 1:50 p.m. the physician ordered Metformin (oral antidiabetic) 500 mg. two times a day, first dose now.

Review of the MAR (Medication Administration Record) dated 10/22/12 revealed the Metformin "Now" dose of 500 mg. was administered at 3:20 p.m., 1 hour and 30 minutes after ordered by the physician.

On 10/24/12 at 9:30 a.m., in a face-to-face interview, S5 Psychiatric Nurse Manager stated "Now" medications were administered when the nurse received the medication from the pharmacy. S5 verified there was no specified time frame for the administration of "Now" ordered medications.

On 10/25/12 at 3:00 p.m., in a face-to-face interview S1 Quality Management Director stated the hospital's only policy on medication administration times was the policy titled Timely Administration of Medications. S1 indicated the hospital was aware of the revised regulatory requirements for the timing of medication administration and stated they were working on a policy. S1 verified the current approved policy did not include time frames for the administration of "Now" or "Stat" medications ordered by the physician.

Review of the hospital policy titled, Timely Administration of Medications, number 5-209, reviewed 2/2012, and provided as current by S1 Quality Management Director, revealed in part the following:
Time critical medications must be administered within 30 minutes before or after the scheduled time of administration in order to be considered "on time". (These medications include antibiotics that are administered every 6 hours or more frequently, antibiotics that require therapeutic monitoring....oral antidiabetics...)
Scheduled medications do not include:
Stat or Now
First Doses or loading doses
One time doses....
There was no documentation in the policy of the time frame for administration of Stat and Now doses of medication.
Review of the policy revealed antibiotics and oral antidiabetics were identified as time critical medications that when scheduled, should be administered within 30 minutes of the scheduled time.

2) Failing to ensure medication was administered as ordered by the physician:
Review of Patient #5's medical record revealed that he was a [AGE] year old male admitted on [DATE] with diagnoses of Psychoses, Suicidal Ideation, Essential Hypertension, and Coronary Atherosclerosis.

Review of Patient #5's "Physician's Orders Sheet" revealed that RN (registered nurse) S27 received a telephone order from Psychiatrist S14 on 10/05/12 at 10:10am to administer Haldol 5 mg, Ativan 2 mg, and Benadryl 50 mg by mouth or Intramuscularly (IM) every 4 hours as needed for agitation. Further review revealed that the admit orders included an order for Ativan 2 mg to be given by mouth every 6 hours as needed for moderate anxiety/agitation.

Review of Patient #5's nurses' notes revealed an entry on 10/05/12 at 10:10am by RN S27 that she administered Ativan 2 mg IM for severe agitation. Review of the nurses' notes and MARs (medication administration record) revealed no documented evidence that Patient #5 received Haldol 5 mg and Benadryl 50 mg as ordered on [DATE] at 10:10am.

In a face-to-face interview on 10/24/12 at 1:35pm, Psychiatric Nurse Manager S5 reviewed Patient #5's chart and indicated that he did not receive the medication "cocktail" as ordered by the psychiatrist on 10/05/12. She further indicated that RN S27 who administered and charted the medication administration was not available to be interviewed due to having to leave work for a family emergency.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the hospital failed to ensure physician's orders for the use of restraints were obtained in accordance with hospital policy as evidenced by failing to include the reason for the restraint and the criteria for release from restraints in the restraint orders for 1 of 4 random sampled patients reviewed for restraint usage (R1). Findings:

Review of the Violent/Self-Destructive Restraint Log for October 2012 revealed Patient R1 was placed in 4 point restraints on 10/14/12 at 4:00 p.m. The log indicated the reason for restraint use was the patient was combative, agitated, violent to staff/self/others, and self-destructive.

Review of the medical record for Patient R1 revealed the patient was a [AGE] year old female admitted to ACPU (Acute Care Psychiatric Unit) on 10/10/12 with diagnoses of Opiate Dependence, Benzodiazepine Abuse, Panic Disorder, PTSD (Post Traumatic Stress Disorder), and Bipolar II Disorder. The patient was admitted under a PEC (Physician Emergency Certificate) for suicidal ideations. Review of the progress notes revealed an entry by the nurse on 10/14/12 at 4:00 p.m. indicating the patient was agitated, throwing a chair and a table, was yelling, screaming, and cursing, and was combative with staff. The entry also indicated the patient was placed in 4 point restraints.

Review of the physician orders dated/timed 10/14/12 at 4:15 p.m. revealed an order for 4 point restraints for a maximum of 4 hours. Review of the section, "Behavior that made restraint necessary:", revealed the section was left blank. Review of the section, "Behavior criteria to remove restraint:", revealed the section was left blank.

On 10/25/12 at 11:20 a.m., in a face-to-face interview, Psychiatric Nurse Manager S5 indicated the physician's orders for restraints should include the reason for the restraint and the criteria for release from restraints. After reviewing the medical record for Patient R1, S5 verified the physician's orders for restraint use on 10/14/12 for R1 did not include the reason for the restraints or the criteria for release from restraints.

Review of the hospital policy titled, Restraints and/or Seclusion (for Violent, Self-Destructive Patient) policy number 6-350, revised 9/2012, and provided as current policy by S1 Quality Management Director, revealed in part the following: Policy: Restraint shall only be used to protect the immediate physical safety of the patient, staff, or others.....Patients will be placed in restraints and/or seclusion following a physician/extender's orders. These orders shall include: any alternatives or other least restrictive interventions attempted, the time limit for restraint (up to 4 hours) and seclusion, the type of restraint (soft, security), the number of points to be restrained, the reason for restraint or seclusion, criteria to remove the restraint, patient and family education.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0178
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the hospital failed to ensure the patient in restraints was seen by a physician or an independent practitioner face-to-face within 1-hour after the initiation of restraints for 1 of 4 random sampled patients reviewed for restraint usage (R2). Findings:

Patient R2
Review of the Violent/Self-Destructive Restraint Log for August 2012 revealed Patient R2 was placed in 4 point restraints on 08/03/12 at 10:25 p.m. The log indicated the reason for restraint use was the patient was combative, agitated, and violent to staff/self/others.

Review of the medical record for Patient R2 revealed the patient was a [AGE] year old male admitted to ACPU (Acute Care Psychiatric Unit) on 07/31/12 with diagnoses of Mood Disorder, Suicidal Ideations, Homicidal Ideation, Poly-Substance Abuse, and Rule Out Bipolar Disorder. The patient was admitted under a PEC (Physician Emergency Certificate) for suicidal ideations. Review of the progress notes revealed an entry by the nurse on 08/03/12 at 10:25 p.m. indicating the patient was violent, combative with staff and completely uncooperative, and was placed in 4 point restraints.

Review of the physician orders dated/timed 08/03/12 at 10:27 p.m. revealed and order for 4 point restraints for a maximum of 4 hours. Further review of the restraint orders revealed S21 Physician signed the section for In-Person Evaluation by Physician, but there was no date or time documented for the evaluation.

Further review of the physician progress notes and nurse's notes revealed no documented evidence of a 1-hour in person evaluation after the initiation of restraints.

On 10/25/12 at 11:20 a.m., in a face-to-face interview, S5 RN Psychiatric Nurse Manager indicated the physician orders for restraints should include the date and time the physician conducted the 1-hour in person evaluation after restraints were initiated. After reviewing the medical record for Patient #R2, S5 verified there was no date or time documented for the 1-hour evaluation by the physician. S5 verified there was no 1-hour evaluation documented in the progress notes.

Review of the hospital policy titled, Restraints and/or Seclusion (for Violent, Self-Destructive Patient) policy number 6-350, revised 9/2012, and provided as current policy by S1 Quality Management Director, revealed in part the following: Policy: Restraint shall only be used to protect the immediate physical safety of the patient, staff, or others.....In-Person Evaluation: A physician or other LIP (Licensed Independent Practitioner) responsible for the care of the patient or clinical psychologist evaluates the patient in-person within one hour of the initiation of restraint or seclusion used for the management of violent or self destructive behavior that jeopardizes the physical safety of the patient, staff, or others....The assessment can be documented on the restraint order form, physician progress note, or nurses notes.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0179
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the hospital failed to ensure that patients placed in restraints were evaluated within 1-hour for the patient's immediate situation, reaction to the intervention, the medical and behavioral condition, and the need to continue or terminate the restraint for 2 of 4 random sampled patients reviewed for restraint usage (R1, R2). Findings:

Patient R1
Review of the Violent/Self-Destructive Restraint Log for October 2012 revealed Patient R1 was placed in 4 point restraints on 10/14/12 at 4:00 p.m. The log indicated the reason for restraint use was the patient was combative, agitated, violent to staff/self/others, and self-destructive.

Review of the medical record for Patient R1 revealed the patient was a [AGE] year old female admitted to ACPU (Acute Care Psychiatric Unit) on 10/10/12 with diagnoses of Opiate Dependence, Benzodiazepine Abuse, Panic Disorder, PTSD (Post Traumatic Stress Disorder), and Bipolar II Disorder. The patient was admitted under a PEC (Physician Emergency Certificate) for suicidal ideations. Review of the progress notes revealed an entry by the nurse on 10/14/12 at 4:00 p.m. indicating the patient was agitated, throwing a chair and a table, was yelling, screaming, and cursing, and was combative with staff. The entry also indicated the patient was placed in 4 point restraints.

Review of the physician orders dated/timed 10/14/12 at 4:15 p.m. revealed and order for 4 point restraints for a maximum of 4 hours. Further review of the restraint orders revealed the physician documented an in-person evaluation on 10/14/12 at 4:15 p.m., but the section titled, Provider Assessment, was left blank. There was no documented evidence in the medical record of the patient's reaction to the intervention, the patient's medical and behavioral condition, and the need to continue or terminate the restraint.

Further review of the physician progress notes and nurse's notes revealed no documented evidence of a 1-hour in person evaluation after the initiation of restraints.

On 10/25/12 at 11:20 a.m., in a face-to-face interview, S5 RN Psychiatric Nurse Manager indicated a 1-hour in person evaluation of the patient after initiation of restraints should be documented on the restraint orders. After reviewing the medical record for Patient #R1, S5 verified the physician failed to document the 1-hour evaluation of the patient in the record.

Patient R2
Review of the Violent/Self-Destructive Restraint Log for August 2012 revealed Patient R2 was placed in 4 point restraints on 08/03/12 at 10:25 p.m. The log indicated the reason for restraint use was the patient was combative, agitated, and violent to staff/self/others.

Review of the medical record for Patient R2 revealed the patient was a [AGE] year old male admitted to ACPU on 07/31/12 with diagnoses of Mood Disorder, Suicidal Ideations, Homicidal Ideation, Poly-Substance Abuse, and Rule Out Bipolar Disorder. The patient was admitted under a PEC for suicidal ideations. Review of the progress notes revealed an entry by the nurse on 08/03/12 at 10:25 p.m. indicating the patient was violent, combative with staff and completely uncooperative, and was placed in 4 point restraints.

Review of the physician orders dated/timed 08/03/12 at 10:27 p.m. revealed and order for 4 point restraints for a maximum of 4 hours. Further review of the restraint orders revealed S21 Physician signed the section for In-Person Evaluation by Physician, but there was no date or time documented for the evaluation. Review of the Provider Assessment revealed S21 documented only the following: "Patient was threatening staff and peers and was non-redirectable."

Further review of the physician progress notes and nurse's notes revealed no documented evidence of a 1-hour in person evaluation after the initiation of restraints.

On 10/25/12 at 11:20 a.m., in a face-to-face interview, S5 RN Psychiatric Nurse Manager indicated the physician orders for restraints should include the date and time the physician conducted the 1-hour in person evaluation after restraints were initiated. After reviewing the medical record for Patient #R2, S5 verified there was no date or time documented for the 1-hour evaluation by the physician, and the evaluation only included the reason the patient was placed in restraints. S5 verified the evaluation did not contain all the required components and there was no restraint evaluation documented in the progress notes or nurses notes.

Review of the hospital policy titled, Restraints and/or Seclusion (for Violent, Self-Destructive Patient) policy number 6-350, revised 9/2012, and provided as current policy by S1 Quality Management Director, revealed in part the following: Policy: Restraint shall only be used to protect the immediate physical safety of the patient, staff, or others.....In-Person Evaluation: A physician or other LIP (Licensed Independent Practitioner) responsible for the care of the patient or clinical psychologist evaluates the patient in-person within one hour of the initiating of restraint or seclusion used for the management of violent or self destructive behavior that jeopardizes the physical safety of the patient, staff, or others....The in-person evaluation includes the documentation of the following: an evaluation of the patient's immediate situation, the patient's reaction to the intervention, the patient's medical and behavioral condition, and the need to continue or terminate the restraint or seclusion. The assessment can be documented on the restraint order form, physician progress note, or nurses notes.
VIOLATION: PATIENT SAFETY Tag No: A0286
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the hospital failed to develop an effective system for identification of errors in medication administration as evidenced by relying on self-reporting of errors by the nursing staff as the primary means of identification that resulted in the identification of a medication error for Patient #5 being identified by the surveyor rather than the hospital. The hospital failed to identify that their medication policy did not address the time frame for the administration of Now and Stat doses that resulted in 2 of 6 sampled patients receiving Now doses of medications over 1 hour after ordered (#2, #4). Findings:

In a face-to-face interview on 10/25/12 at 11:05am, Psychiatric Nurse Manager S5 indicated that medication variances were either reported to the psychiatric unit from the pharmacist or by the nurse self-reporting the error. She further indicated that no one conducted chart audits related to medication variances.

Patient #5
Review of Patient #5's "Physician's Orders Sheet" revealed that RN (registered nurse) S27 received a telephone order from Psychiatrist S14 on 10/05/12 at 10:10am to administer Haldol 5 mg, Ativan 2 mg, and Benadryl 50 mg by mouth or Intramuscularly (IM) every 4 hours as needed for agitation. Further review revealed that the admit orders included an order for Ativan 2 mg to be given by mouth every 6 hours as needed for moderate anxiety/agitation.

Review of Patient #5's nurses' notes revealed an entry on 10/05/12 at 10:10am by RN S27 that she administered Ativan 2 mg IM for severe agitation. Review of the nurses' notes and MARs (medication administration record) revealed no documented evidence that Patient #5 received Haldol 5 mg and Benadryl 50 mg as ordered on [DATE] at 10:10am.

In a face-to-face interview on 10/24/12 at 1:35pm, Psychiatric Nurse Manager S5 reviewed Patient #5's chart and indicated that he did not receive the medication "cocktail" as ordered by the psychiatrist on 10/05/12. She further indicated that RN S27 who administered and charted the medication administration was not available to be interviewed due to having to leave work for a family emergency.

Patient #2
Review of the medical record for Patient #2 revealed the patient was a [AGE] year old male admitted to ACPU (Acute Care Psychiatric Unit) on 10/10/12 with diagnoses of Amphetamine Induced Psychosis, Amphetamine Abuse, and Alcohol Abuse.

Review of the physician orders revealed on 10/14/12 at 12:00 p.m., the physician ordered Zithromax (antibiotic) 250 mg. 2 (500 mg) one time now, then 1 daily starting 10/15/12 for 4 days.

Review of the MAR (Medication Administration Record) dated 10/14/12 revealed the Zithromax "Now" dose of 500 mg. was administered at 13:47 (1:47 p.m.), 1 hour and 47 minutes after ordered by the physician.

Patient #4
Review of the medical record for Patient #4 revealed the patient was a [AGE] year old male admitted to ACPU on 10/10/12 with diagnoses of Mood Disorder and PTSD (Post Traumatic Stress Disorder), Hypertension, and Diabetes Mellitus.

Review of the physician orders revealed on 10/22/12 at 1:50 p.m. the physician ordered Metformin (oral antidiabetic) 500 mg. two times a day, first dose now.

Review of the MAR (Medication Administration Record) dated 10/22/12 revealed the Metformin "Now" dose of 500 mg. was administered at 3:20 p.m., 1 hour and 30 minutes after ordered by the physician.

On 10/24/12 at 9:30 a.m., in a face-to-face interview, S5 Psychiatric Nurse Manager stated "Now" medications were administered when the nurse received the medication from the pharmacy. S5 verified there was no specified time frame for the administration of "Now" ordered medications.

On 10/25/12 at 3:00 p.m., in a face-to-face interview S1 Quality Management Director stated the hospital's only policy on medication administration times was the policy titled Timely Administration of Medications. S1 indicated the hospital was aware of the revised regulatory requirements for the timing of medication administration and stated they were working on a policy. S1 verified the current approved policy did not include time frames for the administration of "Now" or "Stat" medications ordered by the physician.

Review of the hospital policy titled, Timely Administration of Medications, number 5-209, reviewed 2/2012, and provided as current by S1 Quality Management Director, revealed in part the following:
Time critical medications must be administered within 30 minutes before or after the scheduled time of administration in order to be considered "on time". (These medications include antibiotics that are administered every 6 hours or more frequently, antibiotics that require therapeutic monitoring....oral antidiabetics...)
Scheduled medications do not include:
Stat or Now
First Doses or loading doses
One time doses....
There was no documentation in the policy of the time frame for administration of Stat and Now doses of medication.
Review of the policy revealed antibiotics and oral antidiabetics were identified as time critical medications that when scheduled, should be administered within 30 minutes of the scheduled time.

Review of the hospital's "Organizational Performance Improvement Plan", presented by Quality Management Director S1 as the current QAPI plan, revealed, in part, "...Information reporting will contain concurrent data related to ongoing patient safety and medical error issues, as well as information related to the proactive risk assessments and improvement endeavors. ... Types of patient safety or medical/health care errors included in data analyses are: ... Medication Errors Adverse Drug Reactions... All departments within the organization , including patient care and non-patient care departments are responsible for reporting unanticipated adverse events and potential occurrences to the Quality Management staff, which will aggregate occurrence information and present a report to the Quality Management and Medical Executive Committee at least quarterly..."

Review of the hospital policy titled, Medication Variances/Medication Errors, policy number 5-100, revised 5/2009, and provided as current policy by S1 Quality Management Director, revealed, in part, the following, "Policy: Medication variances should be reported immediately by the staff member finding the variance to the Charge Nurse or Supervisor. The physician should be notified for any variance resulting in wrong medication or dose. The person discovering the variance should complete a 'Medication Variance Report' ...8. Pharmacy will investigate each variance. 10. Reports will be reviewed monthly by Nursing Administration, Pharmacy & Therapeutics Committee, and Quality Management Council to identify areas for improvements and make recommendations for action..."
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interview the hospital failed to focus performance improvement activities on high-risk, high-volume or problem prone areas as evidenced by failure to develop and implement quality indicators to track, analyze, and trend the high utilization of security personnel on the psychiatric unit. This resulted in a patient exhibiting increased agitation that required security guards to escort him to a quiet area being escorted by security personnel who did not use approved IMAB (intervention management of aggressive behavior) techniques for 1 of 1 patient's record reviewed who required an escort by security guards from a total sample of 6 patients (#5). Findings:

Review of the "Monthly Indicator Trends Report Summary - 2012 Inpatient", presented by Quality Management Director S1 as the quality indicators for the inpatient psychiatric unit, revealed no documented evidence that the high utilization of security personnel on the psychiatric unit was being tracked, analyzed, and trended through the QAPI (quality assessment and performance improvement) program.

In a face-to-face interview on 10/25/12 at 11:05am, Psychiatric Nurse Manager S5 indicated that she collected data for QAPI for the psychiatric unit. She further indicated that the psychiatric unit relied on the use of security personnel frequently for assistance with agitated, hostile, or combative patients. S5 indicated that she did not include the high utilization of security personnel for patient care as a quality indicator for QAPI, and no data was tracked, analyzed, and trended to determine that the care provided was appropriately performed and patient safety was maintained.

Review of Patient #5's medical record revealed that he was a [AGE] year old male admitted on [DATE] with diagnoses of Psychoses, Suicidal Ideation, Essential Hypertension, and Coronary Atherosclerosis. Further review revealed that he was PEC'd on 10/05/12 at 12:40am due to being suicidal and a danger to himself.

Review of Patient #5's nurses' notes revealed that on 10/05/12 at 10:10am RN (registered nurse) S27 documented that Patient #5 became agitated when the staff attempted to get his cell phone from him. Further review revealed that the security guard escorted Patient #5 to the quiet room where he was administered Ativan 2 mg (milligrams) intramuscularly for severe agitation.

In a face-to-face interview on 10/24/12 at 2:25pm, Police Officer S7 indicated that he and Security Officer S28 were called to the psychiatric unit for a problem sometime around the beginning of October. He further indicated that Patient #5 refused to give his cell phone to a staff member.. S7 indicated that he asked Patient #5 3 or 4 times to give him the cell phone, but Patient #5 refused, saying that his cell phone had "drilling missile sites" in it. S7 indicated that while Patient #5 was seated in a chair, Security Officer S28 reached down to get the phone. He further indicated that he (S7) grabbed Patient #5's left arm, and Security Officer S28 grabbed his right arm and escorted Patient #5 to the restraint room. S7 indicated that since he (S7) had a splint on his finger due to it being broken, Security Officer S28 stood behind Patient #5, brought both of his (patient's) arms around to his (patient's) back, and walked Patient #5 to the restraint room (S7 demonstrated the position that was used by S28 to escort Patient #5). When asked if this type of hold was an approved IMAB hold, S7 indicated that it was.

In a face-to-face interview on 10/24/12 at 3:33pm, RN Instruction Coordinator S10 indicated that it required 2 people to hold a patient when escorting a patient, but using 3 people would be better. When S10 was shown the hold that was demonstrated by Police Officer S7, S10 indicated that holding a patient's arms from behind by one person to escort a patient was not an approved hold technique taught in IMAB. When asked if it was appropriate for someone to hold a patient's arm on each side to escort a patient, S10 indicated "no". She further indicated that a one person escort of a patient was not an approved IMAB technique.

RN S27 and Security Officer S28 were not available to be interviewed during the survey.

Review of Security Officer S28's personnel file revealed that he was hired on 11/29/10. Further review revealed that he had completed the 2011 IMAB Renewal Part 1 on 04/28/11 and Part 2 on 02/13/11. Further review revealed that S28 had completed the 2012 IMAB Renewal Part 1 on 06/16/12 and was scheduled for Part 2 on 11/07/12. There was no documented evidence that S28 had attended a renewal course (Part 1 and 2) every 12 months as required by hospital policy.

Review of the hospital's "Organizational Performance Improvement Plan", presented by Quality Management Director S1 as the current QAPI plan, revealed, in part, "...Process Improvement Model: ... All PI (performance improvement) activities will be incorporated into a systematic, organizational-wide approach through collaborative monitoring and performance improvement teams. ... Priorities for hospital-wide performance improvement activities are designed to improve patient outcomes. ... Evaluation: ... Continuous and ongoing measurement activities will include: 1. Measurement of both processes and outcomes. 2. Processes must be measured on a continuing basis. 3. Priority issues chosen for improvement will include high volume, high risk and problem prone issues..."
VIOLATION: NURSING SERVICES Tag No: A0385
Based on record reviews and interviews, the hospital failed to meet the requirements for the Condition of Participation for Nursing Services as evidenced by:

1) Failing to ensure that the psychiatric unit was staffed to meet the needs of the patient or according to the unit's staffing grid per hospital policy for 20 of 21 days reviewed. This resulted in the patients' psycho-education group not being conducted according to the patients' interdisciplinary treatment plan for 6 of 6 sampled patients (#1, #2, #3, #4, #5, #6) (see findings in tag A0392); and

2) Failing to ensure that the RN (registered nurse) supervised and evaluated the nursing care of each patient. The nurse failed to supervise the MHTs' (mental health tech) observation of the patients on the psychiatric unit which resulted in MHTs not initialing their documentation on the patient's observation record, inaccurate documentation of the location of patients, and no documentation by the MHT who provided relief for bathroom and meal breaks for 5 of 6 sampled patients (#1, #2, #3, #4, #5) and 1 of 4 random patients reviewed for restraint usage from a total of 10 random sampled patients (R2) (see findings in tag A0395).
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the hospital failed to ensure that the psychiatric unit was staffed to meet the needs of the patient or according to the unit's staffing grid per hospital policy for 20 of 21 days reviewed. This resulted in the patients' psycho-education group not being conducted according to the patients' interdisciplinary treatment plan for 6 of 6 sampled patients (#1, #2, #3, #4, #5, #6). Findings:

Review of the Psychiatric Unit's staffing grid that was presented by Director of Nursing (DON) S2 as the current grid used to staff the Psychiatric Unit revealed the unit was not staffed according to the hospital's staffing policy for the number of staff required based on the patient needs and census from 10/03/12 to 10/23/12. This resulted in patients' psycho-education group not being conducted according to each patient's interdisciplinary treatment plan for Patients #1, #2, #3, #4, #5, and #6.

Review of Patient #1's medical record revealed that he was admitted on [DATE]. Review of his "Interdisciplinary Treatment Plan" revealed the clinical intervention for his identified problem of Suicidal Ideations was attendance at a psycho-education group 1 time a day for 1 hour for 1 to 4 days per week. Further review revealed the clinical intervention for his identified problem of Depressed Mood was attendance at a psycho-education group 1 time a day for 1 hour for 1 to 5 days per week. Review of Patient #1's medical record revealed no documented evidence that he had attended or refused to attend a psycho-education group from admission on 10/16/12 through 10/22/12.

Review of Patient #2's medical record revealed that he was admitted on [DATE] and discharged on [DATE]. Review of his "Interdisciplinary Treatment Plan" revealed the clinical intervention for his identified problem of Suicidal Ideations was attendance at a psycho-education group 1 time a day for 1 hour for 1 to 4 days per week. Further review revealed the clinical intervention for his identified problems of Altered Thoughts, Inability to remain Alcohol/Drug Free, and Depressed Mood was attendance at a psycho-education group 1 time a day for 1 hour for 1 to 5 days per week. Review of Patient #2's medical record revealed no documented evidence that he had attended a psycho-education group during his entire hospital stay.

Review of the "Interdisciplinary Treatment Plan" for Patient #3 revealed the clinical intervention for his identified problem of Depressed Mood was attendance at a psycho-education group 1 time a day for 1 hour for 1 to 5 days per week. Further review revealed the clinical intervention for his identified problem of Suicidal Ideations was attendance at a psycho-education group 1 time a day for 1 hour for 1 to 4 days per week. Review of Patient #3's medical record revealed no documented evidence that he had attended a psycho-education group since his admission on 10/20/12 (chart reviewed on 10/23/12).

Review of Patient #4's medical record revealed that he was admitted on [DATE]. Review of his "Interdisciplinary Treatment Plan" revealed the clinical intervention for his identified problem of Altered Thoughts was attendance at a psycho-education group 1 time a day for 1 hour for 1 to 5 days per week. Review of Patient #4's medical record revealed no documented evidence that he had attended a psycho-education group since his admission (chart reviewed on 10/24/12).

Review of Patient #5's "Interdisciplinary Treatment Plan" revealed the clinical intervention for his identified problem of Suicidal Ideations was attendance at a psycho-education group 1 time a day for 1 hour for 1 to 4 days per week. Further review revealed the clinical intervention for his identified problem of Altered Thoughts was attendance at a psycho-education group 1 time a day for 1 hour for 1 to 5 days per week. Review of Patient #5's medical record revealed no documented evidence that he had attended a psycho-education group during his entire stay from 10/05/12 to 10/12/12.

Review of Patient #6's medical record revealed that he was admitted on [DATE] and discharged [DATE]. Review of his "Interdisciplinary Treatment Plan" revealed the clinical intervention for his identified problem of Suicidal Ideations was attendance at a psycho-education group 1 time a day for 1 hour for 1 to 4 days per week. Further review revealed the clinical intervention for his identified problem of Poor Impulse Control was attendance at a psycho-education group 1 time a day for 1 hour for 1 to 5 days per week. Review of Patient #6's medical record revealed no documented evidence that he had attended a psycho-education group or refused to attend a group during his hospital stay.

In a face-to-face interview on 10/24/12 at 1:35pm, Psychiatric Nurse Manager S5 indicated that the nurse education groups had been one of the interventions that had been decreased or eliminated on some shifts when the nursing staff was busy since the budget cuts had been implemented by the state.

In a face-to-face interview on 10/24/12 at 3:40pm, RN S11 indicated that he didn't always document in the nurses' notes when he conducted group therapy. S11 indicated that when group was held, it was usually on life style or medications. He further indicated that patient education was usually done at the time of discharge or just prior to discharge.

In a face-to-face interview on 10/25/12 at 7:38am, RN S17 indicated that since the unit increased to 24 beds and the clerk had been laid off, the nurses had not been doing group therapy regularly.

In a face-to-face interview on 10/25/12 at 8:03am, RN S18 indicated that sometimes the nurse did an education group on the night shift with patients who were awake. She further indicated that if a group was held, it would be documented on the education group form that should be placed in each patient's medical record. S18 indicated that when the shift was short of staff for MHTs, the nurse would have to help the MHTs with patient needs and observations and could not hold group therapy. After reviewing Patient #5's medical record, S18 confirmed that there was no documented evidence that Patient #5 had attended or refused to attend any education groups.

In a face-to-face interview on 10/25/12 at 11:05am, Psychiatric Nurse Manager S5 indicated that the psychiatric unit had been understaffed for the last fiscal year. She further indicated that the unit's weaknesses were group activity and documentation (clarified that what's being done "isn't coming out on that piece of paper").

Review of the hospital policy titled "Staffing for Patient Care-Inpatient Units and Emergency Department", policy number 02-026, revised 07/12, and presented as the current policy by RN Manager S9, revealed, in part, "...Each unit has a core of RN's, LPN's, Nurse Aides, and other staff to meet the needs of their average patient population. The hours of care are based on number and acuity of patients and staff required to address the needs. ... Staffing is reviewed by the RN Supervisor and RN House Manager on a daily basis to ensure adequate coverage for the next twenty-four hour period. Adjustments are made by the charge nurse under direction of the supervisor as patient census or needs change on off shifts..."

Review of the hospital policy titled "Assignment of Nursing Personnel", policy number P-103, revised 01/09, reviewed 01/12, and presented by RN Manager S9 as the current policy, revealed, in part, "...Upon completion of shift report, the Charge Nurse will make patient assignments based on the patient's level of acuity (i.e. [that is] Observation status) and the qualifications of the staff members..." Attached to the policy was the psychiatric unit staffing grid.
VIOLATION: FORM AND RETENTION OF RECORDS Tag No: A0438
Based on observation and interview, the hospital failed to ensure medical records were properly secured as evidenced by the hospital storing medical records on open shelving with no protection from water damage if the sprinkler system had been activated.
Findings:
A tour of the Medical Records department was conducted on 10/24/12 at 9:30 a.m. with the Director of Medical Records S25. Observation revealed the medical records were housed in a building behind the main hospital. Upon entering the building, offices and work areas were observed to be located to the left and right of the entry with the medical record storage in the center. A sprinkler system was located throughout the ceiling of the building. Further observation revealed an open shelving unit with 27 sections 2-3 feet in length containing medical records.
In an interview on 10/24/12 at 9:40 a.m. with the Director of Medical Records S25, she indicated that the records on the open shelving were pulled and placed on the shelving for patients' clinic visits within 48 hours of their appointments. S25 further indicated that there were approximately 713 records on the open shelving unit. S25 confirmed that the medical records on the open shelves were not protected from water damage if the sprinkler system would have been activated.
Further observation of the medical record storage building on 10/24/12 at 9:40 a.m. revealed 4 sections of shelving that had 7 sets of electronically moveable shelves each. The 4 sections were separated by stationary shelves. When the shelving units were compressed together, all of the shelving units were protected from water damage except the back side of the last moveable shelf of each section and the stationary shelf facing the last shelves. The last section of shelving at the back of the moveable shelves had 2-3 foot long shelves, 8 sets high and 7 rows deep having a total of 56 shelves exposed to water. On the stationary shelves facing them, 40 shelves of 2-3 foot long lengths were open to possible water exposure. Observation of the 4 sections of shelving units, when they were closed for safety, revealed the following shelves and medical records that were not protected:
Section 1: 48 shelves contained exposed medical records on the last section of moveable shelves, 35 shelves contained exposed medical records on the stationary shelving.
Section 2: 42 shelves contained exposed medical records on the last section of moveable shelves.
Section 3: 49 shelves contained exposed medical records on the last section of moveable shelves, 33 shelves contained exposed medical records on the stationary shelving.
Section 4: 35 shelves contained exposed medical records on the last section of moveable shelves, 15 shelves contained exposed medical records on the stationary shelving.
Observation of an open shelving unit in the back of the record storage room revealed 46 shelves which were 2-3 feet long which contained medical records which were not protected from water damage if the sprinklers had been activated.
In an interview on 10/24/12 at 9:45 a.m. with Medical Records Director S25, she indicated that 2 years' worth of medical records were kept in the medical record building. She further indicated that after 2 years, the records were sent to an offsite storage facility. S25 further indicated that the medical records were not scanned into a computer for storage. S25 indicated that the bulk of the medical records were kept on shelving units with an electronic system that would move the shelves for access and safety, and if there was a fire in the building, the shelves could be closed together to protect the records from fire damage or water damage from the sprinkler system. S25 confirmed that when the shelves were closed, 8 shelving units were left exposed to water from the sprinkler system if it had been activated. S25 could not give an accurate number of how many medical records were located on the exposed shelves, but she estimated there were thousands of records. She indicated that she could see that there would be a definite problem with medical records being destroyed if there had been a fire in the building or if the sprinkler system was activated. S25 confirmed that there was no other means in use of protecting the exposed medical records.
Review of the policy titled Security of Medical Records , Policy # 8-360, Revised 1/9/12 stated in part: Medical records will be maintained in such a manner that shelving will be secure to protect the records from damage by fire and/or water.
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the hospital failed to ensure that all medical record entries were dated, timed, and authenticated by the person responsible for providing the service according to hospital policy for 1 of 6 sampled patients' records reviewed for timing and dating medical record entries (#5) and 2 of 4 random patients' records reviewed for timing and dating medical record entries from a total of 10 random patients (R2, R4). Findings:

Patient #5
Review of Patient #5's medical record revealed that he was a [AGE] year old male admitted on [DATE] with diagnoses of Psychoses, Suicidal Ideation, Essential Hypertension, and Coronary Atherosclerosis.

Review of Patient #5's "Physician's Orders Sheet" revealed a telephone order was received from Psychiatrist S21 at 11:05pm by RN (registered nurse) S18 with no documented evidence of the date the order was given by S21 and the date and time S18 received the order. Further review revealed an order was written on 10/09/12 at 1210 (12:10pm) by Nurse Practitioner (NP) S23 and co-signed by Psychiatrist S21 with no documented evidence of the date and time that S21 co-signed the order.

Review of Patient #5's "Acknowledgement Of Notification Of Rights", signed by Patient #5, revealed no documented evidence of the signature of the staff member who witnessed the patient's signature and the date and time that the signature was witnessed.

Review of Patient #5's "Acute Care Psychiatry Unit Psychiatry MD Progress Notes" documented by NP S23 on 10/09/12 at 11:30am, 10/10/12 at 12:20pm, 10/11/12 at 12:15pm, and 10/12/12 at 10:00am revealed no documented evidence of the date and time that Psychiatrist S21 co-signed the progress notes.

Patient R2
Review of the Violent/Self-Destructive Restraint Log for August 2012 revealed R2 was placed in 4 point restraints on 08/03/12 at 10:25 p.m. The log indicated the reason for restraint use was the patient was combative, agitated, and violent to staff/self/others.

Review of the medical record for Patient R2 revealed the patient was a [AGE] year old male admitted to ACPU(Acute Care Psychiatric Unit) on 07/31/12 with diagnoses of Mood Disorder, Suicidal Ideations, Homicidal Ideation, Poly-Substance Abuse, and Rule Out Bipolar Disorder. The patient was admitted under a PEC (Physician Emergency Certificate) for suicidal ideations. Review of the progress notes revealed an entry by the nurse on 08/03/12 at 10:25 p.m. indicating the patient was violent, combative with staff ,and completely uncooperative, and was placed in 4 point restraints.

Review of the physician orders for 4 point restraints on 08/03/12 revealed S21 Physician signed the section for In-Person Evaluation by Physician, but there was no date or time documented for the evaluation.

On 10/25/12 at 11:20 a.m., in a face-to-face interview, RN Psychiatric Nurse Manager S5 indicated the physician orders for restraints should include the date and time the physician conducted the 1-hour in person evaluation after restraints were initiated. After reviewing the medical record for Patient R2, S5 verified there was no date or time documented for the 1-hour evaluation by the physician.

Patient R4
Record review revealed Patient R4 had been admitted on [DATE] at 10:20 a.m. with diagnoses which included Paranoid Schizophrenia, Mood Disorder, Cocaine Abuse, and Alcohol Abuse.

Review of the Emergency Department Record for Patient R4 revealed a 3 page Emergency Department Record with an arrival time of 2117 (9:17 p.m.) but no date had been written. Further review revealed under the section titled Final Disposition-ED (emergency department) Departure, the space for the time of departure from the ED was blank. Further review revealed the spaces for the Provider and Staff signature, date and time were all blank.

In a face-to-face interview on 10/25/12 at 2:35pm, Quality Management Director S1 indicated that the timing and dating of entries was a problem that he hoped would be corrected when the hospital implemented computer software planned for the future.

Review of the hospital policy titled "Medical Record Content", policy number 8-280, revised 02/02/09, reviewed 01/09/12, and presented as the current policy by RN Manager S9, revealed, in part, "...All medical record entries shall be timed and dated, have identified author of the entry, be authenticated, be legible...".