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.

EASTERN NEW MEXICO MEDICAL CENTER 405 W COUNTRY CLUB ROAD ROSWELL, NM 88201 April 22, 2015
VIOLATION: QAPI PERFORMANCE IMPROVEMENT PROJECTS Tag No: A0297
Based on review and interview, the hospital failed to reduce medication errors, a performance improvement project, in the Emergency Department and the inpatient Behavioral Unit over 15 months from 01/14 to 03/15. The hospital also failed to perform a root cause analysis on a sentinel event, an unexpected occurrence involving death. These failures exposed patients to potential harm from medication errors and unresolved, identified problems. The findings are:

A. Record review of the facility's Performance Dashboard indicates the medication variance (errors) had not changed from 01/14 to 03/15 despite an ongoing improvement project. For nine of 15 months during this period, including the first three months of 2015, 4 or more (adjusted per 1000 days) medication errors occurred per month. The raw numbers of errors were respectively as follows: for 01/15, 12 errors, for 02/15, 7 errors, and for 03/15, 13 errors. Each error was a wrong patient or wrong medication, the potentially worst scenario for medication errors.

B. During interview on 04/16/15 at 3:00 pm, the Risk Manager and Director of Quality confirmed that the medication errors continued to be a serious concern despite projects by both Nursing and the Pharmacy over the past 15 months (2014 and 2015 to date). "The nurses on [the behavioral unit] and the [emergency department] continue to make errors."

C. During interview on 04/16/15 at 3:10 pm, the Pharmacy Director was asked about the medication errors. She stated, "We have tried different tracking and monitoring methods on errors. We feel we are identifying all the errors but I have had to work more closely with nursing to educate the nurses we have identified. I have recently asked our pharmacists to spend more time with the nurses to solve the problems."

D. Record review of Patient #23's medical record indicated a death on 01/19/15 some time after placement of a new pacemaker placed on 09/03/14. The cause of death on was suspected to be sepsis (global infection).
1. The Risk Manager and Quality Director were asked to present the Root Cause Analysis (RCA) on the sentinel event for Patient #23. They replied that no RCA had been performed because "it was going to peer review first."
VIOLATION: PATIENT RIGHTS Tag No: A0115
This is a repeat condition-level deficiency from a complaint survey on 01/30/15 and a full hospital validation survey completed on 11/04/11.

Based on interview, observation and record review, it was determined that the hospital failed to (1) ensure that patients who were served at the outpatient laboratory were provided a copy of their patient rights for 2 (Pt #74 and 75) of 2 (Pt #74 and 75) random patients receiving care at the outpatient laboratory (refer to A 117); and (2) develop, build and maintain safe and/or seclusion rooms in the Emergency Department (ED) for the holding of patients with behavioral and/or mental health issues who were at risk for either harming themselves or others. The facility ED is a triage unit for both the geographic region and the acute inpatient behavioral unit (refer to A 144). The cumulative effect of these systemic practices resulted in the hospital's inability to ensure that the patients were fully informed of their rights and that the patients received care in a safe environment.
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
Based on interview and observation, the hospital failed to ensure that patients who were served at the outpatient laboratory were provided a copy of their patient rights for 2 (Pt #74 and 75) of 2 (Pt #74 and 75) random patients receiving care at the outpatient laboratory. This deficient practice could result in patients not being informed of their patient rights. The findings are:
A. On 04/15/15 at 8:15 am, during interview, Staff #28 stated that every patient is provided a folder that includes a copy of the patient rights and hospital information.
B. On 04/15/15 at 8:17 am, during observation, Patient #74 was seen sitting at a blood draw station having blood drawn. The folder was not with the patient. At 8:18 am, Patient #74 was observed leaving the outpatient laboratory without a hospital folder.
C. On 04/15/15 at 8:21 am, during interview, Patient #75 stated that she did not receive any information from the hospital regarding her rights. Patient #75 reported having signed in and had her blood drawn but was not provided documentation upon her arrival or departure from the outpatient laboratory regarding patient rights.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observation, record reviews and interview, the hospital failed to maintain a safe environment in the facility's Emergency Department (ED) and the inpatient behavioral unit for patients with behavioral and/or mental health issues who were at risk at either harming themselves or others. The hospital failed to maintain safe and/or seclusion rooms in the ED (which is a triage unit for both the geographical region and the acute inpatient behavioral unit) and in various rooms that are utilized by patients in the behavior unit. The hospital also failed to have enough trained staff in crisis prevention intervention (CPI) on the behavioral unit. These deficient practices exposed all patients with behavioral and/or mental health issues to the potential of physical harm. The findings are:

A. During observation on 04/13/15 at 9:05 am, the following was seen in the ED for both exam rooms #5 and #18, that were designated by the ED staff as safe and/or seclusion rooms:
1. The rooms each had a metal sink directly under an air conditioning vent (grill) with openings that were approximately 1 inch by 1 inch. (A patient could stand on the sink to access the vent grill.)
2. Two electrical sockets were on opposite walls, uncovered. (The sockets could be shorted.)
3. A single bed consisting of a metal frame wrapped with a wood frame was in the middle of the floor in each room. The wood could easily be broken creating potential tools or weapons. The beds in each ED room were unsecured and were easily moved.
4. A keypad for the electronic door lock was located just inside the door. It protruded just over an inch from the wall. A shoestring could be attached to the inside door handle and the keypad, thereby blocking access to the room from the outside.

B. On 04/13/15 at 9:15 am, during interview regarding triage, ED physician #1 was asked how often the ED assigns Level I (potential harm to self and others) to behavioral cases. He responded, "Almost daily." When asked if he thought the rooms being used as "safe rooms" or "seclusion rooms" were appropriate, he responded, "they're what we have." When asked if he would prefer dedicated rooms that fulfill the criteria for both "safe" and/or "seclusion," he responded, "sure."

C. On 04/15/15 at 10:05 am, during observation, in the ED the following was observed in exam rooms #5 and #18:
1. The keypad just inside each door was gone.
2. The metal and wood frame beds were gone, both replaced by a transport cart.

D. Record review of the facility's policy titled "Suicide Risk/Behavioral Disorder Assessment" dated 08/10 and revised on 08/11 and 09/11 the policy did not define "safe." The policy did not describe when "safe" was appropriate for the needs of the patient, or how to direct the staff achieve it. The policy did not define a seclusion room, describe when it was appropriate, or direct how the staff to achieve it.

E. Record review of the facility quality reports indicated only "restraint episodes per 1000 patients broken down by unit." Use of ED exam rooms as "safe" or "seclusion" were not tracked by the ED or in the quality data.

F. Record review of the ED list of patients reported by the facility that had been placed into exam rooms #5 and #18 from January 2015 through March 2015 for behavioral reasons revealed twenty-two different patients had been placed in these rooms due to behavioral reasons.

G. Record review of the facilities policy/procedure titled "Restraint and Seclusion" dated 03/07 and revised on 02/15 indicated no definitions of a "safe" room or a "seclusion" room. Nor were any specifications for such rooms contained in the document.

H. On 04/15/15 between 8:30 am and 10:30 am in the inpatient behavioral unit the surveyor, accompanied by the Clinical Director, observed the following:
1. During observation the seclusion bathroom door had a latch on the inside, which a sheet or rope could be tied against the toilet and be secured from the inside. There was a light fixture above the bed in which the cover is made of hard plastic that was not flush which can be broken and used as weapons.
2. During observation in room #614 the following was found: drawers in dressers could be removed and used as weapons against staff or other patients. There was a plastic paper towel dispenser and soap dispenser by the sink, both flimsy and could be broken and used as weapons. Sprinkler heads were not recessed into the ceiling. The bed was wrapped in a wood frame which can be broken. Doors had pieces of wood veneer coming apart and away from the solid core door. The bathroom door had regular hinges which can be used to hang sheets from and had the potential for patients to hurt themselves.
3. During interview on 04/15/15 at 9:15 am, the Program Director confirmed that room #614 has the same fixtures as the other rooms on the unit.
4. During observation, one of two showers in the East wing had mold growing in the shower head and there were sharp edges on the grab bars.
5. During observation in the "break room," three of the chairs were loosely attached to the floor and had the potential to be easily broken and used as weapons. One of the two-person seats had a loose panel which could be removed and used as a weapon. Tables were secured to the floor with thin "L" shape braces which were not completely stable.
5. During observation, the "lunch room" had tables secured in the same manner as the break room. The middle table could be easily lifted and used as a barricade.
6. Patients were observed during meals taking trays with plastic utensils into their rooms.
7. During interview on 04/15/15 at 9:30 am, the Clinical Director confirmed that the staff do not monitor the eating utensils that the patients are using.
8. During a tour of the smoking area for the behavioral unit, the following areas of concern were observed:
a. The area did not have a video monitoring system.
b. The metal picnic table could be lifted and placed against the door to block access to the smoking area.
c. The area had multiple places to hide pills and contraband.
9. During interview on 04/15/15 at 9.40 am, the Clinical Director stated that one staff member might take out 4 or 5 patients out to the smoking area at one time. When asked, she confirmed that this might not be a safe ratio for the patients or the staff member. When asked, she confirmed there is no video monitoring system, that the metal picnic table could be placed against the door blocking access, and there are many places to hide contraband.
10. During observation of the behavioral health unit, the patients were not being scanned with the medication computer's scanner when given medication. It was further observed that the patient's mouth was not checked to see if medication was being "cheeked."
11. During observation on 04/15/15 at 9:45 am, there were two staff in the snack room with the door propped open to pass snacks. The drawers had several random items, coffee grinds among them, that could create the potential for an insect infestation. During interview, the Clinical Director stated that there was an incident where a patient took a Coke can from the snack room and made comments to staff later about wanting to cut herself with the broken can.

I. During interview on 04/16/15 at 9:40 am, Tech #1 stated she had completed CPI training in January, and that the training lasted about 5 hours. Tech #1 further stated that around the end of January, a female tech had been assaulted by a patient in the unit. The tech was told by unit nurse to continue working and was not allowed to go home. The tech that was assaulted at the time was new and was the only one working on the floor that evening. When asked what the tech to patient ratio was, Tech #1 stated that the ratio was 2 to 25 often, seldom 3 to 25 and the nurse to patient ratio was typically 3 to 25. Tech #1 stated that they were feeling unsafe in the unit due to staffing patterns and lack of training.

J. During interview on 04/16/15 at 9:50 am,Tech #2 was asked about staffing ratios. He stated that 4 techs would be ideal but typically it is really 1 tech per every 12 to 13 patients. There are situations where a tech may be required to provide 1:1 care while attending to other patients as well.

K. During interview on 04/16/15 at 10:13 am,Tech #3 stated that the typical staff to patient ratio is 3:25 / 2:25 on average. Tech #3 stated that staff are hired with little or no formal training. Tech #3 also stated that at one point a tech was working the unit alone at night for about 1.5 months. Tech #3 did not disclose name of the person who worked alone. Tech #3 reported feeling uncomfortable giving names during the interview.

L. During interview on 04/16/15 at 10:38 am, Tech #4 stated that the typical staff to patient ratio is 2 to 25 or 1 to 25. Tech #4 added that there is little to no communication or teamwork between the nurses and techs, and that nurses are not expected to do much, other than pass medications. Tech #4 reported having very little time for meal breaks and staff often eat while working.

M. During interview on 04/16/15 at 11:05 am, RN #1 stated that they did not remember being trained to work in the unit. RN #1 reported receiving orientation training and computer training at the start of employment, but did not receive training on the unit until recently. RN #1 stated that staffing should be increased and trained. RN #1 also reported that a couple of weeks ago a patient had a lighter and cigarettes in her room. RN #1 added that this patient had previously exhibited self-injurious behavior.

N. During interview on 04/16/15 at 11:16 am, RN #2 stated that the RNs need to help with tech duties. RN #2 is a recent nursing graduate who had been tasked with charge nurse duties and does not feel was adequately trained for the charge nurse position. RN #2 stated that there has been too much information given in a short period of time.

O. During interview on 04/17/15 at 4:40 am, Tech #5 stated that she worked alone for 4 days straight. One of the evenings, Tech #5 was assaulted by a patient. She could not remember the date but that it occurred in late February. Tech #5 reported being hit on right side of her face near the eye. She was told by the charge nurse that she could not use ice and that she had to return back to work. The charge nurse who was present at the time of the assault was a traveler but was gone now. Tech #5 also stated that the nurses come out of the nurse's station only to pass medications. Tech #5 stated that there needs to be better communication and better group therapy for patients. Tech #5 reported that the staffing ratio is typically 2:25 and sometimes it is 3:25.

P. During interview on 04/17/15 at 5:12 am, Tech #6 stated that there are typically 2-3 techs working on the floor and believes that more staff are needed.

Q. During interview on 04/17/15 at 5:21 am, Sitter #1 stated that sitters receive no training for the behavioral unit. Sitter #1 stated that she did receive CPI training at the start of employment during orientation but has not been recertified. Sitter #1 stated that she has worked throughout the hospital as a sitter in all units.

R. During interview on 04/17/15 at 5:30 am, Sitter #2 stated that she did not receive any training for being a sitter on the behavioral unit. Sitter #2 stated that she did not receive CPI training prior to starting on the unit. Sitter #2 added that rules keep changing on an ongoing basis and believes that there is a lack of stability. Sitter #2 reports that typically there are 2 techs that work the night shift.

S. During interview on 04/17/15 at 5:45 am, RN #3 stated that employees lack training and there is little communication. RN #3 also stated that there is a lack of communiction between the front line staff and the administration; threats of termination come from supervisory and administrative personnel when the front line staff ask questions.

T. During interview on 04/17/15 at 6:07 am, RN #4 stated that there are staffing concerns as the unit is constantly short staffed. RN #4 stated that the hospital is continually bringing in nurses from other units to help for coverage, but there is no training involved.

U. During interview on 04/17/15 at 6:20 am, RN #5 stated that staffing is often inadequate.

V. During interview on 04/17/15 at 6:30 am, RN #6 stated that she was from another unit (Medical-Surgical), but floats to the behavioral health unit to help. RN #6 stated that she was not CPI trained at the time. When asked, RN #6 stated that she did not receive any formal training to work in the behavioral health unit.

W. During interview on 04/17/15 at 6:41 am, the Clinical Director reported that staffing patterns need to improve. The Clinical Director stated that she was not currently CPI trained.

X. During interview on 04/17/15 at 7:22 am, the Program Director stated that he is not currently certified in CPI and has not received any training or orientation for the position. The Program Director was provided paper tests by administration to be completed at his own pace. The Program Director stated that more training and mentoring is needed for the unit. The Program Director stated that staff do not work on the floor unless they are CPI trained.

Y. During interview on 04/17/15 at 8:40 am, the Clinical Director confirmed that staff do not account for the eating utensils used by the patient on the behavioral unit and stated, "That's something we need to work on."

Z. During interview on 04/20/15 at 1:55 pm, Social Worker (SW) #1 stated that the unit is short staffed fairly often and there is very little training.

AA. During interview on 04/20/15 at 2:43 pm, Tech #7 stated that training only involves monitoring duties and the documentation process for monitored viewing. Tech #7 stated that she had not received any other training pertaining to the patients on the unit.

BB. During interview on 04/20/15 at 4:15 pm, Tech #8 stated that he is a CPI instructor for the hospital. Tech #8 was asked what the difference was between a one-year and a two-year certification for CPI. Tech #8 stated that he did not know that there was a difference. Tech #8 reported that there has been a big turnover in staff on the unit.

CC. During interview on 04/20/15 at 4:35 pm, RN #8 stated that he has worked on the behavioral health unit 2-3 times but that his primary duties are on another unit. RN #8 has received orientation, training on intake and charting and that he is currently scheduled to attend CPI training in April.

DD. During interview on 04/20/15 at 4:48 pm, RN #10 stated that she received the first half of CPI training but did not receive the other half due to her pregnancy. RN #10 stated that she is scheduled to attend the second part of training the week of the survey. RN #10 stated that there are typically 3 staff (nurses and techs) to 25 patients.

EE. During interview on 04/21/15 at 2:30 pm, the CPI training instructor stated that the first half of the day is classroom training.

FF. During observation on 04/21/15 at 2:35 pm, the Instructor began with the physical releases and placement of restraints. Seven (7) physical skills were taught within an hour and a half. Most, if not all of the participants, were observed having difficulty with maintaining the proper stance and balance as well as appropriate body mechanics. Participants were observed as being unstable as they were executing the skills. They asked their instructor why it felt unnatural, to which he replied, "It will happen."

GG. During interview on 04/21/15 at 4:00 pm, the CPI instructor was asked if it was common to teach so many physical skills at once. He replied, "The hospital used to have a two-year certification but recently adopted a one-year certification period for CPI." He also confirmed that there was no difference in the length of training for Basic CPI and for Advanced CPI.
VIOLATION: QAPI Tag No: A0263
This is a repeat condition-level deficiency from a full hospital validation survey completed on 11/04/11.

Based on record review and interview, hospital failed to ensure that the facility was in compliance with the Condition of Participation for Quality Assessment & Performance Improvement (QAPI). The hospital failed to show measurable improvement in reducing medication errors in the Emergency Department and on the Behavioral Unit. The hospital's QAPI program failed to perform a root cause analysis on a sentinel event, an unexpected occurrence involving death. These deficient practices have the likelihood to diminish patient care and increase medical errors hospital-wide (refer to A 297). The hospital failed to separately break out data for the outpatient laboratory and the outpatient cardiac-pulmonary clinics in the QAPI data. The mismanagement of the data could affect the quality of patient care (refer to A 308).
VIOLATION: NURSING SERVICES Tag No: A0385
Based on observations and staff interviews, the hospital failed to ensure that nursing services provided adequate supervision and trained staff in crisis prevention intervention (CPI) on the acute inpatient behavioral unit. This deficient practice exposed all patients to potential harm from incompetent staff (refer to A 392).

Based on observation, policy review and interview, the hospital failed to properly administer medications for 3 (Pt #31, 32 and 34) of 8 (Pt #28, 30, 31, 32, 33, 34, 35, and 38) sampled patients observed during medication administration (medication pass). This deficient practice could lead to the wrong medication being administered to the wrong patient (refer to A 405).

The cumulative effect of patient's at risk for medication safety resulted in Immediate Jeopardy (IJ) to the health and safety of patients. The Administrator and the Interim Chief Nursing Officer were informed on 04/14/15 at 5:30 pm that an IJ situation had been identified.

On 04/15/15 at 9:00 am, after submission of an acceptable plan of removal and the demonstration of compliance on 04/15/15, the Administrator and Interim Chief Nursing Officer were informed that the IJ had been removed.

The cumulative effect of these deficiencies resulted in noncompliance with the Nursing Services Condition of Participation.
VIOLATION: GOVERNING BODY Tag No: A0043
Based on document review, record reviews, observations, and interview, the hospital failed to have an effective governing body that was responsible for the conduct of the hospital as an institution. The Governing Body failed to ensure that the hospital was in compliance with acute care hospital regulations, and this failure has the likelihood to compromise patient care.

A. This is a repeat condition-level deficiency from a complaint survey on 01/30/15.

Based on interview, observation and record review, it was determined that the hospital failed to do the following:
1. Ensure that patients who were served at the outpatient laboratory were provided a copy of their patient rights for 2 (Pt #74 and 75) of 2 (Pt #74 and 75) random patients receiving care at the outpatient laboratory (refer to A 117).
2. Develop, build and maintain safe and/or seclusion rooms in the Emergency Department (ED) for the holding of potentially violent behavioral patients. The facility ED is a triage unit for both the region and the acute inpatient behavioral unit (refer to A 144).

Based on record review and interview, hospital failed to ensure that the facility was in compliance with the Condition of Participation for Quality Assessment & Performance Improvement (QAPI). The hospital failed to show measurable improvement in reducing medication errors in the Emergency Department and on the Behavioral Unit. The hospital's QAPI program failed to perform a root cause analysis on a sentinel (death) event. These deficient practices have the likelihood to diminish the quality of patient care and increase medication errors hospital-wide (refer to A 297). The hospital failed to separately break out data for the outpatient laboratory and the outpatient cardiac-pulmonary clinics in the QAPI data. These failures could potentially lead to mismanagement of these programs and therefore affect the quality of patient care (refer to A 308).

Based on observations and staff interviews, the hospital failed to ensure that nursing services provided adequate supervision and trained staff in crisis prevention intervention (CPI) on the acute inpatient behavioral unit. This deficient practice exposed all patients on these units to potential physical harm (refer to A 392).

Based on observations and staff interviews, the hospital failed to ensure that medications were properly administered for 3 (Pt #31, 32 and 34) of 8 (Pt #28, 30, 31, 32, 33, 34, 35, and 38) sampled patients. This deficient practice could result in the wrong medication being administered to a patient (refer to A 405).

The cumulative effect of patients at risk for medication safety resulted in Immediate Jeopardy (IJ) to the heath and safety of patients and had the likelihood to cause harm. The Administrator and the Interim Chief Nursing Officer were informed on 04/14/15 at 5:30 pm that an IJ situation had been identified.

On 04/15/15 at 9:00 am, after receipt of an acceptable plan of removal and the demonstration of compliance on 04/15/15, the Administrator and Interim Chief Nursing Officer were informed that the IJ had been remedied .

Based on interview and record review, the Director of Anesthesia Services failed to endorse Anesthesia Services Policies for deep sedation, which include the documentation of an American Society of Anesthesiologists (ASA) risk score.
These policies must be communicated to the Emergency Department (ED) for use. The medical records of 6 sampled patients (Pt #2, #3, #4, #5, #6 and #7) of 6 patients reviewed who received ketamine or other sedation for procedures in the ED did not include this risk score. This deficient practice could expose patients to harm through improper application of medications required for deep sedation (refer to A 1002)

The cumulative effect of these deficiencies resulted in noncompliance with the Governing Body Condition of Participation.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on observations and interviews, the hospital failed to ensure that nursing services provided adequate supervision and trained staff in crisis prevention intervention (CPI) on the acute inpatient behavioral unit. This deficient practice exposed all patients with behavioral and/or mental health issues to harm. The findings are:

A. During observation of the smoking area of the behavioral unit on 04/15/15 between 8:30 am and 10:30 am, the following was witnessed:
1. The area did not have a video monitoring system.
2. The metal picnic table could be lifted and placed against the door to block access to the smoking area.
3. The area had multiple places to hide pills and contraband.
B. During interview on 04/15/15 at 9.40 am, the Clinical Director stated that one staff member might take 4 or 5 patients out to the smoking area at a time. When asked she confirmed that this might not be a safe ratio for the patients or the staff member. She also confirmed there was no video monitoring system and that the metal picnic table could be placed against the door blocking access.
C. During interview on 04/16/15 at 9:40 am, Tech #1 stated they had completed CPI training in January, and that the training lasted about 5 hours. Tech #1 further stated that around the end of January, a female tech had been assaulted by a patient in the unit. The tech was told by unit nurse to continue working and was not allowed to go home. The tech that was assaulted at the time was new and was the only one working on the floor that evening. When asked to describe the patient ratio, Tech #1 stated that the ratio was 2 to 25 often, seldom 3 to 25, and the nurse to patient ratio was typically 3 to 25. Tech #1 stated the techs were feeling unsafe in the unit with these staffing ratios and lack of training.

D. During interview on 04/16/15 at 9:50 am, Tech #2 stated that 4 techs would be a ideal but typically it is 1 tech per every 12 to 13 patients. There are situations in which a tech may be required to provide 1to 1 care while attending to other patients as well.
E. During interview on 04/16/15 at 10:13 am, Tech #3 stated that the typical staff to patient ratio is 3 to 25 / 2 to 25 on average. Tech #3 stated that staff are hired with little or no formal training. Tech #3 also stated that at one point a tech was working the unit alone at night for about 1.5 months. Tech #3 did not disclose name of the person who worked alone. Tech #3 reported feeling uncomfortable giving names during the interview.
F. During interview on 04/16/15 at 10:38 am, Tech #4 stated that the typical staff to patient ratio is 2 to 25 or 1 to 25. Tech #4 added that there is little to no communication or teamwork between the nurses and techs, and that nurses are not expected to do much, other than pass medications. Tech #4 reported having very little time for meal breaks and staff often eat while working.
G. During interview on 04/16/15 at 11:05 am, RN #1 stated that they did not remember specific training to work in the behavioral unit. RN #1 reported receiving orientation training and computer training at the start of employment, but did not receive specific training for the unit until recently. RN #1 stated that staffing should be increased as should training. RN #1 also reported that a couple of weeks ago a patient had a lighter and cigarettes in her room. This patient had previously exhibited self-injurious behavior.
H. During interview on 04/16/15 at 11:16 am, RN #2 stated that the RN's need to help with tech duties. RN #2 is a recent nursing graduate who had been tasked with charge nurse duties and does not feel adequately trained for the charge nurse position. RN #2 stated that there has been too much information given in a short period of time. RN #2 also stated that communication was lacking.
I. During interview on 04/17/15 at 4:40 am, Tech #5 stated that she worked alone for 4 days straight and one night she was assaulted by a patient. She could not remember the date but that it occurred in late February 2015. Tech #5 reported being hit on right side of her face near the eye. She was told by the charge nurse that she could not use ice and that she had to return back to work. Tech #5 also stated that the nurses come out of the nurse's station only to pass medications. Tech #5 stated that there needs to be better communication and better group therapy for patients. Tech #5 reported that the staff to patient ratio is typically 2 to 25 and sometimes 3 to 25.
J. During interview on 04/17/15 at 5:12 am, Tech #6 stated that there are typically 2-3 techs working on the floor and believes that more staff are needed.
K. During interview on 04/17/15 at 5:21 am, Sitter #1 stated that sitters receive no training for the behavioral unit. Sitter #1 stated that she did receive CPI training at the start of employment during orientation but has not been recertified. Sitter #1 stated that she works throughout the hospital as a sitter in all units.
L. During interview on 04/17/15 at 5:30 am, Sitter #2 stated that she did not receive any training for being a sitter on the behavioral unit. Sitter #2 stated that she did not receive CPI training prior to starting on the unit. Sitter #2 added that rules keep changing and believes that there is a lack of stability. Sitter #2 reports that typically there are 2 techs working the night shift.
M. During interview on 04/17/15 at 5:45 am, RN #3 stated that employees lack training and there is little communication. RN #3 also stated that there is a lack of communication between the front line staff and the administration; threats of termination come from supervisory and administrative personnel when the front line staff ask questions.
N. During interview on 04/17/15 at 6:07 am, RN #4 stated that there are staffing concerns as they are constantly short staffed on the unit. RN #4 stated that the hospital is continually bringing in nurses from other units to help for coverage, but there is no training involved.
O. During interview on 04/17/15 at 6:20 am, RN #5 stated that staffing is often inadequate.
P. During interview on 04/17/15 at 6:30 am, RN #6 stated that she was from another unit (Medical-Surgical), but floats to the behavioral health unit to help. RN #6 stated that she was not CPI trained at the time. When asked, RN #6 stated that she did not receive any formal training to work in the behavioral health unit.
Q. During interview on 04/17/15 at 6:41 am, the Clinical Director reported that the staffing ratio needs to improve. The Clinical Director stated that she was not currently CPI trained.
R. During interview on 04/17/15 at 7:22 am, the Program Director stated that he is not currently certified in CPI and has not received any training or orientation for the position. The Program Director was provided paper tests by administration to be completed at his own pace. The Program Director stated that more training was needed for the unit as well as mentoring. The Program Director stated that staff do not work on the floor unless they are CPI trained.
S. During interview on 04/17/15 at 8:40 am, the Clinical Director confirmed that staff do not account for the eating utensils used by the patient on the behavioral unit and stated, "That's something we need to work on."
T. During interview on 04/20/15 at 1:55 pm, Social Worker (SW) #1 stated the unit is short staffed fairly often and there is very little training.
U. During interview on 04/20/15 at 2:43 pm, Tech #7 stated that training only involves monitoring duties and the documentation process for monitored viewing. Tech #7 stated that she had not received any other training pertaining to the patients on the unit.
V. During interview on 04/20/15 at 4:15 pm, Tech #8 stated that he is a CPI instructor for the hospital. Tech #8 was asked what the difference was between a one-year and a two-year certification for CPI. Tech #8 stated that he did not know there was a difference. Tech #8 reported that there has been a big turnover in staff on the unit.
W. During interview on 04/20/15 at 4:35 pm, RN #8 stated that he has worked on the behavioral health unit 2-3 times but that his primary duties are on another unit. RN #8 has received orientation, training on intake and charting for the behavioral unit and is scheduled to attend CPI training in April.
X. During interview on 04/20/15 at 4:48 pm, RN #10 stated that she received the first half of CPI training but did not receive the other half due to her pregnancy. RN #10 stated that she is scheduled to attend the second part of training the week of the survey. RN #10 stated that there are typically 3 staff (nurses and techs) to 25 patients.
Y. During interview on 04/21/15 at 2:30 pm, the CPI training instructor stated that the first half of the day is classroom training.
Z. During observation on 04/21/15 at 2:35 pm, Instructor #1 began to teach the physical releases and restraint component of the training. Seven (7) physical skills were taught within an hour and a half. Most, if not all of the participants, were observed having difficulty with maintaining the proper stance and balance as well as appropriate body mechanics. Participants appeared unstable as they were executing the skills. They asked their instructor why it felt unnatural, to which he replied, "It will happen."
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on observation, policy review and interview, the hospital failed to properly administer medications for 3 (Pt #31, 32 and 34) of 8 (Pt #28, 30, 31, 32, 33, 34, 35, and 38) sampled patients observed during medication administration (medication pass). This deficient practice could harm a patient. The findings are:

A. During observation on 04/14/15 at 2:20 pm, the surveyor witnessed the medication administration (medication pass) by RN # 2:
1. RN #2 failed to scan the unit dose package of Neurontin (a medication used to help relieve certain types of nerve pain) for Pt #32 prior to administering the medication to the patient. Scanning would have reconciled the medication with the physician's order.
2. RN #2 failed to confirm Pt #31's identity prior to administering medication to the patient.

B. During observation on 04/14/15 at 2:35 pm, the surveyor witnessed the medication administration (medication pass) by RN #9.
1. RN #9 left the medication, Neurontin, sitting in a medication cup unattended at the nurses station while looking for Pt #34.
2. RN #9 failed to scan the unit dose package of Neurontin for Pt #34 prior to administering medication to the patient. Scanning would have reconciled the medication with the physician's order.

C. Record review of the facility's Performance Dashboard indicates the medication variance (errors) had not changed from 01/14 to 03/15 despite an ongoing improvement project. For nine of 15 months during this period, including the first three months of 2015, 4 or more (adjusted per 1000 days) medication errors occurred per month. The raw numbers of errors were respectively as follows: for 01/15, 12 errors, for 02/15, 7 errors, and for 03/15, 13 errors. Each error was a wrong patient or wrong medication, the potentially worst scenario for medication errors.

D. During interview on 04/16/15 at 3:00 pm, the Risk Manager and Director of Quality confirmed that the medication errors continued to be a serious concern despite projects by both Nursing and the Pharmacy over the past 15 months (2014 and 2015 to date). "The nurses on [the behavioral unit] and the [emergency department] continue to make errors."

E. During interview on 04/16/15 at 3:10 pm, the Pharmacy Director was asked about the medication errors. She stated, "We have tried different tracking and monitoring methods on errors. We feel we are identifying all the errors but I have had to work more closely with nursing to educate the nurses we have identified. I have recently asked our pharmacists to spend more time with the nurses to solve the problems."

F. Review of the Policy and Procedure titled "Administration of Drugs: General" dated 02/26/13 revealed the following:
1. "Positively identify the patient before administering drugs using two unique identifiers for the patient. The practitioner will ask the patient to state his/her name and date of birth, and then verify this information by checking the patient's name band against the medical record in which the order appears."

G. Review of Policy and Procedure titled "Bedside Barcode Medication Administration (BCMA) and Documentation" dated 04/10/15 revealed the following:
1. "Every patient receives a bar coded identification armband upon entry into the treatment areas of the facility. The armband helps to assure the the right patient is receiving medications and other treatments and must be scanned prior to medication administration. If the band does not scan properly, a new band must be printed and applied. A new patient wrist band can only be reprinted by a registration clerk."
2. "Prior to administration of any medications, the accuracy of the medication must be validated using computer-assisted scan technology to confirm the 'Five Rights' method of verification: Right Patient, Right Drug, Right Dose, Right Route, and Right Time."

H. On 04/14/15 at 5:30 pm, during interview, the Interim Chief Nursing Officer confirmed that the hospital nursing staff was not following hospital policy for properly administering medications.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observations and interviews, the hospital failed to provide and maintain a clean and sanitary environment in the operating and procedural rooms by not following manufacturer's recommendations and standards of practice for terminal cleanings. This deficient practice increased the amount of microorganisms in the environment and increased the potential for patients to contract an infection during surgery. The findings are:

A. During observation on 04/15/15 at 3:00 pm, the surveyor witnessed a terminal cleaning of the operating rooms.
1. As the Environmental Services staff member began to clean operating room #3 she was wearing the following: short-sleeved scrub uniform, gloves, hair cover and shoe covers. The manufacturer of the disinfectant recommends a head covering, eye protection, mask, long sleeves, gloves and a gown to prevent exposure to the skin. The staff member was cleaning the walls and floor with "Virex II 256" and the equipment with "Oxycide Daily Disinfectant Cleaner."
2. The anesthesia Pyxis cart (medication cart where the Certified Registered Nurse Anesthetist obtains medications being used for the surgery cases) drawers were open with unopened syringes, rolls and tape exposed.
3. The anesthesia cart had positioning pillows wrapped in plastic and surgery towels on top.
4. The floor underneath the operating table was stained with a brownish discoloration.
5. The Bair Hugger machine (produces warm air to warm the patient) and hoses were exposed.
6. Three open boxes of different sized gloves were affixed to the wall.
7. A stereo system with two components connected to a wall outlet.
8. Two (2) electric razors were on a counter.
9. A cabinet that contained medical supplies was open. These medical supplies were left exposed to potential splatter from the disinfectant cleaner used to clean the walls, ceilings and exterior surfaces.
10. The air exchange vents in all of the operating rooms were dirty with some kind of splatter and were dusty.

B. During interview on 04/15/15 at 3:40 pm, the Interim Director of Perioperative Services, who has been a consultant at the hospital for 6 weeks, confirmed that the Environmental Services staff member was not wearing the proper personal protective equipment (PPE) for the terminal cleaning. The Director was asked if the hospital had a policy and procedure regarding the terminal cleaning of the operating rooms. She stated that the hospital does not have a policy and procedure, but the staff does follow the 2015 Edition of the Association of Perioperative Registered Nurses (AORN) Guidelines for Perioperative Practice.

C. Review of the AORN 2015 Guidelines For Perioperative Practice for terminal cleaning revealed the following: "Health care personnel who are cleaning must follow standard precautions to prevent contact with blood, body fluids, or other potentially infectious materials. Health care personnel handling contaminated items or cleaning contaminated surfaces must wear personal protective equipment (PPE) to reduce the risk of exposure to blood, body fluids, and other potentially infectious materials...Ventilation ducts, including air vents and grilles, should be cleaned and have their filters changed on a routine basis according to manufacturer's instructions for use. Clean ventilation ducts and filters support optimal performance of the ventilation system."

D. On 04/16/15 at 5:05 pm, during interview, the Infection Control Preventionist, who has been employed at the hospital for three months, stated that she had not observed terminal cleaning of the operating rooms. She stated that the last inservice training for the terminal cleaning of the operating rooms was on 11/20/14.

E. On 04/21/15 at 2:15 pm, during interview, the Director of Environmental Services stated that he was not aware that the Environmental Services staff member should have been wearing goggles, gloves, apron with long sleeves or a mask while cleaning the operating rooms with the disinfectant cleaner.

F. Review of the "Virex II 256" Material Safety Data Sheet dated 11/10/2009 revealed the following: under "Handling and Storage: Handling: Avoid contact with skin, eyes and clothing...Avoid breathing vapors or mists...Exposure Controls/Personal Protection: Eye protection: Chemical-splash goggles. Hand protection: Chemical-resistant gloves. Skin and body protection: Protective footwear. If major exposure is possible, wear suitable protective clothing and footwear. Respiratory protection: In case of insufficient ventilation wear suitable respiratory equipment. A respiratory protection program that meets OSHA's 29 CFR 1910.134 and ANSI Z88.2 requirements must be followed whenever workplace conditions warrant a respiratory's use."

G. Review of the "Oxycide Daily Disinfectant Cleaner" Safety Data Sheet dated 01/25/13 revealed the following: "Precautionary statements Prevention: Due to the form and packaging of the product, no protective equipment is needed under normal use conditions. Chemical splash goggles, impervious gloves and apron should be used when there is a likelihood of exposure to concentrated product."
VIOLATION: QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT Tag No: A0308
Based on record review and interview, the hospital failed to separately break out data for the outpatient laboratory and the outpatient cardiac-pulmonary clinics in the QAPI data. The mismanagement of the data could affect the quality of patient care. The findings are:

A. Record review of the hospital's QAPI Dashboard and other quality reports indicated no data from the outpatient lab or outpatient cardiac-pulmonary units.

B. During interview on 04/15/15 at 8:15 am, the Director of Cardiopulmonary Services stated that the department does not provide outpatient data to the QAPI committee.

C. During interview on 04/15/15 at 8:40 am, the Director of Laboratory Services stated that the department does not provide outpatient data to the QAPI committee.

D. During interview on 04/14/15 at 11:15 am, the Risk Manager and Quality Director were asked where the data were for outpatient laboratory and cardio-pulmonary. They replied, "That data is aggregated with other units. Outpatient lab is a subset of the inpatient lab as cardiac-pulmonary is part of respiratory. We don't break them out separately."
VIOLATION: MEDICAL STAFF RESPONSIBILITIES Tag No: A0358
Based on record review, the medical staff bylaws failed to require a patient history and physical examination to be completed and documented for each patient no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services. This deficient practice limited the facility's ability to determine whether there was anything in the patient's overall condition that would affect the planned course of the patient's treatment, such as a medication allergy, or a new or existing co-morbidity condition that would require additional interventions to reduce the risk to the patient. The findings are:

A. Record review of the hospital's medical bylaws indicated no evidence of a requirement for a history and physical including the prescribed statutory requirement of a history and physical performed and documented no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services.

B. Record review of the bylaws indicated "Article II" required a History and Physical of each patient. Further review confirmed in fact the requirement was not in Article II but in the facility's rules and regulations. The rules and regulations are not part of the bylaws proper and have a completely different mechanism for amendment and approval.
VIOLATION: CRITERIA FOR MEDICAL STAFF PRIVILEGING Tag No: A0363
Based on interview, the hospital failed to delineate the specific skills required for special hospital privileges. This deficient practice could expose patients to potentially incompetent or unqualified physicians, and thereby to potential harm. The findings are:

A. During interview on 04/15/15 at 2:00 pm, the Medical Office Supervisor confirmed that the "laundry list" of delineations used by the facility to privilege physicians lacked the specific criteria for the competencies required to grant those privileges. She also stated that the hospital intended to move to a "core privileging" system which specified the competencies required. This effort had yet to begin.
VIOLATION: ANESTHESIA SERVICES Tag No: A1000
Based on interview and record review, the Director of Anesthesia Services failed to endorse Anesthesia Services Policies for deep sedation, which requires the documentation of an American Society of Anesthesiology (ASA) risk score. This deficient practice could expose patients to harm through improper application of medications required for deep sedation (refer to A 1002). Also, based on interview, the Director of Anesthesia Services failed to develop and implement a protocol for privileging based on the inclusion of deep sedation/analgesia under Monitored Anesthesia Care (MAC). By such failure the hospital permitted administration of deep sedation by practitioners who met only core privileges. The cumulative effect resulted in noncompliance with the Anesthesia Services Condition of Participation.

A. During interview on 04/14/15 at 1:00 pm, the Nurse Manager of the ED confirmed the following:
1. The privilege for deep sedation was contained in the core privileges in the Emergency Medicine core privilege document of the facility. The hospital protocol regarding privileging did not stipulate that approval was required by the Anesthesia Services, although as deep sedation is classified as MAC, deep sedation can only be administered by practitioners under special privileges.
2. The ED did not have a deep sedation policy though deep sedation was, in fact, being administered.
VIOLATION: PRE-ANESTHESIA EVALUATION Tag No: A1002
Based on interview and record review, the Director of Anesthesia Services failed to endorse Anesthesia Services Policies for deep sedation, which requires the documentation of an American Society of Anesthesiology (ASA) risk score. This deficient practice could expose patients to harm through improper application of medications required for deep sedation. The findings are:

A. During interview on 04/14/15 at 1:00 pm, the Nurse Manager of the ED confirmed that the Director of Anesthesia Services had not endorsed Anesthesia Services Policies for deep sedation, which requires the documentation of an American Society of Anesthesiology (ASA) risk score.

B. No risk score was in evidence for 6 sampled patients (Pt #2, #3, #4, #5, #6 and #7) who received ketamine and other deep sedation for procedures in the ED. Also, for each of the records, there was no evidence that an airway assessment was performed. Neither was there evidence of post-anesthesia recovery documentation.
VIOLATION: INTEGRATION OF OUTPATIENT SERVICES Tag No: A1077
Based on record review and interview, the hospital failed to ensure that two of its services, Outpatient Cardiopulmonary and Outpatient Laboratory, were integrated into the hospital-wide Quality Assessment/Performance Improvement (QAPI) program by providing data for their outpatient services. This deficient practice could lead to patients not receiving improved care and services. The findings are:

A. Record review of the list of services that the hospital provides for outpatient services revealed that the list includes Outpatient Cardiopulmonary and Outpatient Laboratory.

B. During interview on 04/15/15 at 8:15 am, the Director of Cardiopulmonary Services stated that the department does not provide data to the QAPI committee.

C. During interview on 04/15/15 at 8:40 am, the Director of Laboratory Services stated that the department does not provide any outpatient data to the QAPI committee.

D. During interview on 04/16/15 and 10:15 am, both the Quality Director and the Risk Manager confirmed that the data for Outpatient Cardiopulmonary and Outpatient Laboratory are not broken out individually in the Quality Dashboard.
VIOLATION: INTEGRATION OF EMERGENCY SERVICES Tag No: A1103
Based on observation, interview, and record review, the hospital failed to ensure the development, building and maintaining safe and/or seclusion rooms in the Emergency Department (ED). The ED is a triage unit for both the geographical region and the acute inpatient behavioral unit, for patients with behavioral and/or mental health issues, who are at risk for harming themselves or others. This deficient practice exposed all patients placed in these rooms with behavioral and/or mental health issues to potential physical harm in the ED. The findings are:

A. On 04/13/15 at 9:05 am, during observation, the following was seen in the ED for both exam rooms #5 and #18, that were designated by the ED staff as safe and/or seclusion rooms:
1. Both rooms had a metal sink directly under an air conditioning vent (grill) with openings that were approximately 1 inch by 1 inch. (A patient could stand on the sink to access the vent grill.)
2. Two electrical sockets were on opposite walls, uncovered. (The sockets could be shorted.)
3. A single bed consisting of a metal frame wrapped with a wood frame was in the middle of the floor in each room. The wood could easily be broken creating potential tools or weapons. The beds in rooms #5 and #18 were unsecured and were easily moved.
4. A keypad for the electronic door lock was located just inside the door. It protruded just over an inch from the wall. A shoestring could be attached to the inside door handle and the keypad, thereby blocking access to the room from the outside.

B. On 04/15/15 at 10:05 am, during observation, in the ED the following was observed in exam rooms #5 and #18:
1. The keypad just inside each door was gone.
2. The metal and wood frame beds were gone, both replaced by a transport cart.

C. On 04/13/15 at 9:15 am, during interview, the ED physician #1(Staff #10) when asked how often does the ED triage serious Level I (potential harm to self and others) behavioral cases? He responded, "Almost daily." When asked if he thought the rooms being used as 'safe rooms' or 'seclusion rooms' "were appropriate?" He responded, "They 're what we have." When asked if he would prefer dedicated rooms that fulfill the criteria for both "safe" and/or "seclusion" he responded, "Sure."

D. Record review of the facility's policy titled "Suicide Risk/Behavioral Disorder Assessment" dated 08/10 and revised on 08/11 and 09/11 the policy did not define "safe." The policy did not describe when it was appropriate for the needs of the patient, or how the direct staff would achieve it. Nor did the policy define a seclusion room, describe when it was appropriate for the needs of the patient, or how the direct staff would achieve it or direct how the staff would achieve it.

E. Record review of the facility's quality reports indicated only "restraint episodes per 1000 patients broken down by unit." Use of ED exam rooms as "safe" or "seclusion" were not tracked by the ED or in the quality data.

F. Record review of the ED list of patients reported by the facility that had been placed into rooms #5 and #18 from January 2015 through March 2015 for behavioral reasons revealed twenty-two different patients had been placed in these rooms due to behavioral reasons.

G. Record review of the facilities Policy /Procedure titled "Restraint and Seclusion" dated 03/07 and revised on 02/15 indicated no definitions of a "safe" room or a "seclusion" room. Nor were there any specifications for such rooms contained in the document.