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.

ST ALEXIUS HOSPITAL 3933 S BROADWAY SAINT LOUIS, MO 63118 July 13, 2012
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, interview, record review and policy review, the facility failed to prevent two (#73 and #51) of 13 patients, who were at risk of harm to themselves or others, from eloping from the facility and the facility failed to ensure patients who presented to the Emergency Department (ED) for psychiatric care were continuously monitored until staff no longer considered the patients to be at risk to themselves or others for six (#47, #51, #54, #56, #57 and #73) of 13 patient records reviewed.

The severity and cumulative results of these findings resulted in the facility's non-compliance with 42 CFR 482.13 - Condition of Participation: Patient's Rights. Subsequently the situation constituted an unabated condition of Immediate Jeopardy (IJ). The facility administration was notified of the IJ on 07/13/12 at 11:45 AM and at the time of survey exit on 07/13/12 at 5:10 PM, the facility had been unable to implement actions to abate this immediate jeopardy situation.

See tag 0144 for the related citation.
VIOLATION: PATIENT VISITATION RIGHTS Tag No: A0217
Based on observation, interview and facility policy review, the facility failed to ensure visitation rights to psychiatric patients in the facility Emergency Department and Psychiatric Intake Area. This affects all psychiatric patients who are admitted to these areas. The facility census was 124.

Findings included:

1. Record review of facility policy titled, "Psychiatric Services, Patient Visitation", dated 11/10, shows details of Purpose, Policy and Procedure for patient visitation. The policy shows that visitors will be allowed in patient care areas.

Record review of facility Policy: 8311-71 titled, "Administration, Subject: Patient Visitation Rights", dated 3/11, shows visitation shall only be restricted when it is clinically necessary. Review shows no visiting restrictions for psychiatric patients who are admitted to the Emergency Department (ED) or Psychiatric Intake Area.

2. During observation of the Emergency Department on 06/07/12 at approximately 9:20 AM through 10:00 AM no patients were observed using the telephone or having visitation with friends or family.

During intermittent observations of the Psychiatric Intake Area on 06/05/12 at approximately 2:10 PM through 3:30 PM while accompanied by Staff L, no patients were observed using the telephone or having visitation with friends or family.

3. During an interview on 06/05/12 at a approximately 1:50 PM, Staff KK an RN who is assigned to the Psychiatric Intake Area and ED, stated that psychiatric patients are not allowed visitors or phone calls while in the Psychiatric Intake and ED area.

During an interview on 06/06/12 at approximately 10:45 AM, Staff L, Manager of Emergency Department and Psychiatric Intake Area, stated that psychiatric patients are not allowed visitors or phone calls while admitted and held in the ED or Psychiatric Intake area.

During an interview on 06/06/12 at a approximately 1:40 PM, Staff O an RN who is assigned to the Psychiatric Intake Area and ED, stated that psychiatric patients are not allowed visitors or phone calls while in the Psychiatric Intake and ED area.

4. During interviews with patients in the Psychiatric Intake Area on 06/07/12 at approximately 10:00 AM Patient #32 and Patient #55 stated that they didn't think they were allowed to have visitors or make phone calls, no one explained it to them but they just knew that it was the rules.
VIOLATION: PHYSICAL ENVIRONMENT Tag No: A0700
Based on observation and interview, the facility failed to maintain a clean, safe and sanitary environment for patient care on three (Broadway, Forest Park, and Jefferson) of three campuses. The facility is responsible for the safety, diagnosis and treatment of patients seeking hospital services. The systemic failure resulted in the facility being out of compliance with 42 CFR 482.41 - Condition of Participation: Physical Environment. The facility census was 124.

Refer to evidence A-0701and A-0724 for findings.
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
Based on observation, record review and interview the facility failed to maintain in a safe condition and/or replace damaged ceiling tiles, walls and floor coverings at the Broadway campus. The facility failed to ensure that walls and floors were maintained in a state that could be kept free of debris on a consistent basis. This failure had the potential to affect all patients admitted to the hospital. The facility census was 124.

Findings included:

1. Record review of the facility's policy titled, "Patient Rights and Responsibilities" dated 4/12, showed that patient's have the right to be cared for in a safe, clean and private environment.

Record review of the facility's policy titled, "Psychiatric Rights of All Patients" dated 11/09, showed patients have the right to safe and sanitary housing.

Record review of the facility's policy titled, "Room Checks and Environmental Surveillance", showed routine environmental surveillance is conducted on an ongoing basis and documented at change of shift. The purpose of the surveillance is to provide patient and staff safety on the inpatient units. Surveillance includes each patient room including the bathrooms and showers. Walls should be inspected for damage and lose or chipped areas, light fixtures should be securely fastened and ceiling tiles are secured. Any discovered safety threat should be immediately reported and repaired.

2. Observation on 6/12/12 at approximately 2:30 PM showed operating room #4 had a six inch long tear or crack in the solid floor covering near the wall. Operating room #3 had four cracks or tears approximately one inch long, one approximately four inches long near two separate walls in the room and one near the door at approximately ten inches long where the flooring adjoins the wall. Operating room #2 had one tear or crack in the floor approximately one inch long near the back wall.

The tears or cracks in the floors did not present a solid surface that could be thoroughly cleaned to ensure a sanitary surgical environment.

3. Observation on 6/12/12 from 11:00 AM to 4:00 PM showed the following areas in occupied patient rooms:
-Room 309- each of the floor tiles had grossly visible dirt with an excessive accumulation of dirt in the corners.
-Room 307- missing a shower head in the shower leaving a hole in the wall.
-Room 320- the paint on the ceiling's metal frame work was peeling away from the metal
-Room 318- in the bathroom near the shower there was water damage to the wall approximately two feet by one foot.
-Room 360- two ceiling tiles were damaged by water and still wet at the time of observation.
-Room 405- There was water damage to the wall between the shower and toilet approximately one foot by one foot which was severe enough to remove the dry wall material and leave the metal support structures underneath exposed.

4. Tours and observations on the 6th floor of the Broadway building on 06/12/12 at 10:40 AM through 06/12/12 at 5:00 PM showed 17 occupied patient rooms; three private occupancy rooms and 14 double occupancy rooms. Each bedroom had a private bathroom, with a shower, toilet, and hand-wash sink. All 17 bathrooms and patient rooms showed the following:
-Black, mold-like residue combined with unidentified soils up to one inch wide extended along the cove base around the perimeter of each patient room and each private bathroom, in doorways, corners, and between tiles in the majority of shower stalls. The heaviest deposits of black soils were in corners of the bathrooms and behind the toilet, where visibility of the floor was often occluded due to the density of black residue that had accumulated.
-Rooms #402 and #403 had shower floors dirty with darkened residue.
-Broken ceramic tile in the bathroom of room #620, loose tile behind the toilet in room #613, pungent urine odor and stained tiles in bathroom of room #615,
-Detached drain grate on the floor in shower of room #619 posed a potential footing hazard and there were broken and missing ceramic tile from the base of a wall between toilet and shower.
-Buckled and peeled surfaces of drywall behind the toilet, stained floor tiles and pungent urine odor in the bathroom of patient room #623

5. During an interview on 06/12/12 at 2:00 PM, Staff MM (Director of Environmental services) stated that housekeeping personnel clean all bedrooms daily. She stated that there are usually two housekeepers assigned per floor. She stated that they needed a system set up so housekeeping gets a call as soon as a patient is discharged so they have time to do a terminal cleaning before the next patient is admitted . She stated that the time spent by housekeepers on each room averages around 20 minutes. She stated that she has floor technicians on standby, but it takes longer to strip, scrub, wax, dry, and buff a room, and they seldom have adequate time to complete their work, because there is someone already standing in the hall waiting for the room. She stated she does inspect the work of her staff and uses the same criteria as is listed on a checklist they complete for each patient room and common area.

6. Record review showed checklists used for 5th and 6th floors, titled Housekeeping Inspection List, makes no mention of floors except for those in the ICU waiting room and Day Rooms.

7. Observation of room #317 on 06/04/12 at 4:00 PM showed missing, cracked, loose broken porcelain tiles. During an interview at the time of the observation, Staff K, Clinical Leader Psychiatric Services, stated that porcelain tiles which are missing, broken, cracked and loose from wall and floor surfaces are hazards to suicidal patients who may want to harm themselves or that the tiles sharp edges may be used to intentionally harm others. Staff K stated that the missing tile, cracked, broken and loose tile in patient room #317 is dangerous and that the patient (#26) who is currently assigned the room and has been for approximately 60 days, reports the tile has been that way their entire admission.

8. During an interview on 06/04/12 at 5:20 PM, Staff A, Performance Improvement and Risk Management Director and Staff C, Chief Executive Office of facility, stated patient care areas are to be safe and clean.

9. During an interview on 06/04/12 at 2:40 PM, Staff J, Manager Adult and Geriatric Psychiatric Services, stated the patient's on suicide precautions are allowed alone in their rooms with the doors closed.

10. During an interview on 06/05/12 at 11:05 AM, while observing patient room #403 in the Adult Psychiatric Unit, Staff J stated, "I had no idea it was so bad, it's not OK with me, it's dirty and smells awful". Staff J stated that all of the sink faucets in patient rooms in the Psychiatric Units on the 3rd and 4th floors have similar faucets and that they all have water control knobs which have ligature points at the space between the base of the water control handle and point of attachment to the base of the faucet. Staff J stated that the water faucets have not been replaced in many years.

11. Observation of room #407 on 06/05/12 at 11:10 AM, and occupied at the time, showed a vent located above the toilet. An electric ventilation fan was located inside the vent. The fan was loose and detached on one corner. An area of drywall, approximately one foot high by eight inches wide was missing, which exposed rusted metal and loose drywall. This posed a safety hazard for any patient in the bathroom. Staff J stated that the hanging vent is a safety hazard and that the bathroom is dirty and the missing area of wall with exposed rusted metal and loose drywall materials is not acceptable for patient care areas and does pose a hazard for all patients who are admitted to the unit.
VIOLATION: FACILITIES Tag No: A0722
Based on observation and interview the facility failed to clean and maintain two of two deep fat fryers located in the kitchen of the Broadway building. The facility census was 124.

Findings included:

1. Observation of the kitchen on 06/13/12 at 12:25 PM showed large accumulations of grease and carbonized bits of food that had spilled over the edges of the doors and pooled around the gas burners and control valve below each of the fryer vats. Brown grease, flecked with black residue dripped off of the bottom edges of the burner shelf and had not been removed by regular cleaning.

2. During an interview on 06/13/12 at 12:25 PM, Staff NN, Director of Food Services, stated that she had been there for two years and did not know that the front door of the deep fat fryers opened. She stated that staff had never cleaned the inside of the burner cabinet, it was not on the cleaning schedule and none of the written cleaning procedures mentioned it.
VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Tag No: A0724
Based on observation and interview the facility failed to ensure that essential supplies and equipment are maintained and provided in a manner to ensure delivery of patient care. The facility failed to ensure that emergency power was available to all buildings and patient care areas. The facility failed to ensure that all patient rooms had access to toilets, hand wash sinks, oxygen or vacuum services and proper separations provided privacy to potential patients at the Jefferson campus and Forest Park campus. The facility census was 124.

Findings included:

1. Observation on 06/13/12 at approximately 10:00 AM of the Jefferson campus showed the following:
-Room 360 had damage to the entire surface of the two walls with the nurse call, oxygen outlets and vacuum outlets. Ceiling tiles in one portion removed due to the damage caused by water.
-Room 362 had one entire wall damaged by water. The oxygen, vacuum and electrical outlets had been removed due to the damage. There was damage to the toilet floor and a hole through the wall which adjoined room 360. Another wall in the room had damage to approximately one fourth of the wall.
-Room 364 had damage to one wall which resulted in the oxygen, vacuum and electrical outlets being removed and remaining hardware rusted.

The damage to the rooms was more substantial than previous damage cited to these same rooms in April of 2011 during a survey process.

2. During an interview on 06/13/12 at approximately 10:00 AM Staff PP, lead maintenance, stated that the roof had previously leaked and had since been fixed.

3. Observation on 6/13/12 at approximately 10:15 AM showed that the nurse's station near rooms 360 through 365 and another nurse's station for rooms 303-337 were checked for emergency power. There were no lights connected to emergency power near the nurse's station, medication room and only minimal lighting being lit in emergency egress corridors as Staff PP demonstrated after being asked about the availability of power.

Rooms 330, 331, 332 and 333 were on the same side of the corridor. All four rooms were open to each other on the interior of the rooms and were listed as being semi-private or for two patients each. The wall between each room only extended three fourths of the way across the interior area leaving each room open to the next.

The bathrooms in each room had the utilities removed and from four original bathrooms only two handwash sinks and one toilet remained in the rooms.

4. During an interview on 06/13/12 at 8:50 AM Staff PP stated that the oxygen supply and vacuum service for the Jefferson campus no longer are operational.

5. Rooms were observed to have outlets for oxygen and a small percentage of the rooms to have additional vacuum outlets to serve the patients.

6. During an interview on 6/13/12 at 12:55 PM Staff PP stated that the Jefferson campus building has two generators. No inspection forms could be found for one of of the two (smaller) generators on the campus. Record review showed only an inspection from 02/28/12 and was only for the larger of the two generators.

Staff PP stated that there were no other forms nor was there any testing of either of the generators weekly or a load test done monthly on the generators that he was aware of since February of 2012.

7. Observation on 06/13/12 from 9:00 AM through 11:00 AM showed the unoccupied Forest Park building in a state of disrepair from neglect. Most of the power on each floor had been turned off with the only illumination from some lights at the nurse's station located in the center of the wing. Only a security guard at the desk and a maintenance worker salvaging out equipment (specific lighting, furnishings, printers, copy machines and office cabinets still to be picked up) remained at the facility. Patient rooms, corridors and separate departments of Laboratory, Pharmacy, Radiology, Surgery, Emergency Department etc., were in the state of abandon and were devoid of essential furnishings and supplies such as lights, tables, beds, cabinets, linen, and medication supplies. The building has not been occupied or cleaned in some time as evidenced by thick layers of dust on floors and numerous items staged for retrieval or destined for the dumpster. All supplies and medications had been removed from the premises and transferred to other facilities. All oxygen and medical gas service has been terminated, with manifold system and bulk tanks removed from the premises. Most of the utilities are shut off and a couple of the elevators are not working properly. Emergency power had been taken off line as the building no longer serves patients. Most of the air handlers in the building had been shut down. Serviceable beds, cabinets and furnishings had been salvaged and removed from the building. The remaining items were pooled or stored in select areas for salvage or pickup. Patient rooms were unfurnished and not capable of providing adequate accommodations for patients or staff. With the exception of miscellaneous pieces of trash and broken furniture, offices and exam rooms throughout the building were empty and devoid of furniture. Most beds had been moved or removed from the building. Assigned maintenance personnel are salvaging medical cabinets and furniture, copiers, etc. out of the building. In the present disheveled condition, the building is not appropriately staffed or supplied and does not meet minimum federal standards for a clean and sanitary environment.
VIOLATION: PATIENT RIGHTS: PARTICIPATION IN CARE PLANNING Tag No: A0130
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, record review and facility policy review the facility failed to develop a treatment plan that provided five of five patients (#29, #30, #31, #32, #33) the right to participate in the development of a plan of care. The facility census was 124.

Findings included:

1. Review of the facility policy titled, "Psychiatric Services Treatment Plan", dated 11/10, shows details of purpose, policy and procedure for treatment planning. Review shows the treatment plan will identify patient needs and systematically plan the course of clinical treatment and serve as the central reference of interventions, expectations, goals and objectives for treatment.
The treatment plan will;
-be initiated upon admission by the Admitting Registered Professional Nurse (RN) based upon the physicians order and nursing assessment
-contain/document a problem list with the dates the problems were identified, expected resolutions, interventions, long and short term goals, be ongoing and kept current
-involvement of the patient, guardian, family and/or significant other will be sought and encouraged throughout the hospital course.
-patient/guardian family involvement will be documented.

2. Review of medical record for Patient #29 on 06/06/12 at approximately 2:00 PM, who at the time of review was admitted to the hospital in the Psychiatric Intake Area (a distinct one room area designated for patient care with seven numbered recliner cots where patients are assigned for patient care), showed the patient was admitted on [DATE] and showed no development of a treatment plan by the admitting RN.

3. Review of medical record for Patient #30 on 06/06/12 at approximately 2:00 PM, who at the time of review was admitted to the hospital in the Psychiatric Intake Area (a distinct one room area designated for patient care with seven numbered recliner cots where patients are assigned for patient care), showed the patient was admitted on [DATE] and showed no development of a treatment plan by the admitting RN.

4. Review of medical record for Patient #31 on 06/06/12 at approximately 2:00 PM, who at the time of review was admitted to the hospital in the Psychiatric Intake Area (a distinct one room area designated for patient care with seven numbered recliner cots where patients are assigned for patient care), showed the patient was admitted on [DATE] and showed no development of a treatment plan by the admitting RN.

5. Review of medical record for Patient #32 on 06/06/12 at approximately 2:00 PM, who at the time of review was admitted to the hospital in the Psychiatric Intake Area (a distinct one room area designated for patient care with seven numbered recliner cots where patients are assigned for patient care), showed the patient was admitted on [DATE] and showed no development of a treatment plan by the admitting RN.

6. Review of the medical record for Ptient #33 on 06/06/12 at approximately 2:00 PM, who at the time of review was admitted to the hospital in the Psychiatric Intake Area (a distinct one room area designated for patient care with seven numbered recliner cots where patients are assigned for patient care) showed the patient was admitted on [DATE] and showed no development of a treatment plan by the admitting RN.

7. During an interview on 06/06/12 at approximately 1:40 PM, Staff O, an RN who is assigned to the Psychiatric Intake Area and Emergency Department whose primary responsibility is to conduct admission assessments, stated treatment planning is done after they are transferred to the units. Staff O stated the average length of stay for psychiatric patients in the Psychiatric Intake Area prior to being transferred to a psychiatric unit is 3-4 days.

8. During an interview on 06/07/12 at approximately 9:30 AM, Staff AA, RN who is assigned to the Psychiatric Intake Area and Emergency Department whose primary responsibility is to conduct admission assessments, stated that treatment planning is done after they are transferred to the psychiatric units. Staff AA stated that the average length of stays for psychiatric patients in the Psychiatric Intake Area prior to being transferred to a psychiatric unit is 3-4 days.

9. During an interview on 06/07/12 at approximately 2:30 PM, Staff KK who is assigned to provide patient care to psychiatric patients assigned to the emergency department, stated that there is no problem list or treatment plan to follow while the patients are in the ED. Staff KK stated staff do not have patient assignments in the emergency department and that the average length of stay for psychiatric patients who are admitted to the facility but are waiting for a bed in a psychiatric unit is three to four days in the emergency department.

10. During an interview on 06/07/12 at approximately 3:15 PM, Staff LL, a Patient Care Technician (PCT) who is assigned to provide patient care to psychiatric patients assigned to the emergency department, stated that there is no problem list or treatment plan to follow while the patients are admitted and assigned to the emergency department waiting for a psychiatric bed. Staff LL stated that the average length of stay for psychiatric patients who are admitted to the facility but are waiting for a bed in a psychiatric unit is three to four days in the emergency department. Staff LL stated staff do not have patient assignments in the emergency department and that all staff share taking care of the psychiatric patients who are admitted to the emergency department waiting for beds.

11. During an interview on 06/07/12 at approximately 9:00 AM, Staff A, Director of Performance Improvement and Risk Management, stated that treatment planning is expected to begin upon admission for all patients in all areas of the facility.
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, policy review and record review the facility failed to obtain consents for treatment for four (#9, #10, #36, #66) of four current patients and four (#1, #42, #43, #44) of four discharged patients reviewed. This had the potential to affect all patients admitted to this facility. The facility census was 124.

Findings included:

1. Record review of the facility policy titled "Informed Consent" revised 03/11 showed the following direction:
-Purpose: To define the obligations in obtaining and documenting informed consent by physicians and staff to provide patients the opportunity to participate in medical decision making to the fullest extent possible thereby respecting patient autonomy and self-determination and to meet all ethical and legal responsibilities to patients and their families.
-Definitions
Informed Consent: A process that involves the simple, through, objective exchange of the material risks and alternatives to an operation/procedure and the skills of the person who will perform it. Provided in a setting which the patient, or patient representative, may be the final judge of whether to accept or to reject the treatment.
-Policy: All adults have the right to make decisions regarding their treatment and to be provided sufficient information in order to make informed decisions regarding their healthcare. Minors and incompetent adult's rights regarding informed consent will be exercised through their parents or legal representative.
- Registration staff will be responsible for obtaining consent to treat and condition of service for both inpatients and outpatients and covers such therapy/procedure/treatment as physical examinations, routine nursing care, administration of non-investigational/experimental medications and therapies, x-rays without contrast media, and collection of blood and urine for laboratory testing (excluding HIV testing).
- For Behavioral Patients with Legal Guardian/Power of Attorney: Psych [Psychiatric] Intake nursing staff will be responsible for obtaining signatures and/or verbal consent for Behavioral Health patients who have a Responsible Party (Legal Guardian/DPOA). The nursing staff will ensure that the required forms are documented and filed in the patient's medical chart (Conditions of Service/Consent to Treat, Notice of Privacy Practices and Important Message from Medicare).
- The consent must be documented in writing, and where applicable, on the forms provided. The consent should be filled out completely, should be legible and in black ink. The patient's first and last name shall be on the consent form. No abbreviations may be used.

2. Record review of the medical chart of Patient #10 showed that the patient did not sign the Consent for Treatment after admission to the facility on [DATE].

3. Record review of Patient #66's Nursing Admission Assessment - Psychiatry admitted on [DATE] showed that no Consent to Treat was signed

4. Record review of Patient #36's Nursing Admission Assessment - Psychiatry admitted on [DATE] showed that no Consent to Treat was signed.

During an interview on 06/24/12 at 3:35 PM Staff D, Nurse Manager stated that after reviewing the medical charts there were no Consent to Treat signed by the patients (#10, #66 and #36.)

5. Record review for Patient #9 showed the facility failed to obtain a consent for treatment at the time of the patient's admission on 06/01/12.

During an interview on 06/05/12 at 10:04 AM, Staff K, Registered Nurse (RN), Clinical Leader, confirmed the original consent to treat for Patient #9 failed to be signed by the patient.

6. Record review of Patient #1's discharged record showed it did not contain consent to admit and treat.

7. Record review of Patient #42's discharged record showed it did not contain consent to admit and treat.

8. Record review of Patient #43's discharged record showed it did not contain consent to admit and treat.

9. Record review of Patient #44's discharged record showed it did not contain consent to admit and treat.
VIOLATION: PATIENT RIGHTS: ADVANCED DIRECTIVES Tag No: A0132
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interviews, policy and record reviews, the facility failed to determine if three (#2, #6 and #63) of six current patients had established an advanced directive and failed to ensure each patient and or the patients' representative were offered the opportunity to establish an advanced directive. This had the potential to affect all patients admitted to the facility. The facility census was 124.

Findings included:

1. Record review of the facilities policy titled "Advance Directives" revised 2/12, showed the following direction:
-To aid individuals and families in preparation of Advance Directives and to ensure proper communication of patient advance directives among caregivers
-At the time of any inpatient admission to the Hospital, all competent adult patients (over 18 years of age) and emancipated minors will be provided written information concerning the individual's right to make decision concerning medical care and the hospital's policies regarding implementation of advance directives. This information is a component of their patient information packet.
-For patients being admitted from the Emergency Department, the Registration representative will ask if Advance Directives are available when obtaining information and/or consent to treat. Written information will be provided in the form of the inpatient information packet for all admitted patients.
-The Registration Department representative will document on the Conditions of Services Form whether the patient has executed an Advance Directive, and if so, whether the patient brought a copy. If a copy of the advance directive is presented, the copy will be forwarded to the nursing unit with the patient, and shall be made a permanent part of the medical record.
-If the patient does not have an advance directive, an opportunity to prepare an advance directive will be made available upon admission by the Registrar and by the Admitting nurse.

2. During an interview on 06/04/12 at 2:40 PM, Patient #6 stated that staff did not address or offer information regarding advance directives during the admission process.

Review of Patient #6's medical record showed the patient had an Advance Health Care Directive in the chart updated 04/17/12. The Advance Health Care Directive showed the patient desired the following care and treatments:
-Resuscitation Status: If my heart stops or I stop breathing, I would want treatment performed to bring me back to life (Resuscitate).
-Goals: If I am unable to make my own choices due to illness I want ...
Most Function-treat any problem if it can be cured. If not, help me avoid pain and suffering.
-Options: For other wishes if wanted:
-Hospital Admission, for test and treatments: I want;
-Mechanical breathing (breathing by machine with a tube in the throat,
Except for surgery and Cardiopulmonary Resuscitation (CPR: manual restoration of oxygenated blood flow to the brain and heart): I want to try this treatment, but stop if it is not helping;
-Major surgery (for example, cardiac bypass, removing the gallbladder or part of the colon: I want;
-Chronic kidney dialysis (cleaning the blood by machine or fluid passed through the belly): I want;
-Blood transfusion or blood products: I want;
-Artificial nutrition and hydration (given through a tube in the vein or stomach): I want to try this treatment, but stop if it is not helping;
-Simple diagnostic test (blood tests or x-rays): I want;
-Antibiotics (drugs to fight infection): I want.

Review of the patient's Admission Assessment, Invasive/Surgical Procedure Verification & Time Out Checklist showed the following information:
-Admission assessment dated [DATE] showed that staff documented "none" in the Advance Directive section of the assessment.
-Pre-Procedure Verification dated 05/29/12 showed that staff documented by checking the box Do Not Resuscitate (DNR: Does not want CPR if their heart stops or they stop breathing) Status Verified.
-Time Out Verification Checklist dated 05/29/12 at 8:55 AM, showed that staff did not document the DNR Status Verified and left the box blank.
-Pre-Procedure Verification dated 06/01/12 showed that staff documented by checking the box next to DNR Status Verified.
-Time Out Verification Checklist dated 06/01/12 at 9:15 AM, showed that staff documented by checking the box DNR Status Verified.

During an interview on 06/04/12 at 3:40 PM, Staff D Nurse Manager, confirmed that Patient #6 did have an Advance Health Care Directive on the chart and that staff had documented the patient's code status as DNR but the patient did want treatment or at least for staff to try if she needed CPR.

3. Record review of current Patient #63's medical record showed that the Advance Directives portion of the "Conditions of Service/Consent for Treatment" form was checked to indicate that the patient did not have an Advance Directive and that the patient did not bring a copy of an Advance Directive to the hospital. The patient signature line of the form showed, "pt (patient) unable to sign due to medical condition". Review of the patient's admission assessment showed that the patient was confused and disoriented to time and place. There was no indication in the record that the patient was able to appropriately answer whether he did or did not have an Advance Directive or if the patient's family member was contacted to verify that the patient did not have an Advance Directive.

4. Record review of current Patient #2's medical record showed that the Advance Directive portion of the "Conditions of Service/Consent for Treatment" form was checked to indicate that the patient did not have an Advance Directive and that the patient did not bring a copy of the Advance Directive to the hospital. The patient signature line of the form showed, "Patient was unable to sign due to medical condition". Review of the patient's admission assessment showed that the patient was intubated (artificial breathing through a tube inserted though the mouth and into the lungs) and was sedated with Propofol (medication used to sedate patients while they are intubated). There was no indication in the record that the patient was able to answer whether he did or did not have an Advance Directive or if the patient's family member was contacted to verify that the patient did not have an Advance Directive.

5. During an interview on 06/04/12 at 3:25 PM Staff D, Nurse Manager, stated that no documentation of an Advance Directive status in the admission assessment would mean a patient would be treated as a full code (life saving measures such as medications, chest compressions, a tube to assist breathing) in an emergency.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, record review and policy review, the facility failed to:
-Prevent two (#73 and #51) of 13 patients, who were at risk of harm to themselves or others, from eloping from the facility;
-Ensure patients who presented to the Emergency Department (ED) for psychiatric care were continuously monitored until staff no longer considered the patients to be at risk to themselves or others for six (#47,
#51, #54, #56, #57 and #73) of 13 patient records reviewed. This had the potential to affect the safety of patients, staff, and visitors in the ED. The ED has approximately 1200 - 1500 patient visits per month. During the month of May 2012, the ED treated 158 mental health patients;
-Provide a safe environment for suicidal patients by ensuring rooms are free from hanging and strangulation hazards for 31 patient rooms (#301, #302, #303, #304, #305, #306, #307, #309, #310, #311, #312, #313, #314, #315, #316, #317, #318, #320, #322, #324, #326, #402, #403, #405, #407, #409, #412, #413, #414, #416, and #418);
-Ensure the safety of one of nine suicidal patients (#9) who had access to a hospital gown with ties which are looping and hanging hazards;
-Ensure patients were reassessed by staff after a fall in order to implement additional interventions to reduce the risk of further falls for three (#69, #1, and #44) of four discharged patients;
-Include physician ordered observation and precaution levels on the observation rounding sheets as required by policy in 21 (#7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26 and #27) of 21 patients.
The facility census was 124.

Findings included:

1. Record review of the facility's policy titled "Emergency Department - Psychiatric Patients Screening: Mental Health Assessment" revised 03/08, showed direction for Emergency Department (ED) staff to continuously monitor all psychiatric patients and to maintain a safe environment in order to prevent injury to self or others until the patient is determined stable by the ED physician.

Record review of the facility's policy titled "Elopement" revised 02/11, showed direction for the hospital to minimize the potential for elopement from the facility through prompt identification of patients at risk and appropriate interventions by:
-Implementing and maintaining elopement precautions, which includes utilizing 1:1 observation (one staff member is assigned to observe one patient constantly) as appropriate, until the patient is assessed to no longer be at risk;
-Restricting the patient to the unit and the frequency of observation will be determined by nursing assessment and judgment; and
-Evaluating elopement precautions daily.

Further review of the facility policy indicated that a "CODE Green" (elopement process in which the operator is contacted with the last location of the patient and a brief description of the patient, and this information is announced on overhead speakers throughout the hospital for immediate response from all areas) should be initiated for the following patient's elopements: Psychiatry, ED, confused, vulnerable, or if their potential elopement could further compromise their condition.

2. During an interview on 06/05/12 at approximately 4:15 PM, Staff V, ED Director stated that close monitoring of patients who presented with psychiatric complaints, including suicidal or homicidal patients, does not occur and is not documented until an order for the patient's admission is received from the psychiatrist, because it wasn't the ED's practice. Staff V couldn't answer why 15 minute observations weren't necessary for patient safety prior to receiving admission orders.

3. During an interview on 07/13/12 at 8:27 AM, Staff TT, Chief Nursing Officer stated she did not know what "continuous monitoring" of psychiatric patients consisted of, but Staff A, Director of Performance Improvement and Risk Management stated that "continuous monitoring" meant that the patients would be assessed every 15 minutes for safety and that the monitoring would be documented in the patients' record.

4. During an interview on 07/13/12 at 2:57 PM, Staff HH, Medical Director stated that:
-He was able to look into patient rooms from where he sits and see that patients in the ED are "ok";
-He was aware of the required 15 minute observations for psychiatric patients, but "I wonder if the 15 minute observation regulation wasn't meant for an admitted patient" because he "doesn't see the logic behind it";
-If it's (15 minute observation documentation) not on the paper, we can't prove if we did or didn't do it".

5. Record review of discharged Patient #73's medical record showed the patient:
-(MDS) dated [DATE] at 7:55 PM with suicidal ideations and auditory hallucinations "voice tells me to kill myself";
-Was placed (by an ED staff member) in ED room #10, which was a standard ED room;
-Record did not contain evidence that staff continuously monitored the patient, that 15 minute observations were initiated in the ED, or that the patient was identified as an elopement risk;
-Eloped from the ED on 04/29/12 at 3:40 AM;
-Returned (walked) to the ED on 04/29/12 at 5:00 AM;
-Was admitted to psychiatric services on 04/29/12 at 6:00 AM with close observation, assault, suicide, and elopement precautions ordered, but remained in the ED because no beds were available in the psychiatric unit;
-Record did not contain evidence that staff continuously monitored the patient or that 15 minute observations were initiated when the patient returned to the ED, or that the patient was identified as an elopement risk, after he had eloped at 3:40 AM;
-Escalated on 04/29/12 at 3:40 PM to the point that security was requested and the Psychiatrist notified, who ordered the patient to be made involuntary (a process in which the patient is legally prohibited from leaving the facility to ensure his safety);
-Record did not contain evidence that staff continuously monitored the patient, that 15 minute observations were initiated after the patient escalated, that the patient was identified as an elopement risk or that the patient was made involuntary;
-Eloped a second time from the ED on 04/29/12 at 4:20 PM, but a physician and security staff ran after the patient and brought Patient #73 back into the ED;
-Record did not contain evidence that staff continuously monitored the patient, that 15 minute observations were initiated after the patient eloped at 4:20 PM, that the patient was identified as an elopement risk or that the patient was made involuntary;
-Eloped a third time on 04/29/12 at 7:15 PM, when the patient "somehow" got out of a locked room in the ED. Three staff ran after the patient, but were unsuccessful in returning the patient to the ED after he jumped off a ten foot embankment. The facility notified police of the patient's elopement.

Record review of Patient #73's "Visit Information" indicated that the patient had not returned to the facility for care since he eloped on 04/29/12.

Record review of the facility's security log showed:
-An entry dated 04/29/12 indicated that security was notified by radio that Patient #73 had eloped from the ED at approximately 3:29 AM, that a "Code Green" was not initiated by the ED staff (for unknown reasons), and that a search of the grounds did not locate the patient. The report did indicate that the patient returned to the ED at 5:00 AM;
-There was no security report written related to the Patient #73's elopement on 04/29/12 at 4:20 PM;
-A second entry dated 04/29/12 indicated that security was notified by radio ("Code Green" was not initiated) that Patient #73 had eloped at approximately 7:07 PM from a locked room, fled from the facility, and the patient was not able to be returned to the facility.
Both security log reports were sent by Staff WW, Director of Security through email notification on 04/29/12 to Staff A; Staff C, Chief Executive Officer; Staff V, ED Manager and Staff TT, Chief Nursing Officer.

During an interview on 07/13/12 at 8:27 AM, Staff C, CEO and Staff TT, CNO stated that they were unaware of Patient #73's multiple elopements. During the same interview, Staff A, Director of Risk Management stated that she was aware of the patient's multiple elopements when a regulatory survey team identified the elopements during a survey from 06/04/12 through 06/13/12. Staff A added that the facility had not changed their monitoring process of psychiatric patients in the ED to prevent patient elopements, because she didn't realize the elopements were a problem. Both Staff A and Staff TT stated they were waiting for their report from the regulatory survey from June to see what changes needed to be made.

6. Record review of current Patient #51's medical record showed the patient:
-Arrived to the ED on 06/04/12 at 7:07 PM with auditory hallucinations and a suicide plan to cut her wrists;
-Was not placed "in a secured room, none available. Patient in chair in hallway" (Hallway bed #2);
-Was admitted to inpatient psychiatry on 06/05/12 at 3:30 PM (but physically remained in the ED) with orders for Close Observation (15 minute monitoring and documentation of the patient's activity and whereabouts), Suicidal, Seizure, and Fall Precautions and that the patient "may not leave unit unattended";

The record did not contain evidence that staff continuously monitored the patient or that 15 minute observations were initiated while in the ED.

During an interview on 06/07/12 at approximately 1:30 PM, Staff SS, ED Registered Nurse stated that Patient #51 eloped from the ED while he was the primary care nurse, but he didn't see the patient leave the ED because he wasn't in the department. [Staff SS was in another department at the time.] Staff SS added that a staff member from another department saw the patient in a hallway outside of the ED, and saw the patient exit through an employee entrance. Staff SS stated that after approximately five minutes of searching, the patient was found lying underneath a parked car in the facility parking lot. Staff SS stated that staff did not continuously monitor the patient or perform 15 minute observations of the patient.

During an interview on 06/07/12 at 10:45 AM, Staff GG, Security Officer stated that:
-He was the security officer in the ED at the time Patient #51 eloped, but didn't see her leave or know how she got out of the ED;
-One security officer in the ED is not enough to keep the patients and staff safe;
-At times, there are eight to 11 psychiatric patients in the ED at once and that there isn't enough staff in the ED to safely monitor the patients;
-We (security officers) can't monitor the patients to ensure they won't injure themselves or others because we are required to leave the department;
-The security officer staffed in the ED can be gone for up to 45 minutes at a time to assist with other requirements.

7. During a telephone interview on 07/13/12 at 8:45 AM Staff V stated that she was not aware of any elopements from the ED since the survey team exited on 06/13/12. Staff V stated that she would be made aware if elopements occurred.

8. During an interview on 07/13/12 at 9:20 AM, Staff A stated that she verified there were no psychiatric ED patient elopements since 06/07/12, because she reviewed all facility event reports, which are required for elopements, from 06/07/12 to current.

9. During an interview on 07/13/12 at 2:10 PM, Staff WW, Director of Security stated that he notifies Staff A and Staff C by email of any security issue that is reported. Staff WW stated that he also includes any staff member who oversees the department(s) related to the security incident, such as Staff TT and Staff V when a psychiatric patient elopes from the ED.

10. During an interview on 07/13/12 at 9:05 AM Staff UU, ED Charge Nurse, stated that it is not unusual for patients to remain in a hallway bed for their entire stay, sometimes 12 hours or more. Staff UU stated that psychiatric patients are closely monitored, always in view of a staff member and stated, "It's everyone's job to watch".

11. During an interview on 07/13/12 at 9:30 AM Staff SS, RN, stated that psychiatric patients should always be closely monitored, in the line of sight of a staff member, but that practically speaking that is not possible in this ED. Ideally they should be 1 to 1 (patient would have a staff member assigned to monitor that patient only) but that's not possible in this ED.

12. Patient #47 was admitted on [DATE] at 8:20 PM, with homicidal ideations and anger after threatening nursing home staff where he resided. The patient was placed in an ED room with another psychiatric patient, Patient #46. The record did not show staff continuously monitored the patient according to the facility's policy to ensure the patient's safety and the safety of others, and 15 minute observations were not initiated until 06/06/12 at 3:30 PM.

13. Patient #54 came to the ED by ambulance on 06/06/12 at 10:40 AM with depression and suicidal ideations and placed in hallway bed #2. The record did not show staff continuously monitored the patient according to the facility's policy to ensure the patient's safety, and 15 minute observations were not initiated until 06/06/12 at 7:15 PM.

14. Patient #56 came to the ED on 06/06/12 at 11:35 AM, with depression, suicidal ideations, auditory hallucination and self mutilation and staff placed the patient in a hallway bed (#3). The record did not document staff continuously monitored the patient according to the facility's policy to ensure the patient's safety, and 15 minute observations were not initiated until 06/07/12 at 6:15 AM.

15. Patient #57 came into the ED on 06/04/12 at 3:12 PM, with suicidal and homicidal ideations, auditory hallucinations and paranoia after being off psychiatric medications for 60 days. Staff placed the patient in a hallway bed (#2). The record did not show staff continuously monitored the patient according to the facility's policy to ensure the patient's safety, and 15 minute observations were not initiated by staff until 06/05/12 at 5:45 PM.

16. During an interview on 06/07/12 at 10:40 AM, Staff V, ED Director stated that she felt the psychiatric patients were protected from self harm or harming others while in the ED because "we have security here 24/7".

17. During an interview on 06/06/12 at 3:50 PM, Staff FF, Security Officer, stated that she doesn't feel the psychiatric patients are monitored closely enough for their safety, especially when security is required to leave the ED.

18. Observation on 06/05/12 at 2:35 PM showed ten standard ED rooms which contained several items that could be used to cause self injury, such as:
-Cloth gowns with ties which could be used to create a ligature, greater than two feet in length
-Monitor cable cords, which could be used to create a ligature, greater than three feet in length;
-Electrical cords, which could be used to create a ligature greater than two feet in length;
-A medical cleansing solution on the counter, which could be toxic if drank;
-Sink handles, approximately 44 inches from the floor that could be used to attach a ligature;
-A standard emergency cart, approximately 30 inches from the floor, with side rail and bars that could be used to attach a ligature;
-A trash can, approximately 36 inches tall, contained a plastic bag that could be used to create a ligature or used for suffocation.

19. Observation on 06/06/12 at 2:30 PM of the ED bathroom showed:
-The toilet contained piping approximately 30 inches from the floor that could be used to attach a ligature;
-A trash can, approximately 30 inches tall, contained a plastic bag that could be used to create a ligature or for suffocation;
-The sink contained two handles, approximately 40 inches from the floor, which could be used to attach a ligature;
-A wooden door contained a metal coat hook on the back of the door which could be used to attach a ligature and only opened inward, which could be locked and/or barricaded.

20. During an interview on 06/06/12 at 3:05 PM, Staff V, stated that:
-Any patient, including suicidal patients, could be placed in a standard ED room;
-Any patient in the ED, including suicidal patients, has access and ability to use the ED bathroom;
-Patients, including suicidal patients, are not supervised while using the bathroom;
-During the facility's last regulatory survey, the plastic trash can liners were found to be a safety concern in rooms with psychiatric patients so the facility changed from using plastic to paper liners;
-Paper liners didn't work in the ED trash cans because they would get wet and the trash would fall through the bag, so they stopped using them and returned to using plastic liners.

21. Record review of the patient census for 06/05/12 showed:
-The third floor female psychiatric unit had nine patients on suicide precautions (SP) and ten patients on assault precautions (AP);
-The third floor male psychiatric unit had six patients on SP and 13 patients on AP;
-The fourth floor co-ed psychiatric unit had nine patients on SP and 14 patients on AP.

22. Recognized standards of practice for a psychiatric facility include:
The Veteran's Health Administration (VHA) National Center for Patient Safety formed a national committee that developed The Environment of Care Checklist for the purpose of reducing environmental factors that contribute to inpatient suicides, suicide attempts, and other self-injurious behaviors. This initiative is consistent with the Joint Commission patient safety goals as well as the current literature on prevention of suicidal behaviors (Suicide Prevention Strategies: A systematic review. The Journal of the American Medical Association, (JAMA), 2005, v 294, 2064 -2074).

The Joint Commission (TJC), formerly the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), is a United States-based not-for-profit organization. The Joint Commission accredits over 19,000 health care organizations and programs in the United States.

JAMA, published continuously since 1883, is an international peer-reviewed general medical journal published 48 times per year. JAMA is the most widely circulated medical journal in the world.

The VHA, TJC and JAMA have all established accepted standards of practice for psychiatric inpatient facilities in the United States.

The VHA committee developed the Mental Health Environment of Care Checklist (MHEOCC) with the goal to prospectively identify and eliminate environmental risks for inpatient suicide and suicide attempts.
The following is one item included on the MHEOCC to reduce environmental risks for inpatient suicide:
- Faucets and spouts in sinks and showers should be an institutional type. Institutional faucets will not provide an anchor point for hanging.

Record review of the facility's policy titled, "Patient Rights and Responsibilities" dated 4/12, showed that patient's have the right to be cared for in a safe, clean and private environment.

Record review of the facility's policy titled,"Psychiatric Rights of All Patients" dated 11/09, showed patients have the right to safe and sanitary housing.

Record review of the facility's policy titled, "Room Checks and Environmental Surveillance", showed routine environmental surveillance is conducted on an ongoing basis and documented at change of shift.
-The purpose of the surveillance is to provide patient and staff safety on the inpatient units.
-Surveillance includes each patient room including the bathrooms and showers.
-Any discovered safety threat should be immediately reported and repaired.

23. Observation on the Adult Psychiatric Units on 06/04/12 at approximately 2:20 PM through 4:00 PM while accompanied by Staff J, Manager of Adult and Geriatric Psychiatric Services, showed water faucets in patient rooms that provided looping hazards and ligature points (points of hanging hazards for suicidal persons) and heavy plastic (non-breathable) shower curtains hanging in the shower stalls which are a strangulation hazard for suicidal patients. Rooms observed included #301, #302, #303, #304, #305, #306, #307, #309, #310, #311, #312, #313, #314, #315, #316, #317, #318, #320, #322, #322, #324, #326, #402, #403, #405, #407, #409, #412, #413, #414, #416, and #418. All areas observed were assigned patients and all areas observed were assessable to all patients.

24. During an interview on 06/04/12 Staff J Manager of Adult and Geriatric Psychiatric Services at 2:40 PM, stated that the faucets are hanging hazards for suicidal patients and that all suicidal patients do have access to the faucets and shower curtains. Staff J stated that the patient's on suicide precautions are allowed alone in their rooms with the doors closed and that they are placed in whatever room is available at the time.

25. During an interview on 06/04/12 at 5:20 PM, Staff A, Performance Improvement and Risk Management Director and Staff C, Chief Executive Officer, stated all patient care areas are to be safe and clean.

26. During an interview on 06/05/12 at 11:05 AM, while observing patient room's in the Adult Psychiatric Unit, Staff J Manager of Adult and Geriatric Psychiatric Services stated that all of the sink faucets in patient rooms in the Psychiatric Units on the 3rd and 4th floors have similar faucets and that they all have water control knobs which have ligature points at the space between the base of the water control handle and point of attachment to the base of the faucet. Staff J stated that the water faucets have not been replaced in many years.

27. Observation of room #317 on 06/04/12 at 4:00 PM showed missing, cracked, loose broken porcelain tiles. During an interview at the time of the observation, Staff K, Clinical Leader Psychiatric Services, stated that porcelain tiles which are missing, broken, cracked and loose from wall and floor surfaces are hazards to suicidal patients who may want to harm themselves or that the tiles sharp edges may be used to intentionally harm others. Staff K stated that the missing, cracked, broken and loose tile in room #317 is dangerous and that the current patient (#26) reported the tile has been that way their entire admission (approximately 60 days.)

28. During an interview on 06/05/12 at 9:24 AM, Staff J Manager of Adult and Geriatric Psychiatric Services, stated that each shift (day shift, evening shift and night shift) is responsible for completing and documenting the "Shift Change Safety Checklist" for the psychiatric units. The staff should be evaluating the environment for the psychiatric patients to ensure a safe environment and reporting any safety issues so they can be corrected. Staff J stated that she did not have an answer as to why the staff failed to identify and report environmental safety hazards such as missing ceramic wall tiles that exposed sharp edges of the surrounding tile, parts of walls that were missing which exposed metal trim and metal tubing of which the patient could use to cut themselves or others and crumbling drywall that patients could ingest.

29. Record review of the "Shift Change Safety Checklist," documentation showed:
-An unidentified Psychiatric Unit on 06/04/12, day shift, (untimed), showed a blank form with no documentation by staff;
-4th Floor, Psychiatric Unit, 06/04/12, 3:00 PM, day shift, documented checking all patient areas including patient rooms for unsafe conditions and/or contraband and none were identified;
-4th Floor, Psychiatric Unit, 06/04/12, 11:15 PM, evening shift, documented checking all patient areas including patient rooms for unsafe conditions and/or contraband and none were identified;
-4th Floor, Psychiatric Unit, 06/04/12, night shift, documented the safety check date and time as 06/05/12 at 5:00 AM, but failed to document doing a safety check, the form is blank other than the date/time and unit name;
-Three East and Three West Floor, Psychiatric Unit, on 06/04/12, night shift, documented checking all patient areas including patient rooms for unsafe conditions and/or contraband and none were identified on 06/05/12 at 1:15 AM;
-Three West, Psychiatric Unit, 06/05/12, the time is not documented, day shift, documented checking all patient areas including patient rooms for unsafe conditions and/or contraband and none were identified;
-Three East, Psychiatric Unit, 06/05/12, 10:30 PM, evening shift, documented checking all patient areas including patient rooms for unsafe conditions and/or contraband and none were identified;
-Three East and Three West, Psychiatric Units, 06/05/12, night shift, documented checking all patient areas including patient rooms for unsafe conditions and/or contraband and none were identified on 06/06/12 at 3:05 AM;
-4th Floor, Psychiatric Unit, 06/05/12, 7:30 AM, day shift, documented checking all patient areas including patient rooms for unsafe conditions and/or contraband and none were identified;
-4th Floor, Psychiatric Unit, 06/05/12, 11:15 PM, evening shift, documented checking all patient areas including patient rooms for unsafe conditions and/or contraband and none were identified;
-4th Floor, Psychiatric Unit, 06/05/12, night shift, documented checking all patient areas including patient rooms for unsafe conditions and/or contraband and none were identified on 06/06/12 at 5:30 AM;
- The facility failed to provide the "Shift Change Safety Checklist" for the Geriatric Psychiatric Unit during the survey.

30. Record review of Safety Inspections reports under the direction of Staff QQ, Plant Operations Manager, showed the following safety inspection results for the first quarter of 2012:
-03/28/12, safety inspection report of 4th Floor Psychiatric Unit;
-04/17/12, safety inspection report of 3-East and 3-West Psychiatric Units; and both reports failed to include wall damage identified during the survey in which exposed metal trim and exposed metal tubing, and broken ceramic wall tile presented a cutting hazard to patients either by cutting themselves or other patients.

31. During an interview on 06/07/12 at 10:20 AM, Staff QQ, Director of Plant Operations stated that he was not aware of the wall damage with missing drywall, exposed metal trim, exposed metal tubing, and broken ceramic wall tile in the psychiatric units. He stated he depends on the safety reports he received to be informed of the condition and safety of the building and further stated he did not walk through the building and check on the safety of the environment himself. He stated during staff orientation all staff are educated to immediately notify a charge nurse of any safety concerns that need to be repaired by plant operations. In addition, he stated that he supervises the housekeeping staff and they are to report building safety issues to him so repairs can be made. He stated he had not been aware of any patient safety concerns that were identified as a result of the survey. He stated the building damage should have been reported to his department so the repairs could have been made. He stated he did not have an answer as to why building safety concerns that posed a threat to patient safety failed to be reported to him. Staff QQ failed to produce documented evidence that the plant operations department had received requests for building repairs for the first quarter of 2012 regarding the psychiatric units as related to patient safety hazards identified by the survey team.

32. Review of the facility policy titled, "Fall Risk Precautions; Post Fall Management" revised 01/2011 showed the following direction:
-Assess for any injury, (i.e. abrasion, contusion, laceration, fracture, head injury) including change in ROM (Range of Motion, arms and legs can move freely) and/or pain.

33. Review of the discharged medical record for Patient #69 showed the patient entered the facility on 03/02/12. Staff assessed the patient as a high fall risk on admission.

Review of the medical record showed documentation of a fall on 03/03/12 at 6:45 AM and a notation in the Nurses Notes showed that the patient had a bruise on her left hip. There was no documentation of an assessment of the patient for an injury after the fall. The patient's family visited and requested an x-ray be taken.

Review of the x-ray report on 03/03/12 which was ordered by the physician at 3:50 PM (approximately 8 hours after the patient had fallen)showed the patient had a fracture of the left hip. The care plan did include interventions such as call light within reach, yellow non slip socks and assist of staff but the staff did not update the care plan after the fall with additional interventions put in place to prevent further falls and/or injuries.

34. During an interview on 06/05/12 Staff D, Nurse Manager, stated that after a fall the patient should be assessed by the nurse for physical injury including head injury or changes in Range of Motion.

35. Record review of Patient #1's discharged record showed that the patient entered the facility on 02/16/12 for complaints of chronic paranoid schizophrenia.

Review of the patient's medical record showed the following information:
-Staff documented on the Nursing Admission Assessment 02/16/12 -Psychiatry a fall risk score of 21 (a score of greater than five is a high fall risk)
-Staff documented on the Fall Risk Assessment Form dated 02/24/12 a fall risk score of 17.
-Staff documented on the Multidisciplinary Master Treatment Plan dated 02/16/12 Fall Precautions-Yes.

Review of the patient's Multidisciplinary Treatment Plan Potential for Injury Related to Fall Risk dated 02/16/12 showed the following information:
Short Term Goals:
-Utilize two methods to reduce risk of falls by 02/23/12;
-No falls every shift by 02/23/12.
Interventions:
-Nursing will complete fall risk assessment on admission and daily.
-Nursing will provide wheelchair for mobility.
-Nursing will teach patient methods to reduce risk of falls.
-Nursing will implement fall prevention protocol per assessed risk.
-Reduce environmental hazards.

Record review of the patient's Multidisciplinary Progress Notes showed the following information:
-Staff documented on 02/25/12 at 7:42 AM; Found on floor sitting on buttocks fully dressed in scrubs without non-skid slippers in use. Vital signs stable (VSS). Denies complaints of pain or discomfort. Nursing supervisor, nurse practitioner and legal guardian notified.
-Staff documented on 03/05/12 at 5:34 PM, Patient standing and fell in multipurpose room landing on right knee. Before fall, tonic clonic seizure (seizure that affects the entire brain) noted. VSS. Nurse Practitioner notified and message left with legal guardian.
Staff did not document assessment for injury post fall on 02/25/12 or 03/05/12 as directed in their policy or reassessment of the patient to implement additional interventions to reduce the risk of further falls.

36. Review of Patient #44's discharged record showed that the patient entered to the facility on [DATE] with complaints of substance induced mood disorder.

Record review of the patient's Physician Orders showed on 04/13/12 at 11:30 PM, the physician ordered fall precautions

Review of the patient's medical record showed the following information:
-Staff documented on the Nursing Admission Assessment-Psychiatry dated 04/13/12 a fall risk score of zero (a score of greater than five is a high fall risk)
-Staff documented on the Multidisciplinary Master Treatment Plan dated 04/14/12 Fall Precautions-Yes.

Review of the patient's Multidisciplinary Treatment Plan Potential for Injury Related to Fall Risk dated 04/17/12 showed the following information:
Short Term Goals:
-Identify two methods to reduce risk of falls by 04/19/12.
-Utilize two methods to reduce risk of falls by 04/19/12.
-No injury every shift by 04/19/12.
-No falls every shift by 04/19/12.
Interventions:
-Nursing will complete fall risk assessment on admission and daily.
-Nursing will assist to chair transfer or ambulate.
-Nursing will implement fall prevention protocol per assessed risk.

Review of the patient's Multidisciplinary Progress Note showed the following information:
-Staff documented on 04/17/12 at 12:20 AM, Patient fell shortly after shift change at approximately 11:35 PM. fell at doorway trying to go to the bathroom. Patient has 2 by 1 centimeter (cm) hematoma (localized collection of blood outside the blood vessels) just above left eye. No break in skin and no complaints of pain or discomfort. Physician called and orders received. Patient to start neuro checks and CT scan of the head. Patient alert and oriented time
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0208
Based on record review and interview the facility failed to:
-Document training and competency for the use of patient seclusion at the time of hire for four (XX, YY, ZZ, and AAA) of four registered nurse staff;
-Document training and competency for the use of patient restraints at the time of hire for two (XX and YY) of four registered nurse staff. The facility census was 124.

Findings included:

1. Record review of an undated document titled "Restraint Application" showed that the staff shall demonstrate proper application of restraints initially and with yearly recertification.

Record review of personnel, orientation and educational records showed the following:
-Staff XX, YY, ZZ and AAA failed to have documented evidence of patient seclusion training and competency at time of hire; and
-Staff XX and YY failed to have documented evidence of patient restraint training and competency at time of hire.

2. During an interview on 06/06/12 at 3:00 PM, Staff BBB, Education Coordinator, confirmed the facility failed to have documented evidence of patient seclusion training and competency for staff at time of hire and documented evidence of patient restraint training and competency at time of hire. Staff BBB stated there is not a seclusion competency, but the seclusion policy is reviewed with newly hired nurses. Staff BBB stated at the annual facility training the nurses do complete a competency for restraints, but a competency for restraints is not documented at time of hire.