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.

MOUNTAIN VIEW HOSPITAL 3201 SCENIC HIGHWAY GADSDEN, AL Aug. 25, 2011
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on record reviews, observations, hospital policies and interviews the facility failed to assure:

A. Care was provided in a safe setting to include:

1. The patients' rooms were clean.
2. Furniture and fixtures were continually maintained and safe for the patients to use.
3. Safety locks were not available for patient use in patient care areas.
4. Seclusion room was occupied only when ordered.

Refer to A 144

B. Patients were free from abuse/harassment. The facility failed to:

1. Follow their policy on possible patient abuse and investigated the allegation timely.

2. Provided a safe environment for an adolescent patient who had an altercation with a staff member.

3. Documented a complete investigation and resolution for an incident between a patient and a staff member.

4. Reassigned a nurse who was involved in an incident/altercation with a patient.

Refer to A 145

C. The physician signed orders for restraint.

Refer to A 168

This had the potential to affect all patients served by this facility.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation and interview with administrative staff it was determined the facility failed to:

1. Ensure the patients' rooms were clean.
2. Ensure furniture and fixtures were continually maintained and safe for the patients to use.
3. Ensure safety locks were not available for patient use in the patient care areas.
4.Ensure the seclusion room was occupied only when ordered.

This had the potential to affect all patients.


Findings include:

On 8/15/11 at 1:15 PM, the surveyors conducted a tour of the first floor of the hospital which housed the adolescent girls.

The following was observed:

In the break room, where the adolescent girls eat their meals, the air conditioner vent was broken. There were bare coils and metal ends that exposed hazardous areas that posed a potential harm to patients.

The shower areas contained two shower stalls which had shower curtains that did not breakaway thus leaving hazardous areas in which a patient could harm themselves.

In patient room 106 and 112 the air conditioner vent had metal exposed which caused a potential hazardous area that could harm patients.

On 8/15/11 at 1:30 PM, the surveyors conducted a tour of the third floor of the hospital which housed the adolescent boys and children.

The following were observed:

The bathroom between patient rooms 302 and 304 had twist locks on either side which would allow a patient to be locked into the bathroom with no way out.

In patient room 326 the entire air conditioner vent was off leaving bare coils which caused a potential hazardous area in which patients could harm themselves.

In patient room 328 the air conditioner vent had pulled up edges which caused a potential hazardous area in which patients could harm themselves.

The above observations were verified by Employee Identifier (EI) # 1, Chief Operations Officer and EI # 2, the Director of Services during the tour.

An observation of the seclusion room on the children's wing on 8/15/11 at 1:40 PM, revealed a bed made up with a bottom and top sheet, bed spread and pillow. There were 2 used Band-Aids on the floor. When the surveyors asked who had been using the seclusion room as a bedroom none of the staff could verify the name of the patient or when they had occupied the seclusion room. After approximately 10 minutes of reviewing records and talking with patients, the staff stated a patient used the room on the night of 8/11/11. The surveyor then asked why the room had not been cleaned in 4 days, no response was given. EI # 1 and 2 then directed the housekeeping department to clean the seclusion room.

A second observation of the seclusion room after cleaning by the housekeeping department on the children's wing on 8/15/11 at 1:50 PM, revealed the bed had been made up with the same bottom sheet as evidenced by cereal crumbs on the bottom sheet. This was verified by EI # 2.

During a second tour of the third floor of the hospital on [DATE] at 2:00 PM, it was noted the seclusion room bed had metal brackets (for the use of restraints) hanging down which were exposed and presented a cutting hazard.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on review of medical and personnel records, facility policy and procedure and interview with administrative staff it was determined the facility failed to:

1. Follow their policy on possible patient abuse and investigate the allegation timely.

2. Document a complete investigation and resolution of the alleged incident between a patient and staff.

3. To reassign the nurse involved in an incident with a patient while an investigation was being conducted.

This has the potential to affect all patients served by the facility and did affect Patient Identifier (PI) # 2.

Findings include:

Facility Policy: Identifying and Reporting Patient Abuse and Neglect

Policy: It is the policy of ... that any instances of physical, psychological, sexual or any other abuse by any employee or any professional staff... toward a patient will not be tolerated. All employees are expected to report any suspected patient abuse or neglect to their immediate supervisor or the Chief Executive Officer on an Incident report.

Procedure:
B. Penalties for discipline are determined through investigation by the Chief Executive officer and the respective Department Manager.
3. Penalties to be imposed shall consist of one of the following, based upon the investigation conducted by the Chief Executive Officer, Department Head and/or supervisor(s).
a. Official reprimand
b. Reassignment
c. Demotion
d. Suspension
e. Dismissal

E. Staff Responsibilities:
1. Hospital staff
a. Staff receiving or witnessing an incident of patient abuse or neglect must report the incident to their immediate supervisor or the Chief Executive Officer by filing an incident report...
b. Document all information concerning the incident on the Incident Report form being as descriptive as possible.
c. Submit completed Incident Report to their immediate supervisor who brings the incident report to the Chief Executive Officer.

2. Upon receipt of the completed Incident Report form that alleges patient abuse or neglect, the Director of Patient Services will contact the Hospital Chief Executive Officer and:
a. Shall investigate all complaints as soon as administratively possible.
b. Ascertain that all substantial allegations in a complaint shall remain open until adequate remedial action has been provided.

3. Chief Executive Officer
a. Upon receipt of an incident report or complaint that alleges employee, family or patient abuse or neglect, will meet as soon as possible with the supervisor.
d. Shall conduct a disciplinary hearing with involved staff and issue penalties.
f. Files the incident report in the professional, employees or contract employees personnel file.

4. Hospital Executive Committee:
a. Shall review all data in relation to allegations of patient abuse/neglect.
b. Shall interview all staff involved or who has knowledge of the allegations of patient abuse/neglect and ascertain if the patient's rights have been violated.
c. Shall make written recommendations to the Chief Executive Officer for remedial action.

Facility Policy: Quality Assurance Reporting

Purpose:
To provide a mechanism for reporting hospital occurrences related to patient/employee safety.

Policy:
All occurrences on or within Corporate property should be reported to an immediate supervisor/ physician and documented in the patient record when appropriate. A Quality Assurance Report will be completed and forwarded to the Risk Manager for follow-up.

The following occurrences should warrant completion of an Quality Assurance Report, but is not inclusive:
1. Patient injury, patient abuse, or patient emergency
2. Visitor injury
3. Employee injury
4. Falls
5. Injuries resulting from Restraint/ Seclusion


Patient findings:

1. Patient identifier (PI) # 2 was admitted to the facility 1/19/11 with an Axis I diagnosis of Bipolar Disorder not otherwise specified/ Impulse Control Disorder not otherwise specified/ Polysubstance Abuse.

An incident report dated 6/2/11 by Employee Identifer (EI) # 4, the Nurse Manager documented an altercation between the floor nurse and a female patient. Attached to the incident report were statements from EI # 4 on 6/7/11 when interviewed by the nurse manager. Two of the Psychiatric technicians involved provided written statements 6/8/11 and written statements were obtained from EI # 3, Registered Nurse (RN) # 1 and EI # 5, RN # 2 on 6/25/11. Two other Psychiatric technicians involved provided written statements 6/8/11 and 6/25/11. The house supervisor was not asked to complete a statement regarding the incident nor was the male Psychiatric technician who responded to the Code Yellow asked to document his observations.

During an interview on 8/15/11 at 12:30 PM with EI # 10, Director of Human Resource, he was asked why it was 6/25/11 before the statements of the two RN's were obtained. EI # 10 stated, " I can't remember why it took so long to get their statements."

EI # 10 was asked why the incident report was started by the Nurse Manager, EI # 4 on 6/2/11 and signed off on 6/7/11. EI # 10 stated that EI # 4 just started the Incident report and he completed it 6/25/11 after he received the two RNs' statements.

There was no documentation in the personnel file of the nurse involved in the altercation with the patient when reviewed by the surveyor 8/17/11.

An interview was conducted on 8/16/11 at 8:05 AM, with EI # 3, RN # 1 who was involved in the altercation with PI # 2 on 6/2/11. EI # 3 was asked if she completed an incident report concerning the incident. EI # 3 stated that she completed an incident report before the end of her shift the early AM of 6/3/11 and asked two of the Psychiatric Technicians who worked with her that night to sign it and then she put it under the door of the Nurse Manager.

An interview was conducted on 8/16/11 at 7:10 AM, with EI # 6, Psychiatric Technician, she was asked who asked her to complete a statement concerning the incident. EI # 6 stated it might have been the Nurse Manager on 6/7/11 because I did it and turned it in 6/8/11. EI # 6 was asked if an incident report was completed by the nurse involved. EI # 6 stated that she signed an incident report that was completed by EI # 3, any of the people involved had to sign it.

The incident report completed by EI # 3 the RN involved in the altercation with PI # 2 was not located while the surveyor was onsite. The Nurse Manager stated that she did not see an incident report under her door 6/3/11 when she came into work.

In an interview with EI # 4 on 8/15/11 at 12:30 PM, the surveyor asked when EI # 3 was moved to another unit. EI # 4 stated, " When I met with her 6/7/11, I told her she should not work with PI # 2. She worked with her even though I told her not too."

A review of the Child and Adolescent schedules for the month of June confirmed the nurses were not assigned to a specific area to work except for the schedule dated 6/29/11 which documented EI # 3 was to work 4 th floor residential.

A review of the medical record confirmed EI # 3 worked with PI # 2 on 6/2/11, 6/6/11, 6/7/11, 6/10/11, 6/12/11, 6/15/11, 6/16/11, 6/20/11, 6/21/11, 6/24/11 and 6/25/11.

During an interview with EI # 2, the Director of Clinical Services she confirmed that she had a conversation on 6/29/11 at 5:10 PM and instructed EI # 3 that upon return to work she would be working on Adult unit or residential unit and that she was not to go on the third floor where PI # 2 was located. The facility failed to ensure EI # 3, the nurse involved in the incident with PI # 2, was reassigned to a different area.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on a review of medical records, facility policy and procedures and interview with Employee Identifer( EI) # 1, the Chief Operations Officer and EI # 4 the Nurse Manager it was determined the facility failed to assure the physician signed orders for restraint. This had the potential to affect all patients served by this facility and did affect Patient Identifer # 2.

Facility Policy: Restraints and Seclusion

Section Three: Physician Orders for Restraint and Seclusion and Evaluation
If the Registered Nurse (RN) initiates the restraint or seclusion, as soon as possible, but no longer than one hour, the Registered Nurse must notify and Obtain an order from the Psychiatrist... The Psychiatrist or trained Registered Nurse will do the following:
1. Reviews with the RN the physical and psychological status of the patient.
2. Determine whether restraint or seclusion should be maintained.
3. Supplies staff with guidance in identifying ways to help the patient regain control so that restraint or seclusion can be discontinued.
4. Supplies a time-limited order.

Facility Policy: Physician's Orders
Procedure:
C. Verbal and telephone orders must be authenticated within twenty-four hours.

Patient Findings:

1. Patient identifier (PI) # 2 was admitted to the facility 1/19/11 with an Axis I diagnosis of Bipolar Disorder not otherwise specified/ Impulse Control Disorder not otherwise specified/ Polysubstance Abuse.

A certified copy of PI # 2's medical record was given to the surveyor on 8/16/11 with the form signed 8/15/11 by the Custodian of Records.

On reviewing the orders for restraint and seclusion it was observed that the orders dated 5/29/11, 6/2/11, 6/5/11, 6/9/11 and 7/10/11 were not authenticated by the physician within 24 hours.

During an interview with EI # 4, the Nurse Manager on 8/18/11 at 9:30 AM, EI # 4 stated, "All of the orders are signed except 6/5/11 and no date was on the 6/9/11 order." The surveyor asked when the orders were signed as the certified copy of the medical record received 8/16/11 and the orders were not signed. EI # 4 said she did not know and produced signed orders dated as follows: the 5/29/11 order was signed by EI # 8, the Medical Director and dated 5/29/11, the 6/2/11 restraint and seclusion order was signed by EI # 8 and dated for 6/30/11 and the 6/9/11 order still does not have a date or time it was signed.

EI # 1, the Chief Operations Officer confirmed the orders were not signed in the copies of the medical record the surveyor received 8/16/11.
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview with the staff, it was determined the facility failed to ensure the medical records reflected the accurate admitted in 1 of 1 closed records reviewed of a patient that was admitted to the acute care hospital from the residential care unit associated with the facility. This affected Patient Identifier (PI) # 3 and had the potential to affect all patients served by this facility.

Findings include:

1. PI # 3 was determined to be admitted to the facility on [DATE] or 5/7/11 with diagnoses including Mood Disorder and Impulse Control Disorder. This patient has a history of Major Depressive Disorder,Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, and Relative Attachment Disorder.

Review of the Discharge Summary dictated 6/6/11 revealed documentation the patient was admitted on [DATE].

Review of the admission Physician Orders revealed a date of 5/6/11 at 19:15.

Review of the Restraint/Seclusion Protocol MD (physician) Orders revealed an order dated 5/6/11 at 16:15.

An interview was conducted with Employee Identifier # 1, the Chief Operations Officer on 8/17/11 at 1:00 PM. The surveyor asked what date the patient was admitted to the facility and the response was, "the patient was a residential client and transferred to the acute care hospital on [DATE] and the acute care would not read the admitted until 5/7/11 due to billing purposes". The admitted was determined to be 5/6/11, however the medical record failed to reflect the actual admitted .
VIOLATION: VERBAL ORDERS AUTHENTICATED BASED ON LAW Tag No: A0457
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical records, interview with Employee Identifer (EI) #1, the Chief Operations Officer and EI # 4, Nurse Manager and facility policy it was determined the physician failed to sign the physician orders within twenty four hours per the facility's policy and to date and time them when they were signed. This had the potential to adversely affect all patients served by the facility.


Facility Policy: Physician's Orders
Procedure:
C. Verbal and telephone orders must be authenticated within twenty-four hours.

Patient Findings:

1. Patient identifier (PI) # 2 was admitted to the facility 1/19/11 with an Axis I diagnosis of Bipolar Disorder not otherwise specified/ Impulse Control Disorder not otherwise specified/ Polysubstance Abuse.

A certified copy of PI # 2's medical record was given to the surveyor on 8/16/11 with the form signed 8/15/11 by the Custodian of Records.

On reviewing the orders for restraint and seclusion it was observed that the orders dated 5/29/11, 6/2/11, 6/5/11, 6/9/11 and 7/10/11 were not authenticated by the physician within 24 hours.

During an interview with EI # 4, the Nurse Manager on 8/18/11 at 9:30 AM, EI # 4 stated, " All of the orders are signed except 6/5/11 and no date was on the 6/9/11 order." The surveyor asked when the orders were signed as the certified copy of the medical record received 8/16/11 and the orders were not signed. EI # 4 said she did not know and produced signed orders dated as follows: the 6/2/11 restraint and seclusion order was signed by EI # 8, the Medical Director and dated for 6/30/11, the 5/29/11 order was signed by EI # 8 and dated 5/29/11, the 6/9/11 order still does not have a date or time it was signed.

A review of other physician orders that were not signed included the following:
6/15/11, 6/21/11, 6/22/11, 7/7/11, 7/10/11, 7/22/11, 8/8/11 and 8/2/11.

EI # 1 confirmed the orders were not signed in the copies of the medical record the surveyor received 8/16/11.

The orders observed in the medical record that were signed by the physician were not consistently dated and timed, only the restraint orders were dated with the exception of the 6/9/11 restraint order.





2. PI # 3 was admitted to the facility on [DATE] with diagnoses including Mood Disorder and Impulse Control Disorder. This patient has a history of Major Depressive Disorder,Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, and Relative attachment Disorder.

Review of the physician orders dated 5/6/11(restraint/seclusion), 5/7/11, 5/8/11, 5/9/11 x 2 orders, 5/13/11 x 2 orders, 5/17/11, 5/23/11 (restrain/seclusion), 5/24/11 (restraint/seclusion), 5/26/11 (restrain/seclusion), 5/27/11, 5/28/11, 5/29/11 (restrain/seclusion),5/30/11, 6/1/11, and 6/2/11 x 3 orders revealed no documentation of a date and time the physician authenticated the orders.

An interview was conducted on 8/17/11 at 2:10 PM with EI # 9, the Counselor and EI # 4 who verified the above.

3. PI # 1 was admitted to the facility on [DATE] with diagnoses including Depressive Disorder and Inhalant Abuse.

Review of the Admission Physician Orders dated 10/25/10 revealed no documentation of a physician's signature for authentication.


Review of the physician orders dated 10/26/1011/3/10, 11/4/10, 11/7/10, 11/8/10, 11/9/10, 11/16/10 (restraint/seclusion)11/13/10, 11/15/10, and 11/17/10 revealed no documentation the physician signed and dated to authenticate the verbal orders.

An interview was conducted on 8/18/11 at 9:20 AM with EI # 9, the Counselor and EI # 4 who verified the above.
VIOLATION: DELIVERY OF DRUGS Tag No: A0500
Based on the review of the Alabama Board of Nursing, Standards of Practice and medical records and interview with the staff, it was determined the facility failed to ensure the nursing staff followed the Alabama Board of Nursing, Standards of Practice for medication administration. This had the potential to affect all patients served by this facility and did affect 1 of 1 open records reviewed, Patient Identifier (PI) # 2.

Findings include:


Refer to 420-5-1-.02(8)(a) Records and Reports
Alabama Board of Nursing, Standards of Practice
Chapter 610-X-6-.06 Documentation Standards (d)(iii)
(d) Timely.
(i) Charted at the time or after the care, including medications, is provided...
(ii) Should the registered nurse or licensed practical nurse add documentation that was omitted, the documentation shall reflect " late entry" including a date and time the late entry was made as well as the date and time the care was provided.

Alabama Board of Nursing, Standards of Practice
Chapter 610-X-6-.07 Medication Administration and Safety (1)(j)
Safety precautions including but not limited to:
(i) Right patient
(ii) Right medication
(iii) Right time
(iv) Right dose
(v) Right route
(vi) Right reason
(vii) Right documentation

1. Patient identifier (PI) # 2 was admitted to the facility 1/19/11 with an Axis I diagnosis of Bipolar Disorder not otherwise specified/ Impulse Control Disorder not otherwise specified/ Polysubstance Abuse.

Review of the Physician's Order dated 5/29/11 revealed an order for Benadryl 25 mg. (milligrams) PO (by mouth) for c/o (complaints of) inability to sleep per "sleep hygiene" request.

Review of the MARs (Medication Administration Record) for the month of May revealed no documentation of the physician's order for the Benadryl dated 5/29/11.

Review of the MAR for the month of June revealed an entry dated 6/2/11 reading, "Benadryl 25 mg po @ (at) HS (hour of sleep) PRN (as needed) in accordance c (with) sleep hygiene". Review of the physician's orders revealed no documentation of an order for the above noted Benadryl.

Further review of the MAR for June revealed Employee Identifier # 3, which is Registered Nurse (RN) # 1 documented the administration of Benadryl 25 mg PO at 22:10 on 6/2/11.

An interview was conducted with EI # 3 on 8/16/11 at 8:00 AM. The surveyor asked EI # 3 to explain what happen on 6/2/11. EI # 3 stated the patient wanted a PRN for sleep. EI # 3 stated she/he pulled the Benadryl from the medication system and handed it to PI # 2. PI # 2 refused to take the Benadryl at that time and an altercation broke out. The surveyor asked where the Benadryl was during the altercation and EI # 3 stated it ended up against the wall on the counter. EI # 3 stated that EI # 5 (RN # 2) came over to help with the altercation and asked if she/he needed to give PI # 2 the Benadryl.

An interview was conducted with EI # 5 on 8/16/11 at 7:35 AM. EI # 5 stated that she/he administered the Benadryl after EI # 3 had left the floor.

Further review of the June MAR revealed a late entry by EI # 5 dated 6/7/11 for 6/2/11, with no documentation of the time the Benadryl was administered.

Review of the June MAR revealed EI # 3 administered Benadryl 25 mg on 6/12/11 at 22:05, 6/20/11 at 22:05 and 6/24/11 at 20:24. Further review of the MAR for June revealed EI # 5 administered Benadryl 25 mg on 6/7/11 at 22:53, 6/21/11 at 20:35 and 6/30/11 at 21:10. There was no documentation of a physician's order for the use of Benadryl after May 29, 2011.

Review of the MAR for the month of July revealed the Registered Nurses administered Benadryl 25 mg on 7/4/11 at 21:05 and 7/12/11 at 21:20. There was no documentation of a physician's order for the use of Benadryl after May 29, 2011.

The surveyor requested the policy for Medication Administration on 8/18/11 from EI # 1, the Chief Operation Officer and the following statement was submitted, "It is the standard practice of Mountain View Hospital to follow the Alabama Board of Nursing, Nurse Practice Act and the Alabama Administrative Code for all nursing procedures performed at this facility". This information provided to the surveyor 8/18/11, had no title or date of approval by the governing body.

EI # 3 failed to ensure a physician's order was valid before medication was administered to a patient. EI # 3 also documented administration of medication that EI # 3 stated she/he had not given on 6/2/11.