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.

PIEDMONT GERIATRIC HOSPITAL 5001 E PATRICK HENRY HWY - HIGHWAY 360 AND 460 BURKEVILLE, VA Sept. 8, 2011
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, clinical record review, staff interview and facility document review, it was determined that the facility staff failed to ensure every patient was afforded the right to be housed in a safe environment. All units of the psychiatric hospital had exposed pipes and curtain rods in patient bedrooms. One of 8 patients reviewed hung himself from the pipes. Five current patients were not monitored according to treatment plans and facility policy. The Quality Assurance program and Governing Body were not monitoring the identified failure that led to Patient # 3's suicide and current patients' safety risks.

Deficiencies were cited at A 0144 and A 0145.

See the following Conditions of Participation for additional information:

482.12 Condition of Governing Body;
482.21 Condition of Participation: Quality Assessment and Performance Improvement Program;
482.41 Condition of Participation: Physical Environment;

Standard level deficiencies were identified at 482.13- Nursing Services.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observations, complaint investigation, clinical record review, employee interview, and policy and procedure review, the facility staff failed to ensure that patients' right to receive care in a safe setting were maintained. Physicians' ordered safety checks were not completed, and safety rounds were not consistently completed for six of eight patient's reviewed (Patient #'s 3, 4, 5, 6, 7 and 8). Patient # 3 committed suicide.

Findings:

1. Patient # 3's safety checks were not completed as required by his individual treatment plan and according to facility policy. The patient committed suicide on 8/05/2011 by hanging himself from exposed sprinkler pipes in his bedroom. The assigned facility staff did not complete the safety checks as ordered and the Registered Nurse (RN # 2) did not do a face to face assessment of the patient at least every two hours as directed by the policy "Accountability for Patients." (See below @ 3. for accountability policy.)

Patient # 3's clinical record was reviewed by the State Survey Team on 9/6/11 and 9/7/2011. The patient was admitted to the facility on [DATE] with the diagnosis of depression with possible psychosis, cognitive disorder and for return to competency status- related to recent legal charges. Patient # 3 attempted to hang himself (by wrapping jumper cables around his neck and to a tree) after an incident which resulted in his arrest. The "Focus of hospitalization " and the "Recovery Treatment Plan" revealed that the patient was a high risk for suicide and 1:1 supervision was initiated upon admission for safety precautions. The patient had a plan for suicide by hanging. The patient's 1:1 supervision was faded (3/29/11), and the patient was placed on 15 minute safety checks (4/11/11) and then 30 minute checks (4/17/2011) as his suicide risk was assessed as decreased. On 4/19/2011 the 30 minute safety checks were discontinued and the facility's standard observation policy of hourly observation was implemented. Patient # 3's clinical record included an hourly check sheet dated 8/5/11. This check sheet contained RN # 2, HSCW # 1 and HSCW # 2's initials from 9:00 p.m. through 11:00 p.m. RN # 2 found Patient # 3 at 11:15 p.m., with a sheet tied around a sprinkler pipe and his neck, with no signs of life. The facility's investigation stated: "During rounds at 11:20 p.m., the Unit RN found the patient hanging from the ceiling with a bed sheet around his neck. Vital signs were absent and CPR was not indicated due to obvious signs of irreversible clinical signs of death (rigor mortis). The patient was pronounced dead by the on call MD at 11:34 p.m."

The facility's Director of Health Care Compliance/Risk Management was interviewed on 9/6/2011 at 5:10 p.m. The Compliance Director stated that the facility's video surveillance tapes were reviewed by the Facility Director and herself, after the patient's successful suicide. The video revealed that RN #2, HSCW # 1 and # 2 did not enter Patient # 3's room or make a face to face assessment of the patient from 9:08 p.m. through 11:15 p.m. The Compliance Director stated that the facility's internal investigation revealed that the RN and HSCW's documented that they observed the patient, but they did not. The Compliance Director stated that Patient # 3 was identified upon admission as having a cultural belief related to mental illness and his potential return to jail, and was an increased suicide risk. The facility investigation stated: "Patient's cultural beliefs: The patient is Cambodian...He expressed feeling shame for being in jail and associated it with his past history..." The investigation identified communication deficits related to sharing pertinent information such as the patient's history of trauma, cultural beliefs and language, with the treatment team and other unit staff. The Compliance Director stated that all nursing employees were immediately retrained on the Accountability Policy and Safety Check completion. No additional employee surveillance or monitoring of staff action was conducted by the Quality Assurance Committee or the nursing administrative staff to ensure compliance.

The facility's investigation into Patient # 3's suicide included an environmental assessment which stated: "Our hospital is an old building with water sprinkler pipes for the fire prevention system extending from the ceiling through-out the facility. The pipes have always been included in our environmental risk assessments We have requested funding for re-construction from our Department of Behavioral Health and Developmental Services (Central Office), but due to tremendous cost the budget was not approved. We received a 'Traditional Equivalency' from The Joint Commission in 2007 for this risk because of our Suicidal Protocol and Environmental Risk Assessment..."

The Facility Director was interviewed on 9/8/11 at 11:15 a.m. The FD stated that The Joint Commission (JC) identified the environmental risk related to the facility's exposed fire sprinkler system, and "Central Office got them to drop it secondary (due to) costs." The FD stated that the current census was 109 patients and potentially all were at risk due to the exposed pipes and curtain rails. (It was noted that not all patients were suicidal.)

The facility's abuse/neglect investigation conducted in response to Patient # 3's successful suicide determined that RN # 2, HSCW's # 1 and # 2 were negligent and they were terminated from employment.

The Facility Director, Director of Health Care Compliance/Risk Manager and the Acting Director of Nursing were interviewed on 9/8/11 at 3:00 p.m. and they acknowledged the above information. Information to evidence monitoring of the nursing staff related to completion of safety checks was requested. No further information was presented during the survey to evidence compliance with each patients' right to receive care in a safe setting.

"The Joint Commission's Sentinel Event Alert", Issue 7-November 6, 1998 (retrieved September 12, 2011 @ 12:00 p.m. from http://www.jointcommission.org/assets/1/18/SEA_7.pdf), documented a root cause analysis related to sixty-five, inpatient facility suicides. In 75% of the cases, hanging was the method of suicide. The analysis concluded, that as part of the root cause of inpatient suicides: "The environment of care, such as the presence of non-breakaway bars, rods or safety rails..."; and " Incomplete or infrequent patient observations ... " . The report included "Reducing Risk Factors: Organizations that experienced the suicides recommended the following risk reduction strategies: ...Identifying and removing or replacing non-breakaway hardware...."

The Joint Commission Sentinel Event Alert, Issue 46, November 17, 2010 (retrieved September 12, 2011 @ 12:19 p.m. at http://www.jointcommission.org/assets/1/18/SEA_46.pdf) updated the prevention strategies presented in the previous Alert (Issue 7, [DATE]). The Alert included risk factors for suicide to include recent suicide attempts, depression, dementia, and age-with older adults having an increased risk. The contributing factors to suicide were included: "...Common environmental risk factors include potential anchor points for hanging, material that can be used for self-injury, and problems maintaining a secure environment. The methods of self harm most frequently used in health care environments-include hanging...-correspond to these common environmental risk factors..."

The American Psychiatric Association: "Practice Guideline for the assessment and treatment of patients with suicidal behaviors" (American Journal of Psychiatry 160:1-60, [DATE]) stated that approximately 1500 suicides occur inpatient hospital settings per year, and one third of these occur while the patient is on 15 minute checks."

2. Current patients were not monitored for safety as directed.

On 9/6/11 at 3:15 p.m. through 4:30 p.m., each hospital Unit was observed by two Medical Facilities Inspectors. Current patients' safety checks and special observation sheets were reviewed. Four patients (#'s 4, 5, 6, and 8) were identified by the RN on each unit as being on safety checks or special observation checks. The safety checks were not completed as directed. All Units in the hospital were observed during this investigation to have multiple anchor points in each room, including 4 inch diameter, exposed water pipes and privacy curtain rails attached to the ceilings. A review of Patient # 7's clinical record revealed that safety checks were not consistently documented as completed. (See 6. a-e below for additional information obtained through clinical record reviews.)

A. Patient # 4 was observed on 9/6/211 at 3:50 p.m. and her safety check document was reviewed. The safety checks had not been documented since a 2:30 p.m. check by HSCW # 3 (nurses aid). The last RN check was documented at 1:30 p.m.
B. Patient # 5 was observed on 9/6/2011 at approximately 3:54 p.m. The patient had physician's orders for 1:1 staff observation due to safety risks. The last documented check by an employee was at 3:15 p.m. The last documented check by a nurse was at 1:00 p.m. RN # 1 was interviewed at this time and she stated that patients with 1:1 supervision should have a safety check documented every fifteen minutes and that a nurse must observe the patient at least every two hours.
C. Patient # 6 was observed at approximately 4:00 p.m. The safety checks did not evidence an assessment or safety check by a nurse for the entire day shift. RN # 3 was interviewed and she stated that patients were to be monitored at least hourly by an aid and every two hours by a RN, or an LPN if an RN was not available.
D. Patient # 8 was observed at approximately 4:10 p.m. The 9/6/11 safety check did not evidence an assessment by any staff at 4:00 p.m. No checks were documented from 1:30 a.m. through 7:00 a.m. This patient was identified by the nurse as requiring "routine checks", or every hour by an aid and every two hours by a nurse. Evidence of implementation of these checks, was not presented during the survey.
E. Patient # 7's clinical record revealed that safety checks were not completed as directed. (See 6. d. below for additional information.)

The Director of Heath Care Compliance was interviewed on 9/6/11 at 5:10 p.m. and informed of the above observations.

The Acting Director of Nursing (DON) was interviewed on 9/7/11 at 10:00 a.m. The DON stated that facility policy for routine safety checks ("Accountability for Patients"), dictated that every patient be checked by an assigned staff member at least every hour and by a Registered Nurse or Licensed Practical Nurse (LPN) at least every two hours. The DON stated that in response to Patient # 3's suicide, all staff were retrained on the Accountability Policy and documentation of patient safety rounds. The DON was informed of the observed safety check and patient accountability documentation and apparent lack of checks being conducted as ordered. The DON stated she did not increase supervision or surveillance of nursing staff to determine compliance with the policy. No information or documentation was presented to evidence increased leadership monitoring of direct care nursing staff compliance with patient accountability and safety assessments.

The Facility Director, Director of Health Care Compliance/Risk Manager and the Acting Director of Nursing were interviewed on 9/08/11 at 3:00 p.m. and informed of the above information. No further information was presented during the survey to evidence that identified employee non-compliance, related to conducting safety checks was sufficiently acted upon and that the event which led to patient neglect was rectified.

The facility staff failed to ensure the patients' right to be housed in a safe environment was maintained. The identified risk related to exposed sprinkler pipes was not acted upon. The facility's corrective action related to the actual suicide was not successful nor monitored to ensure each remaining patient was safe. The facility's request to the Governing Body to modify the identified environmental risk was denied. The Quality Assurance program was not collecting or analyzing data, to determine compliance with the identified issue.

A review of facility policies and additional clinical records revealed the following:

3. The facility's administrative staff provided policies for review, as requested, related to the requirements for patient observations by facility staff and the documentation requirements. Those policies were reviewed with the following findings.

Nursing Administration Policy No. 36, titled Accountability For Patients with the effective date of August 2011 reads in part as follows:
? "The charge nurse (as evidenced by his/her initials on checklist) on each shift will be responsible for checking his/her assigned patients and will monitor to assure compliance to the policy."
? "Each patient assigned to the unit will be accounted for by the charge nurse or designee (must be RN or LPN) on each shift every two (2) hours. These checks will be documented on the Hourly Activity/Hourly Check Sheet and initialed."
? "Hourly checks will be made on each shift by the staff member assigned to make the accountability checks (this is in addition to the every two (2) hour checks made by the nurses). These checks will be documented on the Hourly Activity/Hourly Check Sheet and initialed."
? "Records documenting accountability checks will be forwarded to the Unit Secretary. These records will be filed for three (3) years, after which they will be shredded or burned (Ref. 720-GS.74 "Patient Care Monitoring Reports and Logs")."

Hospital Instruction Policy No.118 (TX) 06, titled Special Observation and Monitoring of Patients with the effective date of March 1, 2006 reads in part as follows:
? "Special observation and monitoring of patients will be ordered on an individual basis for patients based on a physician's order for patients who are assessed to be at risk for self-injury due to medical reasons or due to high risk behaviors (unpredictable hitting, damaging property, intrusiveness). A physician shall order the appropriate level of observation required by the patient."
? "A Physician's Order is required for discontinuation of Special Observation."
? "The RN shall be responsible for assigning appropriate nursing staff to monitor the patient for intervals not to exceed two hours."
? "Documentation of the special observation and monitoring of Patients will utilize PGH form "Special Observation Flow Sheet"."
? "The Observation Record will be filed in the flow sheet section of the patient's medical record."
? "Staff will initial the flow sheets according to instruction printed on the form."

4. An interview took place with the Acting Director of Nursing (DON) on 09/08/11 at 11:45 AM. During the interview the DON confirmed the hospital's expectations are that all staff (nurses and aides) complete their documentation for all patient observations and safety checks immediately at the time the observation actually occurs. The DON was informed of the findings related to observations made by two (2) medical facilities inspectors while conducting a tour of the facility and observations of care on 09/06/11; patients who were identified as being on special observations (see also tag 0144 and 0145) by the facility staff during the tour and observations, with no documentation at the time of the tour for specific safety checks or RN observations that should have been documented. The DON acknowledged those observations should have been documented at the time they were conducted and that since they were not documented there is no evidence the observations occurred. The DON stated all patients are to be observed by an RN (may be done by an LPN in rare instances in which an RN may be unavailable) at a minimum of every two (2) hours even if their physician has not ordered a specific frequency for observations.

5. An interview took place with the DON on 09/08/11 at 1:00 PM. The DON stated she believes the explanation to some of the missing documentation by staff for RN observations and safety checks (see #4 above and #6 below) "may be" because the staff are documenting their observations and safety checks on a worksheet that is used by the staff in the patient care areas instead of on the Observation Record form. She confirmed the worksheet she is referring to is the Hourly Activity/Hourly Check Sheet described in #3 above. The DON was informed during this interview that both inspectors observed this worksheet in use on 09/06/11 during the tour and based on other interviews with staff, it was this inspector's understanding that this worksheet nor it's documentation ever become a part of the patient's clinical record. The DON stated "you are exactly right" and that she had not thought about the fact that the information never makes it to the patient's chart and "that's something we need to work on." The DON confirmed the findings from the review of the policies outlined in #3 above, specifically that the Observation Record's documentation becomes a part of each patient's chart, but any documentation on the Hourly Activity/Hourly Check Sheet does not. The DON acknowledged that when the staff documents required observations and assessments on a worksheet that never becomes a legal part of the patient's clinical record, this creates an inability to confirm compliance with those required observations when reviewing the patient's clinical record. The DON acknowledged understanding that all care provided should be documented in the patient's clinical record.

(Note: It is also a violation of 482.24(b)(1) to destroy medical records maintained less than five (5) years.)

6. The clinical records of patient # 4, 5, 6, 7, and 8 were reviewed on 09/07/11 and 09/08/11. These records were part of a focused review of a total sample of eight (8) records reviewed as a part of this complaint investigation. Below are the findings specific to the records of patient # 4, 5, 6, 7, and 8.

a. The record of patient #4 reveals the patient was admitted to the facility on [DATE] and remains a current patient in the facility at the time of the inspection. The record contains physician's orders dated 09/01/11 at 1:50 PM and continuing through 09/05/11 at 10:15 AM for the patient to have safety checks every 15 minutes by the facility staff for "behaviors." On 09/05/11 at 10:15 AM the physician ordered the safety checks for "impulsive behavior" to be reduced to every 30 minutes and this order is continued on 09/06/11 through the inspection date.
On 09/02/11 the RN documentation reveals the every 2 hour nurse observations were missed a total of four (4) times with ranges noted of 2 and 1/2 hours to 3 hours passing between documented RN checks. On 09/02/11 the documentation reveals the every 15 minute safety checks were missed eleven (11) times that day for times ranging from 1 hour to 2 hours between checks.
On 09/03/11 the RN documentation reveals the every 2 hour nurse observations were missed a total of five (5) times with ranges noted of 3 to 8 hours passing between documented RN checks. On 09/02/11 the documentation reveals the every 15 minute safety checks were missed twenty-six (26) times that day for times ranging from 30 minutes to 1 and 1/2 hours between checks.
On 09/05/11 the RN documentation reveals the every 2 hour nurse observations were missed a total of two (2) times with up to 4 and 1/2 hours passing between documented RN checks. On 09/05/11 the documentation reveals the every 15 minute safety checks were missed one (1) time that day at 4:15 AM.
On 09/06/11 the RN documentation reveals the every 2 hour nurse observations were missed one (1) time with 3 and 1/2 hours passing between documented RN checks.

b. The record of patient #5 reveals the patient was admitted to the facility on [DATE] and remains a current patient in the facility at the time of the inspection. The record contains physician's orders dated 09/01/11 at 11:45 AM and continuing through 09/05/11 for the patient to have Modified 1:1 observation by the facility staff. (Note: Modified 1:1 is defined in the facility's policy No. 118 titled Special Observations and Monitoring of Patients and dated 03/01/06, as the patient constantly observed and "within 2 arms length" of the facility staff and requires the care be documented on the Observation Record in the patient's clinical record).
On 09/02/11 the RN documentation reveals the every 2 hour nurse observations were missed one (1) time with 2 hours and 45 minutes passing between documented RN checks. On 09/02/11 the documentation fails to provide evidence that at 12:00 midnight the patient was receiving the Modified 1:1 observations, as that space in the Observation Record is completely blank.
On 09/03/11 the RN documentation reveals the every 2 hour nurse observations were missed one (1) time with 4 hours passing between documented RN checks.
On 09/05/11 the RN documentation reveals the every 2 hour nurse observations were missed a total of seven (7) times with a range noted of 3 to 10 hours passing between documented RN checks.

c. The record of patient #6 reveals the patient was admitted to the facility on [DATE] and remains a current patient in the facility at the time of the inspection. The record contains physician's orders dated 09/01/11 at 3:00 PM and continuing through 09/07/11 for the patient to have safety checks every 15 minutes by the facility staff for "unsafe behaviors."
On 09/01/11 the Observation Record reveals the safety checks were not begun for patient #6 until 4:00 PM and the first documented RN observation was at 6:00 PM.
On 09/02/11 the RN documentation reveals the every 2 hour nurse observations were missed eight (8) times with the last RN observation being documented at 7:45 AM and not documented again until 8:00 AM on 09/03/11, resulting in 24 hours and 15 minutes passing between documented RN checks. On 09/02/11 the documentation reveals the every 15 minute safety checks were missed nine (9) times that day with times ranging from 1 to 1 and 1/2 hours passing between documented safety checks.
On 09/03/11 the RN documentation reveals the every 2 hour nurse observations were missed a total of eight (8) times with a range noted of 7 hours and 45 minutes to 9 hours passing between documented RN checks. On 09/03/11 the documentation reveals the every 15 minute safety checks were missed one (1) time at 12:00 midnight.
On 09/06/11 the RN documentation reveals the every 2 hour nurse observations were missed a total of eight (8) times with a range noted of 4 to 10 hours passing between documented RN checks. On 09/06/11 the documentation reveals the every 15 minute safety checks were missed twenty-nine (29) times that day, as each 15 minute increment up to 7:30 AM when the first safety check for that date is documented, was completely blank.
On 09/07/11 the RN documentation reveals the every 2 hour nurse observations were missed a total of seven (7) times with 15 hours passing between the last documented RN check at 9:15 AM and the end of the day at 12:00 midnight.

d. The record of patient #7 reveals the patient was admitted to the facility on [DATE] and remains a current patient in the facility at the time of the inspection. The record contains physician's orders dated 09/01/11 and continuing through 09/03/11 for the patient to have safety checks every 15 minutes by the facility staff for "unsafe behaviors." The record contains physician's orders dated 09/03/11 at 6:40 PM for the patient to be transferred by ambulance to another facility's emergency department for evaluation related to an elevated temperature while on antibiotics. The record contains physician's orders dated 09/06/11 for the patient's services to be resumed as she has returned to the facility. The record contains physician's orders dated 09/06/11 at 2:40 PM and continuing through 09/07/11 for the patient to have safety checks every 15 minutes by the facility staff for "unsafe behaviors."
On 09/01/11 the RN documentation reveals the every 2 hour nurse observations were missed a total of seven (7) times with times ranging from 3 hours to 11 hours passing between documented RN checks.
On 09/02/11 the RN documentation reveals the last 2 hour nurse observation entry was made by the RN at 7:00 AM and no further RN observations were documented until 09/06/11 when the patient returns to the facility after having been transferred to another facility on 09/03/11 at around 7:00 PM. On 09/02/11 the documentation reveals the every 15 minute safety checks were missed twenty-six (26) times that day with times ranging from 1 hour to 4 hours passing between documented safety checks. This includes a time frame from 8:00 AM till 12:00 noon in which entries were made on the Observation Record but were not initialed or authenticated in any way by the person or persons making the entries.
On 09/03/11 the RN documentation reveals the every 2 hour nurse observations were missed (see the description of 09/02/11 RN documentation findings above).
On 09/06/11 the RN documentation reveals the every 2 hour nurse observations were missed a total of two (2) times with 4 hours passing between documented RN checks. On 09/06/11 the documentation reveals the every 15 minute safety checks were not started on the patient until 4:00 PM after being ordered by the physician at 2:40 PM.
On 09/07/11 the RN documentation reveals the every 2 hour nurse observations were missed a total of seven (7) times with 14 hours passing between the last documented RN check at 10:00 AM and the end of the day at 12:00 midnight. On 09/07/11 the documentation reveals the every 15 minute safety checks were missed one (1) time at 12:00 noon.

e. The record of patient #8 reveals the patient was admitted to the facility on [DATE] and remains a current patient in the facility at the time of the inspection. The record contains physician's orders dated 08/05/11 and continuing through 09/07/11 for the patient to have Direct Observation while in bed.
The clinical record fails to contain evidence for the time frame reviewed of 09/01/11 to 09/08/11, that every 2 hours the nurse observations were completed as required by facility policy. The Observation Records revealed the RN documented observation of the patient every 2 hours only at times when the Observation Record documented the patient as in bed and requiring the direct observations. The record failed to contain evidence for 09/01/11 to 09/08/11 that the RN performed the every 2 hour observations of the patient at times when he was not on special observation monitoring.

7. During the exit conference on 09/08/11 the DON, the Director of Health Care Compliance, the Medical Director, and the Facility Director were present. All acknowledged the identified failure of the staff to perform and/or document observations and safety checks per facility policies and as ordered by the physician are consistent with their own internal investigation findings from the root cause analysis of the recent patient suicide at this facility. All acknowledged the necessity of having the required tasks, first completed by the staff as indicated by policy and/or physician's order, but also documented in the patient's clinical record.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on clinical record review, staff interview, policy and procedure and facility document review, the facility staff failed to ensure all patients were free from neglect, for six of 8 patients reviewed, Patient #'s 3, 4, 5, 6, 7 and 8.

Patients were not monitored according to physician's orders or according to facility policy. Patient # 3 committed suicide and his safety checks were not conducted; Patients #'s 4, 5, 6, 7 and 8, were not monitored according to physician's orders or facility policy; and the facility's identified environmental risk (exposed sprinkler system) was still present.

Neglect, for the purpose of this requirement (and identified by facility policy), is considered a form of abuse and is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness.

See Conditions of Participation: 482.41-Physical Environment and
Standard 482.23(b)(3) for additional information.

Findings:

1. Patient # 3 was not monitored according to his treatment plan or hospital policy. The patient was not monitored from 9:08 p.m. until found hanging from the sprinkler system pipes in his bedroom at 11:15 p.m. The facility's video surveillance cameras revealed that safety checks were not conducted, although nursing staff documented the checks were completed.

The patient was admitted to the facility on [DATE] with the diagnosis of depression with possible psychosis, cognitive disorder and as being committed for return to competency status, related to recent legal charges. The "Focus of hospitalization " and the "Recovery Treatment Plan" revealed that the patient was a high risk for suicide and 1:1 supervision was initiated upon admission for safety precautions. The patient had a plan for suicide by hanging. Patient # 3 attempted to hang himself during an arrest (by wrapping jumper cables around his neck and to a tree) and prior to this facility admission. The facility's standard observation policy directed that the assigned staff member would physically observe each patient and attest to this, by initialing a document every hour. The policy directed that an RN or LPN would physically observe each client at least every two hours.

On 8/5/11, Patient # 3's hourly check sheet included RN # 2's initials, and HSCW # 1 and # 2's initials from 9:00 p.m. through 11:00 p.m. RN # 2 found Patient # 3 at 11:15 p.m., with a sheet around his neck and a sprinkler pipe, with no signs of life. The facility's internal investigation stated: "During rounds at 11:20 p.m., the Unit RN found the patient hanging from the ceiling with a bed sheet around his neck. Vital signs were absent and CPR was not indicated due to obvious signs of irreversible clinical signs of death (rigor mortis). The patient was pronounced dead by the on call MD at 11:34 p.m."

The facility's Director of Health Care Compliance/Risk Manager was interviewed on 9/6/2011 at 5:10 p.m. The Compliance Director stated that the facility's video surveillance tapes were reviewed by the Facility Director and herself, after the patient's successful suicide. The video revealed that RN #2, HSCW # 1 and # 2 did not enter Patient # 3's room or make a face to face assessment of the patient from 9:08 p.m. through 11:15 p.m. The Compliance Director stated that the facility's internal investigation revealed that the RN and HSCW's documented that they observed the patient, but they did not. The Compliance Director stated that Patient # 3 was identified upon admission as having a cultural belief related to mental illness and his potential return to jail, and was an increased suicide risk. The facility investigation stated: "Patient's cultural beliefs: The patient is Cambodian...He expressed feeling shame for being in jail and associated it with his past history..." The investigation identified communication deficits related to sharing pertinent information such as the patient's history of trauma, cultural beliefs and language, with the treatment team and other unit staff.

The facility's investigation into Patient # 3's suicide included an environmental assessment which stated: "Our hospital is an old building with water sprinkler pipes for the fire prevention system extending from the ceiling through-out the facility. The pipes have always been included in our environmental risk assessments We have requested funding for re-construction from our Department of Behavioral Health and Developmental Services, but due to tremendous cost the budget was not approved. We received a 'Traditional Equivalency' from The Joint Commission in 2007 for this risk because of our Suicidal Protocol and Environmental Risk Assessment..."

The facility's abuse/neglect investigation conducted in response to Patient # 3's successful suicide, determined that RN # 2 , HSCW's # 1 and # 2 were negligent and were terminated from employment.

2. Unit observations were conducted by the State Survey Team on 9/6/11, and during this investigation it was revealed that safety checks or special observation checks were not being consistently conducted on current patients. Patient #'s 4, 5, 6, and 8 did not have safety checks completed as directed. All Units in the hospital were observed during this investigation to have multiple anchor points in each room, including four inch, exposed water pipes and privacy curtain rails attached to the ceilings. Additional patients were observed in their rooms unattended by hospital personal.

See A-0144, and A-0395 for additional information.


The Acting Director of Nursing (DON) was interviewed on 9/7/11 at 10:00 a.m. The DON stated that facility policy for routine safety checks ("Accountability for Patients"), dictated that every patient be checked by an assigned staff member at least every hour and by a Registered Nurse or Licensed Practical Nurse (LPN) at least every two hours. The DON stated that in response to Patient # 3's suicide, all staff were retrained on the Accountability Policy and documentation of patient safety rounds. The DON was informed of the observed safety check and patient accountability documentation and apparent lack of checks being conducted as ordered. The DON stated she did not increase supervision or surveillance of nursing staff to determine compliance with the policy. No information or documentation was presented, to evidence increased leadership monitoring of direct care nursing staff's compliance with patient accountability and safety assessments.

The Facility Director, Director of Health Care Compliance/Risk Manager and the Acting Director of Nursing were interviewed on 9/08/11 at 3:00 p.m. and informed of the above information. No further information was presented during the survey to evidence that identified employee non-compliance related to conducting safety checks was sufficiently acted upon and that the event which led to patient neglect, was rectified.
VIOLATION: QAPI Tag No: A0263
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interviews, select policy reviews, and committee meeting minutes it was determined the hospital's governing body failed to participate in, and provide oversight of, the hospital's Quality Assessment Performance Improvement (QAPI) program.

See also tag A-0043 related to this deficient practice.

The findings include:

1. A request was made during the entrance interview on 09/06/11 for a copy of the hospital's organizational chart to be made available. The organizational chart provided for review was most recently reviewed and approved on 10/04/10 and defines the structure of the organization from the different departments and employee levels to the top of the organizational chart. The highest level of the organizational structure (top of this chart) is listed as the Department of Behavioral Health and Developmental Services (DBHDS), also referred to by the administrative staff as "Central Office." This chart lists the next level down to be that of the hospital's Facility Director, and shows the different departments of the hospital report to the Director who in turn reports to the DBHDS. During the entrance interview, the hospital's Director and the Director of Health Care Compliance (DHCC) confirmed the accuracy of the chart and reporting structure.

2. During the entrance interview on 09/06/11, the Director was asked, who is the governing body? The Director first stated he thought it was suppose to be him, but he knew there had been "confusion" about that role at the state level at one time and he would need to look into that further. The Director was provided the definition from the Conditions of Participation of the Governing Body and asked to present any written evidence he may have that he is the governing body (see details of written evidence provided at tag 0043). The Director confirmed that he serves on the Leadership team for the hospital (which does not include any members from the Central Office), and that this team's review is the highest level of review of the hospital's QAPI program. The Director stated that in the past the Central Office had a department known as the Quality Council with a doctor serving as the leader, and that council was responsible for participation in, and oversight of, the hospital's QAPI program. He stated that several years ago, due to budget limitations, the Quality Council was eliminated and since then the hospital's Director was expected to be the person ultimately responsible for the QAPI program. The Director acknowledged the tracked, trended, analyzed data from the hospital's QAPI program does not get reported to the Central Office.

3. An interview took place on 09/08/11 at 1:50 PM with the Director. During this interview the Director acknowledged that the written evidence he has provided (see details of written evidence provided at tag 0043) fails to identify clearly to the facility and this inspector who is to serve as the governing body and their role. The Director also acknowledged the written evidence provided indicates there is a governing body separate from the Director, and that governing body has authorized the Director to perform a certain task related to granting medical staff privileges but does not delegate the governing body role as a whole, specifically the QAPI responsibilities, to the Director. The Director acknowledged the hospital has no evidence that the governing body plays a role in the development, implementation, and review of the QAPI program.

4. The Director of Health Care Compliance (DHCC) was interviewed on 09/07/11 at 11:30 AM. The DHCC stated she is responsible for the functions of the hospital's Quality Committee. She stated the QAPI information such as the data gathered from the hospital's projects for improvement, patient safety, medication errors, and overall quality do not get reported to a level higher than the Leadership team. The DHCC stated the Central Office has the ability to view specific reports as they are entered into their electronic system such as abuse/neglect investigations, restraints issues, and death reports, however they do not receive anything QA related that has been tracked, trended, and/or analyzed. A request was made that the DHCC provide the hospital's policies directing the functions of the QAPI program.

5. On 09/08/11 the DHCC provided for review the hospital's "Departmental Instruction 301(QM)99 Quality Management Program" issued 07/01/99 and signed by the Commissioner. (Note- this document refers to the DMHMRSAS, which stands for the Department of Mental Health, Mental Retardation and Substance Abuse Services and was the former name of the Department of Behavioral Health and Developmental Services (DBHDS) AKA "Central Office" in this report).
The DHCC stated this document is the only policy she is aware of directing the functions of the QAPI program. The following are findings related to this document.

At 301-4 Responsible Authority the document defines the responsibilities for the facility (hospital) and for the DMHMRSAS (Central Office). This section reads in part: "The Commissioner or his designee is responsible for communicating the agency's priorities to facilities for incorporation in the facility quality management plan".

At 301-5 Specific Guidance the document describes the "Role of Quality Council" as follows:
"Within each organization, the Quality Council will:
prioritize the opportunities for improvement in accordance with the plan, vision and mission of the organization
ensure the formulation of a written quality management plan and update/revise the plan annually, as indicated
ensure an annual comprehensive appraisal of the quality management program is completed and reported
oversee the implementation of quality management processes (planning, process design, measurement, assessment and improvement)
promote quality culture throughout all levels of the organization
establish facility-wide quality initiatives and ensure their completion;
ensure that performance indicators address needs of the individual facility and requirements of relevant external regulatory agencies;
ensure that appropriate disciplines/departments/staff receive feedback on quality management findings; and
monitor implementation and effectiveness of improvement efforts developed in response to quality management findings."

At 301-5 Specific Guidance the document describes the "Role of Central Office" as follows:
"The Department will:
communicate the agency's priorities to the facilities
identify systemic quality or specific performance issues for inclusion in facility quality management plans
review annual quality management reports and updates and provide feedback to facilities; and
evaluate the effectiveness of facility quality management programs."

At 301-6 Procedures under "Annual report" the document reads in part follows:
"At the end of each fiscal year, a thorough review of the year's quality management program and its activities will be performed."
"The annual report will be finalized and approved by the council and reviewed, approved and signed by the facility director and the Commissioner of DMHMRSAS."

6. The Performance Improvement Committee meeting minutes and Leadership meeting minutes were reviewed on 09/07/11 and 09/08/11 for meetings occurring during 2010 and 2011. The minutes failed to provide evidence the hospital's governing body (Central Office) received, acted upon or provided feedback for, the hospital's QAPI findings. The hospital administrative staff were unable to provide evidence the governing body has a role in the development, implementation and review of the hospital's QAPI program.

7. In an interview with the DHCC on 09/08/11 at 2:45 PM, she stated she has been in her role for four (4) years and that in that time frame there has been no reporting of the QAPI information to the Central Office/Governing Body. She stated she was aware of the reporting requirements described in the document outlined in #5 above, but there has been no Quality Council to report the findings to. The DHCC further stated she is unaware of any alternative directives provided by Central Office in relation to how this should be handled in the absence of the Quality Council.

8. During the exit conference on 09/08/11, the Director, the DHCC and the DON all acknowledged the hospital has no evidence that the governing body is involved in the development, implementation and review of the hospital's QAPI program. The Director, the DHCC and the DON also acknowledged that findings by inspectors during the clinical records review and the observations during the tour of the hospital on [DATE], are similar to the hospital's own findings after their internal investigation of the root cause analysis of the recent patient suicide. All acknowledge these findings indicate the hospital does not have effective on-going monitoring in place to assess the effectiveness of improvement measures implemented after the patient suicide. (See citation A 0115, 0144, 0145, and 0395 for additional information.)
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on staff interviews, select policy reviews, and committee meeting minutes there was no evidence that the frequency and detail of data collection was specified by the hospital's governing body.

See tag A-0263 for details related to this deficient practice.
VIOLATION: EXECUTIVE RESPONSIBILITIES Tag No: A0309
Based on staff interviews and committee meeting minutes it was determined the hospital's governing body failed to provide evidence of their responsibility and accountability for ensuring the quality improvement program's compliance with the requirements listed in 482.21(e) Executive Responsibilities, tags A-0310 through A-0317.

See tag A-0263 for details related to this deficient practice.
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on staff interviews and committee meeting minutes it was determined the hospital's governing body failed to provide evidence of their responsibility and accountability for ensuring the quality improvement program's compliance with the requirements listed in 482.21(e) Executive Responsibilities, tags A-0310 through A-0317.

See tag A-0263 for details related to this deficient practice.
VIOLATION: PROVIDING ADEQUATE RESOURCES Tag No: A0315
Based on staff interviews and committee meeting minutes it was determined the hospital's governing body failed to provide evidence of their responsibility and accountability for ensuring the quality improvement program's compliance with the requirements listed in 482.21(e) Executive Responsibilities, tags A-0310 through A-0317.

See tag A-0263 for details related to this deficient practice.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, clinical record review, staff interview and facility document review, the facility staff failed to ensure that patient care was supervised and evaluated by a registered nurse, for six of 8 patients reviewed, Patient #'s 3, 4, 5, 6, 7, and 8. Safety checks were not completed as directed, and one patient, Patient # 3 committed suicide.

Findings:

Patient # 3 was not monitored as directed and subsequently committed suicide by hanging himself from exposed pipes in his bedroom ceiling. Patient #'s 4, 5, 6, and 8 were observed by the Survey Team and the safety checks or special observation checks were not consistently conducted by nursing personnel. A review of clinical records additionally revealed that Patient # 7 was not monitored according to directives.

1. Patient # 3's safety checks were not completed as required by his individual treatment plan and according to facility policy. The patient committed suicide on 8/05/2011 by hanging himself from exposed sprinkler pipes in his bedroom. The assigned facility staff did not complete the safety checks as ordered and the Registered Nurse (RN # 2) did not do a face to face assessment of the patient at least every two hours as directed by the policy "Accountability for Patients." The RN did not supervise the direct care staff (HSCW # 1 and #2) sufficiently to ensure the patient was safe. (See A 0144 and A 0145 for additional information.)

Observations of all units on 9/6/11, revealed that safety checks were not being consistently conducted on current patients. Patient #'s 4, 5, 6, 7 and 8 did not have safety checks completed as directed. All Units in the hospital were observed during this investigation to have multiple anchor points in each room, including large, exposed water pipes and privacy curtain rails attached to the ceilings. The RN's were not completing the patient observations themselves or supervising the non-licensed staff's supervision of patients.

2. A. Patient # 4 was observed on 9/6/211 at 3:50 p.m. and her safety check document was reviewed. The safety checks had not been documented since a 2:30 p.m. check by HSCW # 3 (nurses aid). The last RN check was documented at 1:30 p.m.
B. Patient # 5 was observed on 9/6/2011 at approximately 3:54 p.m. The patient had physician's orders for 1:1 staff observation due to safety risks. The last documented check by an employee was at 3:15 p.m. The last documented check by a nurse was at 1:00 p.m. RN # 1 was interviewed at this time and she stated that patients with 1:1 supervision should have a safety check documented every fifteen minutes and that a nurse must observe the patient at least every two hours.
C. Patient # 6 was observed at approximately 4:00 p.m. The safety checks did not evidence an assessment or safety check by a nurse for the entire day shift. RN # 3 was interviewed and she stated that patients were to be monitored at least hourly by an aid and every two hours by a RN, or an LPN if an RN was not available.
D. Patient # 8 was observed at approximately 4:10 p.m. The 9/6/11 safety check did not evidence an assessment by any staff at 4:00 p.m. No checks were documented from 1:30 a.m. through 7:00 a.m. This patient was identified by the nurse as requiring "routine checks", or every hour by an aid and every two hours by a nurse. Evidence of implementation of these checks, was not presented during the survey.
E. A review of Patient # 7's clinical record revealed that safety checks and an RN assessment was not conducted as directed.

The Acting Director of Nursing (DON) was interviewed on 9/7/11 at 10:00 a.m. The DON stated that facility policy for routine safety checks ("Accountability for Patients"), dictated that every patient be checked by an assigned staff member at least every hour and by a Registered Nurse or Licensed Practical Nurse (LPN) at least every two hours. The DON stated she did not increase supervision or surveillance of nursing staff to determine compliance with the policy. No information or documentation was presented to evidence increased leadership monitoring of the registered nurses' supervision of patient care activities. The DON ws informed of the Survey Team's observations and apparent lack of RN supervision to ensure checks were completed, and/or did not complete the required nurse assessments

The Facility Director, Director of Health Care Compliance/Risk Manager and the Acting Director of Nursing were interviewed on 9/8/11 at 3:00 p.m. and they acknowledged the above information. Information to evidence adequate RN supervision of patient care was requested. No further information was presented during the survey, to evidence that patients were sufficiently evaluated for safety and that non-licensed staff were supervised to ensure provision patient care according to physician's orders and hospital policy.

A review of clinical records and facility policy revealed the following:




3. The facility's administrative staff provided policies for review, as requested, related to the requirements for patient observations by facility staff and the documentation requirements. Those policies were reviewed with the following findings.

Nursing Administration Policy No. 36, titled Accountability For Patients with the effective date of August 2011 reads in part as follows:
? "The charge nurse (as evidenced by his/her initials on checklist) on each shift will be responsible for checking his/her assigned patients and will monitor to assure compliance to the policy."
? "Each patient assigned to the unit will be accounted for by the charge nurse or designee (must be RN or LPN) on each shift every two (2) hours. These checks will be documented on the Hourly Activity/Hourly Check Sheet and initialed."
? "Hourly checks will be made on each shift by the staff member assigned to make the accountability checks (this is in addition to the every two (2) hour checks made by the nurses). These checks will be documented on the Hourly Activity/Hourly Check Sheet and initialed."
? "Records documenting accountability checks will be forwarded to the Unit Secretary. These records will be filed for three (3) years, after which they will be shredded or burned (Ref. 720-GS.74 "Patient Care Monitoring Reports and Logs")."

Hospital Instruction Policy No.118 (TX) 06, titled Special Observation and Monitoring of Patients with the effective date of March 1, 2006 reads in part as follows:
? "Special observation and monitoring of patients will be ordered on an individual basis for patients based on a physician's order for patients who are assessed to be at risk for self-injury due to medical reasons or due to high risk behaviors (unpredictable hitting, damaging property, intrusiveness). A physician shall order the appropriate level of observation required by the patient."
? "A Physician's Order is required for discontinuation of Special Observation."
? "The RN shall be responsible for assigning appropriate nursing staff to monitor the patient for intervals not to exceed two hours."
? "Documentation of the special observation and monitoring of Patients will utilize PGH form "Special Observation Flow Sheet"."
? "The Observation Record will be filed in the flow sheet section of the patient's medical record."
? "Staff will initial the flow sheets according to instruction printed on the form."

4. An interview took place with the Acting Director of Nursing (DON) on 09/08/11 at 11:45 AM. During the interview the DON confirmed the hospital's expectations are that all staff (nurses and aides) complete their documentation for all patient observations and safety checks immediately at the time the observation actually occurs. The DON was informed of the findings related to observations made by two (2) medical facilities inspectors while conducting a tour of the facility and observations of care on 09/06/11; patients who were identified as being on special observations (see also tag 0144 and 0145) by the facility staff during the tour and observations, with no documentation at the time of the tour for specific safety checks or RN observations that should have been documented. The DON acknowledged those observations should have been documented at the time they were conducted and that since they were not documented there is no evidence the observations occurred. The DON stated that all patients are to be observed by an RN (may be done by an LPN in rare instances in which an RN may be unavailable) at a minimum of every two (2) hours even if their physician has not ordered a specific frequency for observations.

5. An interview took place with the DON on 09/08/11 at 1:00 PM. The DON stated she believes the explanation to some of the missing documentation by staff for RN observations and safety checks (see #4 above and #6 below) "may be" because the staff are documenting their observations and safety checks on a worksheet that is used on the patient care areas instead of on the Observation Record. She confirmed the worksheet she is referring to is the Hourly Activity/Hourly Check Sheet described in #3 above. The DON was informed during this interview that both inspectors observed this worksheet in use on 09/06/11 and based on other interviews with staff it was this inspector's understanding that this worksheet nor it's documentation ever become a part of the patient's clinical record. The DON stated "you are exactly right" and that she had not thought about the fact that the information never makes it to the patient's chart and "that's something we need to work on." The DON confirmed the findings from the review of the policies outlined in #3 above, specifically that the Observation Record's documentation becomes a part of each patient's chart, but any documentation on the Hourly Activity/Hourly Check Sheet does not. The DON acknowledged that when the staff document required observations and assessments on a worksheet that never becomes a legal part of the patient's clinical record, this creates an inability to confirm compliance with those required observations when reviewing the patient's clinical record. The DON acknowledged understanding that all care provided should be documented in the patient's clinical record.

6. The clinical records of patient # 4, 5, 6, 7, and 8 were reviewed on 09/07/11 and 09/08/11. These records were part of a focused review of a total sample of eight (8) records reviewed as a part of this complaint investigation. Below are the findings specific to each record.

a. The record of patient #4 reveals the patient was admitted to the facility on [DATE] and remains a current patient in the facility at the time of the inspection. The record contains physician's orders dated 09/01/11 at 1:50 PM and continuing through 09/05/11 at 10:15 AM for the patient to have safety checks every 15 minutes by the facility staff for "behaviors." On 09/05/11 at 10:15 AM the physician ordered the safety checks for "impulsive behavior" to be reduced to every 30 minutes and this order is continued on 09/06/11 through the inspection date.
On 09/02/11 the RN documentation reveals the every 2 hour nurse observations were missed a total of four (4) times with ranges noted of 2 and 1/2 hours to 3 hours passing between documented RN checks. On 09/02/11 the documentation reveals the every 15 minute safety checks were missed eleven (11) times that day for times ranging from 1 hour to 2 hours between checks.
On 09/03/11 the RN documentation reveals the every 2 hour nurse observations were missed a total of five (5) times with ranges noted of 3 to 8 hours passing between documented RN checks. On 09/02/11 the documentation reveals the every 15 minute safety checks were missed twenty-six (26) times that day for times ranging from 30 minutes to 1 and 1/2 hours between checks.
On 09/05/11 the RN documentation reveals the every 2 hour nurse observations were missed a total of two (2) times with up to 4 and 1/2 hours passing between documented RN checks. On 09/05/11 the documentation reveals the every 15 minute safety checks were missed one (1) time that day at 4:15 AM.
On 09/06/11 the RN documentation reveals the every 2 hour nurse observations were missed one (1) time with 3 and 1/2 hours passing between documented RN checks.

b. The record of patient #5 reveals the patient was admitted to the facility on [DATE] and remains a current patient in the facility at the time of the inspection. The record contains physician's orders dated 09/01/11 at 11:45 AM and continuing through 09/05/11 for the patient to have Modified 1:1 observation by the facility staff. (Note: Modified 1:1 is defined in the facility's policy No. 118 titled Special Observations and Monitoring of Patients and dated 03/01/06, as the patient constantly observed and "within 2 arms length" of the facility staff and requires the care be documented on the Observation Record in the patient's clinical record).
On 09/02/11 the RN documentation reveals the every 2 hour nurse observations were missed one (1) time with 2 hours and 45 minutes passing between documented RN checks. On 09/02/11 the documentation fails to provide evidence that at 12:00 midnight patient is receiving the Modified 1:1 observations, as that space in the Observation Record is completely blank.
On 09/03/11 the RN documentation reveals the every 2 hour nurse observations were missed one (1) time with 4 hours passing between documented RN checks.
On 09/05/11 the RN documentation reveals the every 2 hour nurse observations were missed a total of seven (7) times with a range noted of 3 to 10 hours passing between documented RN checks.

c. The record of patient #6 reveals the patient was admitted to the facility on [DATE] and remains a current patient in the facility at the time of the inspection. The record contains physician's orders dated 09/01/11 at 3:00 PM and continuing through 09/07/11 for the patient to have safety checks every 15 minutes by the facility staff for "unsafe behaviors."
On 09/01/11 the Observation Record reveals the safety checks were not begun for patient #6 until 4:00 PM and the first documented RN observation was at 6:00 PM.
On 09/02/11 the RN documentation reveals the every 2 hour nurse observations were missed eight (8) times with the last RN observation being documented at 7:45 AM and not documented again until 8:00 AM on 09/03/11, resulting in 24 hours and 15 minutes passing between documented RN checks. On 09/02/11 the documentation reveals the every 15 minute safety checks were missed nine (9) times that day with times ranging from 1 to 1 and 1/2 hours passing between documented safety checks.
On 09/03/11 the RN documentation reveals the every 2 hour nurse observations were missed a total of eight (8) times with a range noted of 7 hours and 45 minutes to 9 hours passing between documented RN checks. On 09/03/11 the documentation reveals the every 15 minute safety checks were missed one (1) time at 12:00 midnight.
On 09/06/11 the RN documentation reveals the every 2 hour nurse observations were missed a total of eight (8) times with a range noted of 4 to 10 hours passing between documented RN checks. On 09/06/11 the documentation reveals the every 15 minute safety checks were missed twenty-nine (29) times that day, as each 15 minute increment up to 7:30 AM when the first safety check for that date is documented, was completely blank.
On 09/07/11 the RN documentation reveals the every 2 hour nurse observations were missed a total of seven (7) times with 15 hours passing between the last documented RN check at 9:15 AM and the end of the day at 12:00 midnight.

d. The record of patient #7 reveals the patient was admitted to the facility on [DATE] and remains a current patient in the facility at the time of the inspection. The record contains physician's orders dated 09/01/11 and continuing through 09/03/11 for the patient to have safety checks every 15 minutes by the facility staff for "unsafe behaviors." The record contains physician's orders dated 09/03/11 at 6:40 PM for the patient to be transferred by ambulance to another facility's emergency department for evaluation related to an elevated temperature while on antibiotics. The record contains physician's orders dated 09/06/11 for the patient's services to be resumed as she has returned to the facility. The record contains physician's orders dated 09/06/11 at 2:40 PM and continuing through 09/07/11 for the patient to have safety checks every 15 minutes by the facility staff for "unsafe behaviors."
On 09/01/11 the RN documentation reveals the every 2 hour nurse observations were missed a total of seven (7) times with times ranging from 3 hours to 11 hours passing between documented RN checks.
On 09/02/11 the RN documentation reveals the last 2 hour nurse observation entry was made by the RN at 7:00 AM and no further RN observations were documented until 09/06/11 when the patient returns to the facility after having been transferred to another facility on 09/03/11 at around 7:00 PM. On 09/02/11 the documentation reveals the every 15 minute safety checks were missed twenty-six (26) times that day with times ranging from 1 hour to 4 hours passing between documented safety checks. This includes a time frame from 8:00 AM till 12:00 noon in which entries were made on the Observation Record but were not initialed or authenticated in any way by the person or persons making the entries.
On 09/03/11 the RN documentation reveals the every 2 hour nurse observations were missed (see the description of 09/02/11 RN documentation findings above).
On 09/06/11 the RN documentation reveals the every 2 hour nurse observations were missed a total of two (2) times with 4 hours passing between documented RN checks. On 09/06/11 the documentation reveals the every 15 minute safety checks were not started on the patient until 4:00 PM after being ordered by the physician at 2:40 PM.
On 09/07/11 the RN documentation reveals the every 2 hour nurse observations were missed a total of seven (7) times with 14 hours passing between the last documented RN check at 10:00 AM and the end of the day at 12:00 midnight. On 09/07/11 the documentation reveals the every 15 minute safety checks were missed one (1) time at 12:00 noon.

e. The record of patient #8 reveals the patient was admitted to the facility on [DATE] and remains a current patient in the facility at the time of the inspection. The record contains physician's orders dated 08/05/11 and continuing through 09/07/11 for the patient to have Direct Observation while in bed.
The clinical record fails to contain evidence for the time frame reviewed of 09/01/11 to 09/08/11, that every 2 hours the nurse observations were completed as required by facility policy. The Observation Records revealed the RN documented observation of the patient every 2 hours only at times when the Observation Record documented the patient as in bed and requiring the direct observations. The record failed to contain evidence for 09/01/11 to 09/08/11 that the RN performed the every 2 hour observations of the patient at times when he was not on special observation monitoring.

7. During the exit conference on 09/08/11 the DON, the Director of Health Care Compliance, the Medical Director, and the Facility Director were present. All acknowledged the failure of the staff to perform and/or document observations and safety checks per facility policies and as ordered by the physician are consistent with findings from their own internal investigation and root, cause, analysis of the recent patient suicide at their facility. All acknowledge the necessity of having the required tasks, first completed by the staff as indicated by policy and/or physician's order, but also documented in the patient's clinical record.
VIOLATION: PHYSICAL ENVIRONMENT Tag No: A0700
This Condition of Participation is not met based on the findings of a Complaint Investigation conducted on 9/6/11 through 9/8/11. The Standard of A 0701 was not met. The facility's physical environment included multiple anchor points which offer the potential for patient self harm. These anchor points included four inch diameter exposed sprinkler system pipes and privacy curtain rods on all units.

See the following conditions for additional information:

482.12 Condition of Governing Body;
482.13 Condition of Participation: Patient Rights;
482.41(a)-A 0701: Physical Environment
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, clinical record review, facility document review, staff interview and during the course of a complaint investigation, the facility staff failed to ensure a physical environment was provided to ensure patient safety. Patient # 3 committed suicide by hanging himself on exposed sprinkler system pipes.

Findings:

During the course of a complaint investigation, Patient # 3's clinical record was reviewed. The clinical record and the facility's investigation revealed that the patient hung himself on the exposed pipes on 8/5/2011.

On 9/6/11 each patient care unit was observed by the State Survey Team. Each unit was noted to have large sprinkler system pipes and privacy curtain rails attached to the ceilings of patient rooms. During this tour of the units, multiple patients were noted to be in their rooms without direct staff member observations. Multiple patients with special observation requirements were noted to have lapses in the documentation of required observations. (See A 0144, A 0145 and A 0395 for additional information).

The facility's investigation into Patient # 3's suicide included an environmental assessment which stated: "Our hospital is an old building with water sprinkler pipes for the fire prevention system extending from the ceiling through-out the facility. The pipes have always been included in our environmental risk assessments We have requested funding for re-construction from our Department of Behavioral Health and Developmental Services, but due to tremendous cost the budget was not approved. We received a 'Traditional Equivalency' from The Joint Commission in 2007 for this risk because of our Suicidal Protocol and Environmental Risk Assessment..."

The Facility Director was interviewed on 9/8/11 at 11:15 a.m. The FD stated that The Joint Commission (TJC) identified the environmental risk related to the facility's exposed fire sprinkler system, and "Central Office got them to drop it secondary (due to) costs." The FD stated that the current census was 109 patients and potentially all were at risk due to the exposed pipes and curtain rails.

The Facility Director, Director of Health Care Compliance/Risk Manager and the Acting Director of Nursing were interviewed on 9/8/11 at 3:00 p.m. and they acknowledged the above information. No further information was presented during the survey to evidence compliance with the provision of a safe environment.

"The Joint Commission's Sentinel Event Alert", Issue 7-November 6, 1998 (retrieved September 12, 2011 @ 12:00 p.m. from http://www.jointcommission.org/assets/1/18/SEA_7.pdf), documented a root cause analysis related to sixty-five, inpatient facility suicides. In 75% of the cases, hanging was the method of suicide. The analysis concluded, that as part of the root cause of inpatient suicides: "The environment of care, such as the presence of non-breakaway bars, rods or safety rails..."; and " Incomplete or infrequent patient observations ... " . The report included "Reducing Risk Factors: Organizations that experienced the suicides recommended the following risk reduction strategies: ...Identifying and removing or replacing non-breakaway hardware...."

The Joint Commission Sentinel Event Alert, Issue 46, November 17, 2010 (retrieved September 12, 2011 @ 12:19 p.m. at http://www.jointcommission.org/assets/1/18/SEA_46.pdf) updated the prevention strategies presented in the previous Alert (Issue 7, [DATE]). The Alert included risk factors for suicide to include recent suicide attempts, depression, dementia, and age-with older adults having an increased risk. The contributing factors to suicide were included: "...Common environmental risk factors include potential anchor points for hanging, material that can be used for self-injury, and problems maintaining a secure environment. The methods of self harm most frequently used in health care environments-include hanging...-correspond to these common environmental risk factors..."
VIOLATION: GOVERNING BODY Tag No: A0043
Based on a review of the hospital's organizational chart, the quality program, and interviews, it was determined the hospital's administrative staff are unclear as to who serves as the governing body. The highest level of governing oversight listed on the organizational chart, failed to provide evidence of any participation with or oversight of the hospital's QAPI (Quality Assessment Performance Improvement) activities.

The Governing Body also failed to ensure facility compliance with the following Conditions of Participation: 482.13 (Patient rights); 482.21 (Quality Assurance) and 482.41 (Physical Environment).

See also tag A-0263

The findings are:

1. A request was made during the entrance interview on 09/06/11 for a copy of the hospital's organizational chart to be made available. The organizational chart provided for review was most recently reviewed and approved on 10/04/10 and defines the structure of the organization from the different departments and employee levels to the top of the organizational chart. The highest level of the organizational structure (top of this chart) is listed as the Department of Behavioral Health and Developmental Services (DBHDS). This chart defines the next level down to be that of the hospital's Director, and shows the different departments of the hospital report to the Director who in turn reports to the DBHDS. During the entrance interview, the Director and the Director of Health Care Compliance (DHCC) confirmed the accuracy of the chart and reporting structure. Both the Director and the DHCC referred to the DBHDS as "Central Office" and acknowledged this entity as the highest level of direct oversight for the hospital. The Director stated the DBHDS is located on the same campus as the hospital but not in the same building. Both stated as well that the DBHDS had recently changed their name and were previously the Department of Mental Health, Mental Retardation and Substance Abuse Services (DMHMRSAS). For purposes of this report the term "Central Office" will be used instead of either the current or previous names in an attempt to reduce confusion, since it is the term most used and recognized by the hospital's administrative staff as their governing entity.

2. During the entrance interview on 09/06/11, the hospital's Director was asked, who is the governing body? The Director first stated he thought it was supposed to be him, but he knew there had been "confusion" about that role at the state level at one time and he would need to look into that further. The Director was provided the definition from the Conditions of Participation of the Governing Body and asked to present any written evidence he may have that he is the governing body.

3. An interview took place on 09/08/11 at 1:50 PM with the Director. During this interview, the Director provided two (2) memos received by the hospital's Directors from the Central Office, related to the issue of who serves as the governing body for the facility. The Director stated he is aware that both the memos are from quite some time ago, but this is all he has in writing that speaks to who is the governing body for this hospital. Both memos were reviewed by this inspector with the following findings:

Memo #1 dated 07/29/94 was to the Facility Directors, from the Acting Associate Commissioner (at that time) with the subject listed as "Governing Body." This memo reads in part:
"There is no provision in the Code of Virginia for establishment of governing bodies. The Commissioner and State Board are the only legal governing authorities in the Department. I am aware that the governing body concept was developed in response to a JCAHO expectation that the facility director receive input from the community about facility operations. I believe, however, that the same objective can be achieved without using the term "Governing Body." Accordingly, please change the name of your governing body to "Executive Advisory Committee" or a name that accurately reflects the role of the committee."

Memo #2 dated 05/31/02 was to the Facility Directors, from the Commissioner (at that time) with the subject listed as "Delegation of Authority for Medical Staff Privileging." This memo reads in whole:
"I hereby delegate to the facility directors of DMHMRSAS hospitals the authority to act on behalf of the Governing Body for the purpose of granting medical staff privileges in accordance with the facility's medical staff bylaws."

4. At the conclusion of the review of the above described memos (see #3 above), the Director acknowledged that memo #1 fails to identify clearly to the facility who is to serve as the governing body and their role. The Director also acknowledged that memo #2 indicates there is a governing body separate from the Director, and that governing body is authorizing the Director to perform a certain task related to granting medical staff privileges but does not delegate the governing body role as a whole to the Director.

5. For additional details related to this deficiency see tag A-0263 which describes the governing body's failure to participate in and oversee the hospital's QAPI program.